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All U.S. Hospitals Who Provide Maternity Care Can Support Mothers Who Want a VBAC

21 Jan

In its 2017 guidelines for VBAC the American College of Obstetricians and Gynecologists (ACOG) states, “Available data confirm that TOLAC (trial of labor after cesarean) may be safely attempted in both university and community hospitals and in facilities with or without residency programs.”

But, most U.S. community hospitals, those without an in-house physician capable of performing a cesarean, operating room staff, and anesthesia, have been reluctant to accept mothers who want to labor for a VBAC. Many mothers have been told that their only option is a routine repeat cesarean, which in fact exposes them to multiple risks including hemorrhage, serious infection, blood clots, and placental problems. 

As Chief of Obstetrical Services at Spectrum Health Gerber Memorial, a community hospital in Fremont, Michigan, Dr. Tami Michele worked in partnership with maternity and newborn care staff, anesthesia providers, women’s health, hospital administrators, and risk management to develop a consensus hospital policy and a mother’s informed-decision tool to support VBAC within Spectrum Health, an integrated health system headquartered in Grand Rapids, Michigan.  

Dr. Tami Michele, Spectrum Health

Dr. Michele would like to encourage other community hospitals to provide care for VBAC. In the spirit of collaboration Dr. Michele has chosen to share with VBAC.com three documents that can be used as a guide by other community hospitals. They can be found at the end of this article. Please, share them with expectant parents, maternity care professionals, and birth advocates in your community. 

We are honored to publish Dr. Michele’s guest blog post.

It is the shared responsibility of tertiary care hospitals, community hospitals, physicians, and midwives to provide access to care for women desiring VBAC.

The greatest disasters that bring fear and cause barriers to care for VBAC are the cases in which no one knew the signs of uterine rupture and the staff did not act quickly, causing harm to the mother/baby. Comprehensive medical education about VBAC is what is going to change the statistics and drive down the uterine rupture rate.

The American College of Obstetricians and Gynecologists has defined the Levels of Maternal Care in a joint document with the Society of Maternal-Fetal Medicine (released in 2015), specifically acknowledging that trial of labor should take place in a level 1 hospital.  Recent research of home birth data has shown a higher risk in home VBAC for mothers who have never had a prior vaginal birth, yet access to trial of labor in level 1 and level 2 hospitals is lacking.

Change is slow, and hospital policies continue to recommend trial of labor only in large regional hospitals across the nation.  As described in the ACOG practice bulletin on VBAC released in 2010, the autonomy of a woman to accept an increased risk should be honored when she is fully informed of the risks, benefits, and alternatives.

Despite this, community hospitals struggle to allow this choice when they do not have the optimal services. The underlying discussion is complex. When risk management, physicians, anesthesia providers, hospital administrators, and policy-makers collaborate, it is possible to create change.

Our hospital system achieved consensus on the following:

  1. The importance of transparent disclosure to the woman regarding resources available in every hospital;
  2. Providing opportunities to transfer care to a physician working in the tertiary hospital if desired by the patient;
  3. The large regional hospital allowing the patient to present to their facility in labor and accepting her request for VBAC, with physicians who provide VBAC services;
  4. Instructing patients to present to the closest hospital if in active labor, leaking fluid, bleeding, in pain, or if they do not feel safe traveling to the larger regional hospital;
  5. No woman will be forced or coerced into a repeat cesarean just because she has a history of cesarean birth;
  6. Physicians at the tertiary hospital willingly accept patients from the community hospital if a medical induction is necessary for a woman desiring VBAC;
  7. Obstetrician and anesthesia providers stay on site at the hospital when a woman desiring a VBAC is actively laboring to allow timely emergency cesarean if needed;
  8. OR staff (scrub tech, surgical assist, circulator) and pediatrician are notified and are on-call;
  9. Education of physicians and OB nurses regarding the signs/symptoms of a uterine rupture is essential to intervene in a timely manner;
  10. All women with a previous cesarean, not just those requesting VBAC, deserve the same counseling with risks of TOL (trial of labor), risks of repeat cesarean, assessment of individual factors and chance for success;
  11. The attached policy template incorporates these values and can be used by hospital systems to stimulate discussion for policy development.

In my experience, the best outcomes are achieved when collaboration between hospital systems, physicians, nurses, and midwives occurs.

The website, VBAC.com and the VBAC Education Project help women to sort out the complexities of birth after a prior cesarean and helps them to come to an informed personal decision to have a repeat cesarean or to explore VBAC. Well trained doulas are invaluable in assisting the laboring woman through the challenges unique to undergoing a ‘trial of labor.’

Many women are turning to home birth due to hospital barriers, which places a large burden on midwives who also desire safe birth outcomes. We know the risk of uterine rupture is low; however, we do not have the ability to determine when it is likely to happen, and statistically it will happen.  Collaboration between all levels of care is key to patients accessing the appropriate obstetrical services and to support women who desire VBAC.

I would like to stop the worried conversations that, “1 in 100 women will have a uterine rupture.” I am sure we can do much better than that. And if a rupture did occur, the quality standard should be how did the mother and baby do when provided with knowledgeable and experienced medical care.  Hospitals can and should do better.

Dr. Tami Michele, OB/GYN
Spectrum Health Gerber Memorial
Fremont, Michigan
Chief of Obstetrical Services

Consensus Documents for VBAC, Download and Share

Birth Options After a Cesarean, Patient Education

Request for a Trial of Labor After Cesarean Delivery, Consent Form

Community Hospital Policy, Trial of Labor and Vaginal Birth after a Previous Cesarean Birth

For more information contact Dr. Michele at TJMichele@aol.com

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ACOG’s 2017 VBAC GUIDELINES: WHAT MOTHERS NEED TO KNOW

3 Dec

Most mothers in the United States who want to labor for a VBAC still face resistance from their physician or hospital despite clear evidence that VBAC is a reasonable choice for women with a prior cesarean birth.

The American College of Obstetricians and Gynecologists (ACOG) has published and revised several VBAC clinical practice guidelines, the last time in 2010. Although the 2017 revisions seem to be the most supportive of VBAC to date, unfortunately the guidelines are not enforceable. Physicians and hospitals who support VBAC choose to do so voluntarily. It is important for mothers to become familiar with ACOG’s guidelines so that they can start a conversation with their provider during pregnancy and make an informed decision about how and where they want to give birth. Care providers are required to educate mothers about the benefits and risks of VBAC and elective repeat cesarean. Mothers have the right to accept or refuse the physician’s recommendations.

Many mothers today are still told they can’t labor for a VBAC if they are past-due, if their baby is “too big,” or if they have had two prior cesareans. However, ACOG’s guidelines support VBAC in those situations. The College recommends that “…individual circumstances must be considered in all cases.” Ultimately, it is the mother’s choice.

The following are highlights of ACOG’s Practice Bulletin, Number 184, Vaginal Birth After Cesarean Delivery.

[…]

Can I Plan a VBAC After a Cesarean for a “Big” Baby?

19 Oct

Many mothers have given birth to heavier babies vaginally after a cesarean for a “big” baby. How you are cared for during pregnancy, labor and birth can make a big difference.

Estimated Fetal Weight in Pregnancy is Often Inaccurate

Care providers are concerned about vaginal birth for a potential “big” baby (fetal macrosomia) because as fetal birth weight increases so do the risks for shoulder dystocia, vaginal tears, and permanent nerve injury to the newborn. Macrosomia is defined as a suspected birth weight of 8lbs. 13 oz. or more. The problem is that estimating the size of the baby during pregnancy has been shown to be inaccurate. In the U.S. one out of ten babies are big at birth, but a national survey found that one in three women were told during pregnancy that their baby was too big for a vaginal birth.

Ultrasound estimates of fetal weight are not always accurate. ACOG discourages care providers from recommending an ultrasound in the third trimester to estimate the size of the baby or recommending a cesarean because the baby is “too big.”  The Royal College of Obstetricians and Gynaecologists in Britain  suggests that the majority of “big” babies do not develop shoulder dystocia and 48% of newborns who develop shoulder dystocia weigh less that 9lbs. 14 oz. The Society of  Obstetricians and Gynaecologists of Canada state that suspected microsomia is not a reason to discourage mothers from planning a VBAC. 

Helpful Positions for Labor and Birth

Having the freedom to walk around, staying upright during labor and using comfort measures can make a difference.

A woman’s body changes to prepare her for pregnancy and birth. Connective tissues soften in the joints. The pelvis, cervix, and vaginal tissues expand to accommodate the baby. The baby’s head molds as it moves through the mother’s body. Knowing how to move your body and change positions during labor and birth can reduce your pain and help labor progress. Specific positions such as squatting for birth can widen the pelvic diameters and allow a “big”  baby to move through the pelvis with ease.

  • Walk, move about, and stay upright during labor.

 

  • Change positions to make yourself more comfortable.

 

  • Use pillows to support every part of your body.

 

  • Avoid an epidural in early labor which can make it more difficult for your baby to move through your pelvis and turn into a favorable position for birth.

 

  • Give yourself enough time to reach full dilation . Current evidence shows that women are not considered to be in the active phase of labor until the cervix widens to 6cm and the membranes have ruptured. 

 

  • Push your baby down when you feel the urge rather than immediately after reaching 10cm (laboring down). Mothers who have had a vaginal birth can take up to 2 hours and with a prior cesarean without labor, 3 hours to give birth. All mothers need an additional hour if an epidural is still effective.

 

  • Ask your childbirth educator about movements and positions for labor and birth that can help to widen your pelvis. You can download the Optimal Positions Labor Guide from BirthTools.org for examples of helpful positions for laboring with a “big” baby. 

 

  • Consider hiring a doula to support and guide you. Doulas are familiar with comfort measures and non-drug options for pain relief. Women who are supported by doulas have fewer cesareans.

 

  • Consider having a midwife as your primary caregiver. With midwifery care, women have fewer cesareans.

 

Resources

Evidence-Based Birth: The Evidence for Induction or Cesarean Section for a Big Baby

VBAC Education Project: Download Module 5 of  Deciding if a VBAC Is Right for You: A Parent’s Guide and Educational Handouts for Parents: A Parent’s Guide  for additional guidance on planning a VBAC.

 

 

What Are the Odds of Having a VBAC? A Guide for Birth Educators

12 Sep

These guidelines are based on the content of the VBAC Education Project. 

Planning a VBAC presents different challenges for different women. Some are ready to face labor head on without any drugs for pain relief choosing instead a variety of comfort measures, doula care for emotional and physical support, and a midwife as their primary care provider. Others, who may have had a long, difficult, and painful labor before having a cesarean may feel they can only go through another labor if they have dependable pain relief (an epidural), the safety of electronic fetal monitoring, and the reassurance of an “immediately available” physician and operating room staff in case of complications. Every mother’s choice should be respected. There are many ways to support women who labor for a VBAC within their self-selected birth choices.

ACOG’s guidelines for VBAC suggest there are factors that are likely to increase women’s odds for completing a VBAC:

  • A prior vaginal birth;
  • A healthy pregnancy weight;
  • The prior cesarean was for malpresentation (baby in a non-vertex position);
  • Going into labor at or near term;
  • Labor that is not induced or augmented;
  • The bag of waters having ruptured on its own or the cervix having started to dilate before admission to the hospital labor and delivery unit;
  • No complications in the current pregnancy such as preeclampsia.

However, there are other important factors that can make a difference in whether or not a mother will complete a VBAC.

Evidence is mounting and validating what many maternity care professionals have always known, that health outcomes are better when the process of labor is allowed to unfold on its own (physiologic birth) without routine medical interventions and when mothers are full participants in their care. Women are more likely to get the support they need and the care that is best for them when care providers collaborate to bring about healthy outcomes for mothers and babies (Goer & Romano, 2012).

Simkin and Ancheta (2011) have demonstrated that women can have an easier and safer birth when they feel safe and respected by their caregivers and when their values and preferences are taken into consideration. When they have freedom of movement and can stay in upright positions as long as they feel comfortable.

Routine Interventions and Electronic Fetal Monitoring

žAvoiding routine interventions helps labor progress, but with a VBAC, monitoring the baby’s heart rate is important. žThe baby’s heart rate pattern frequently changes when the uterine scar separates.ž Up to 70% of the time electronic fetal monitoring (EFM) has detected an abnormal heart rate pattern, suggesting a separation of the uterine scar (ACOG, 2010).

žSome care providers recommend continuous EFM in active labor. Even with continuous monitoring for a hospital VBAC it’s possible to change positions, rock in a chair, stand and move side to side, lean over the back of the bed or a birth ball and use an upright position for birth. A telemetry unit (portable fetal monitor), or a waterproof hand-held Doppler allows mothers to walk, change positions or use the birth tub while monitoring the baby (Simkin & Ancheta, 2011).

Implications for Educators 

The concept of physiologic birth, allowing birth to proceed without interventions unless medically necessary, moving around in labor, and avoiding an epidural in the early stage of labor will probably be new for most of your students. In U.S. hospitals the majority of women experience multiple interventions, two out of three women have an epidural for pain relief in labor, only four out of ten have freedom of movement once labor begins and more than six out of ten are on their back for the second stage of labor (Declercq, Sakala, Corry, et al., 2013) . 

To help women clarify what options are available to them and how they prefer to give birth use the list of suggested questions in the Educational Handouts For Parents for Module 4 to begin the conversation so that they have the time and opportunity during pregnancy to get the answers they need.

The questions are designed to encourage parents to feel comfortable asking questions of their caregivers and to find out more about their provider’s approach and philosophy of birth. The discussion will also help partners themselves to find out if their views about having a “safe” VBAC are similar or different. Partners may decide they can both benefit from the expertise and support of a doula.

Mothers have their own unique preferences for how they want to give birth and what they need to labor safely for a VBAC. Educators have the tools and knowledge to support them and give them the confidence they need.