Tag Archives: ACOG

New Jersey Poised to Increase Access to VBAC

6 Jan

New Jersey has one of the highest cesarean rates in the country. According to U.S. Preliminary data for 2012 New Jersey has the third highest cesarean rate in the nation,  38.7% preceded by Florida (38.1%) and Louisiana (40.2%). In the last two decades repeat cesarean births without labor more than doubled in New Jersey, from 40% to 85%. According to the New Jersey Department of Health currently one in four cesareans are routine repeat operations without serious risk indications. The New Jersey VBAC Task Force wants to change that.

Task Force members agree that VBAC should be available to all low-risk women who choose to labor after a prior cesarean and increasing access to VBAC would improve obstetric care. New Jersey hospital VBAC rates vary widely, from 31.0% at Monmouth Medical Center to 0% for Memorial Hospital and Southern Ocean Medical Center in 2011. The Task Force suggested establishing a network of regional VBAC referral centers who can meet safety requirements for VBAC. The Task Force is a multidisciplinary collaborative group which includes the New Jersey Hospital Association, health insurance payers and malpractice insurers.  20111225_Jess_6619_2000

Hospitals often deny VBAC care by referring to the costly and realistically unattainable ACOG guidelines which recommend a surgical team and anesthesia be “immediately available” when women labor for a VBAC. Having had a prior cesarean adds a level of risk to the subsequent laboring process, however, the risks of laboring for a VBAC are the same as for women giving birth for the first time, yet women giving birth for the first time are not denied medical care, nor are they told that they are at risk because the hospital cannot guarantee that a surgical team and anesthesia will be “immediately” available in case they would need a cesarean section.

The New Jersey VBAC Task Force concluded that ACOG’s definition of “immediate access” has never been defined by ACOG or any other authority and the legal liability of this ambiguous recommendation is “not conducive to frank discussion with patients, resulting in obscure and often misleading counseling.”

Providing safe medical care for women in New Jersey who want to plan a VBAC is not an impossible task. After more than one year of deliberations, the Task Force concluded that many of New Jersey’s hospitals already have the resources that can meet the safety standards recommended to support mothers who want to plan a VBAC. The Hospital Capacity and Regional Accessibility Subcommittee reasoned that being able to provide advanced neonatal care was just as critical for responding to complications that may develop during labor for a VBAC.

New Jersey licenses 20 hospitals as intensive perinatal centers or intermediate/regional perinatal centers. These hospitals are required to have full-time on-site coverage by neonatal and pediatric specialists and consulting arrangements with anesthesiology. Responding to a Task Force survey, 14 of 20  intensive care perinatal centers  reported having 24-hour in-house obstetric coverage for cesarean, availability of anesthesia and operating room teams, and 60% of the intermediate and basic perinatal centers reported 24-hour on-site coverage and the rest the availability of an off-site obstetrician within 30 minutes once the need for a cesarean was established.

Also in response to the Task Force survey, 7 of the intensive perinatal care centers and 6 of the intermediate care centers were in favor of becoming a regional VBAC referral center.

To successfully increase access to VBAC the Task Force made several recommendations:

  • Re-evaluate the risks of laboring for a VBAC by comparing low-risk women with a prior cesarean with New Jersey’s benchmark population, low-risk multiparous women without a previous cesarean for a more realistic evaluation of potential maternal and neonatal complications.
  • Develop a VBAC education program to educate expectant parents about the benefits and risks of laboring after a prior cesarean.
  • Educate providers and hospitals about the benefits and risks of VBAC, adequate staffing and resources, labor progress patterns for VBAC , guidelines for augmentation of labor, signs and symptoms of uterine rupture or dehiscence and practice drills for appropriate response for a uterine rupture.
  • Educate in-hospital staff about VBAC including, risk management, nursing, anesthesiology, neonatology, lab and blood banks to have a more coordinated response in case of complications.
  • Providers should try to shift the focus of their conversation with their patients from “defensive communication and liability strategies toward true shared decision making.”

Tom Westover, MD of Cooper University Hospital in New Jersey and a member of the New Jersey VBAC Task Force will address health professionals and birth advocates about increasing access to VBAC on March 26 at the New Jersey BirthNetwork Symposium at Rutgers University Inn & Conference Center, Supporting NJ’s Birth Plan: Taking the Next Step and Implementing Evidence-Based, Mother-Friendly Maternity Practices in New Jersey.

 Resources

Northern New England Perinatal Quality Improvement Network,  VBAC Project

Childbirth Connection, Maternity Care and Liability: Pressing Problems, Substantive Solutions

TRIAL OF LABOR, A New Film About Four Mothers and Their Determination To Give Birth Naturally After A Prior Cesarean

22 Jul

Two fathers, Robert Humphreys, an independent, award winning film maker and Dr. Elliot Berlin, a Chiropractor specializing in alternative prenatal care, set out to make a documentary film about the VBAC Ban in U.S. hospitals and its impact on the physical and psychological health of women who want to birth naturally after a prior cesarean. TRIAL OF LABOR, a documentary initially conceived as an educational film about the medicalization of birth in the U.S. and the pros and cons of VBAC and repeat cesarean, evolved into a powerful and inspiring personal journey of four mothers who had a prior cesarean and who were determined to find caregivers who would support their choice for a VBAC. The children of both Humphreys and Berlin were born at home. As men and fathers, they witnessed how powerful and validating birth can be.

With a healthy pregnancy, and a low horizontal scar on the uterus, women who go into labor on their own at term have about a 70% to 75% chance that they will have a safe VBAC. Avoiding a routine repeat cesarean protects women from complications of major abdominal surgery as well as potential complications in a subsequent pregnancy.

However, current controversial ACOG guidelines (Practice Bulletin #115) requiring that trial of labor (TOLAC) should take place in hospitals where resources for emergency cesarean are “immediately available” make it very difficult for expectant mothers to find VBAC supportive careproviders.

The National Institutes of Health (NIH) found that this “immediately available” recommendation was based on consensus and expert opinion rather than strong support from high-quality evidence.  The NIH also found that this recommendation had influenced about one-third of hospitals and one-half of physicians to no longer provide care for women who want a VBAC.

Told from the mothers’ own point of view, TRIAL OF LABOR is a sensitive and insightful look at four strong and courageous mothers who challenge an irrational and un-affirming medical care system to escape from a routine repeat operation-initially, the only option they thought they had.

Their journey to VBAC forces them to look back at their unexpected and unwanted cesarean birth. Face conflicting emotions about their ability to give birth and examine carefully the benefits and downside of both a natural birth and another operation.

“It was the most surreal Kafkaesk experience,” said one mother about her cesarean. “When I reflect about it,” says another, “I get visibly angry. That I didn’t inform myself enough.”

The mothers’ decision to give birth vaginally, where and with whom , did not come easy. “It’s very difficult to step away from the medical establishment,” expressed one expectant mother and yet,  chose to have a VBAC at home, her last resort, despite the lack of published evidence about its safety. Each mother decided for herself how she can best give birth this time.

The U.S. saw an increase in VBACs from the 1980s through the mid 1990s, but the VBAC rates have consistently declined since. One in four women had a VBAC in 1996 compared to 1 in 100 today.

Filmmaker, Robert Humphreys said, “Women have the power and wisdom to give birth. They have been doing it for thousands of years. We men need to step back and respect their strength and ability to give birth on their own.“

The producers of TRIAL OF LABOR have received an encouraging response to their request for  funding to complete the film and meet their post-production costs. They also plan to produce DVDs of the film. Humphreys and Berlin have launched a Kickstarter campaign to raise the funds and are asking the birthing community and the public at large to view the trailer and spread the news about this important and much needed film.

To view the trailer and find out more about the film visit, TRIAL OF LABOR.

The Home Birth Scare in the U.K.

19 Oct

It seems that the trend to demonize women who choose a home birth with a midwife is not limited to the United States. In Britain, as reported in the Telegraph, women who want to have a home birth are being told  by  their physicians  that they are too young, too old, or too overweight to risk giving birth at home. The National Health Service in the U.K. has established guidelines for low-risk women who want a home birth, but leaders in the Royal College of Midwives are protesting that physicians are treating women as abnormal  and scaring them into having a hospital birth.

Although the American College of Obstetricians and Gynecologists  (ACOG) states that the safest place to give birth is in the hospital, research shows that for low-risk women, a planned home birth with a licensed midwife is a safe option. With a home birth women are less likely to end up needing  a cesarean and outcomes for mothers and babies are as safe as for hospital births.

National Organizations Ask ACOG To Do More To Increase Access to VBAC

28 Sep

Last August the American College of Obstetricians and Gynecologists (ACOG) published revised VBAC guidelines that encouraged women to plan a VBAC and removed some of the barriers that led many women to have repeat cesareans. However, what ACOG did not do is change its recommendation that VBACs should take place in hospitals where emergency cesareans are “immediately available.”

In a Sept. 9, 2010, letter to Dr. Richard Waldman, president of the American College of Obstetricians and Gynecologists (ACOG), the Coaltion For Improving Maternity Services (CIMS) and 18 co-signing organizations urged ACOG to revise its current recommendation and its patient education publications as well as its online consumer resources to include comprehensive information on the benefits and risks of cesarean section and VBAC. Current ACOG pamphlets on cesarean section and VBAC do not fully provide  their short- and long-term benefits and risks so women  cannot realy make an informed choice about how they want to give birth.

CIMS posted the letter on their home page and is asking consumers, health professionals, and organizations to add their name to the petition. CIMS will collect the names of additional organizations and individuals in support of this request through October 31, 2010, and will send the updated list of co-signers to Dr. Waldman.


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