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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