VBAC Policies: Should they Circumvent Mom's Wish?

When Kendra became pregnant with her second child, she knew the baby would be delivered by cesarean section (c-section) due to the fact that her first child was a c-section birth and the doctor told her at that time that all subsequent deliveries would also be c-sections.  The doctor told her it was simply too dangerous to deliver a child vaginally after a c-section.

The American College of Obstetricians and Gynecologists released guidelines stating, “attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans.

"The current cesarean rate is undeniably high and absolutely concerns us as ob-gyns," said Richard N. Waldman, MD, president of The College. "These VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy. Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate."

Past recommendations were that most women with one previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about VBAC and offered a trial of labor after cesarean (TOLAC).

 "The College guidelines now clearly say that women with two previous low-transverse cesarean incisions, women carrying twins, and women with an unknown type of uterine scar are considered appropriate candidates for a TOLAC," said Jeffrey L. Ecker, MD, from Massachusetts General Hospital in Boston and immediate past vice chair of the Committee on Practice Bulletins-Obstetrics who co-wrote the document with William A. Grobman, MD, from Northwestern University in Chicago.

A successful VBAC has fewer complications than an elective repeat cesarean while a failed TOLAC has more complications than an elective repeat cesarean.

Repeat cesarean and a TOLAC both include risks of maternal hemorrhage, infection, operative injury, blood clots, hysterectomy, and death. Most maternal injury that occurs during a TOLAC happens when a repeat cesarean becomes necessary after the TOLAC fails.

If uterine rupture occurs, which carries a risk factor of 0.5% - 0.9%, during a TOLAC, it is an emergency situation. A uterine rupture can cause serious injury to a mother and her baby.  The College maintains that a TOLAC is most safely undertaken where staff can immediately provide an emergency cesarean.

"Given the onerous medical liability climate for ob-gyns, interpretation of The College's earlier guidelines led many hospitals to refuse allowing VBACs altogether," said Dr. Waldman. "Our primary goal is to promote the safest environment for labor and delivery, not to restrict women's access to VBAC."

"It is absolutely critical that a woman and her physician discuss VBAC early in the prenatal care period so that logistical plans can be made well in advance," said Dr. Grobman.
The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will.

 Lamaze International is an organization which promotes a natural, healthy and safe approach to pregnancy, childbirth and early parenting practices.  In a press release today,  the organization states it “is pleased to see several key components within the guidelines, including the acknowledgment that a woman’s choice for a planned VBAC should be honored; recognition of associated decrease in maternal morbidity and risk of complications in future pregnancies; and, affirmation that planned VBAC could decrease the overall cesarean rate.”

The Duggar Family, celebrities in the Northwest Arkansas area, and made famous due to an American reality television show “19 Kids and Counting”, are a good case-in-point for VBAC.  Michelle Duggar has given birth to 19 children in 21 years.  Jim Bob and Michelle’s 1st child was born vaginally; 2nd and 3rd children (twins) were born via c-section; their 4th through 14th children were all VBAC; number 15 was a c-section; 16th and 17th VBAC; 18th and 19th c-sections.

When asked, “How was the 18th pregnancy compared to your 1st?” Michelle responded, that the greatest change that she has seen in the field of obstetrics, and most troubling, is the idea that once a woman has had a C-section all future pregnancies must be delivered by a C-section.  It is much healthier for mom and baby to avoid major surgery and all the complications that go along with a C-section if possible. Granted, there are health situations that would warrant such, but for years obstetrics encouraged TOL A with many successful healthy vaginal births.

Adding, “I was quite alarmed to be told that I could no longer have a vaginal birth due to hospital or insurance company’s regulations. It appears that what is best for the patient is not the priority with this decision. I feel our health care is being jeopardized by this unhealthy approach. Doctors are having to tell their patients that they no longer offer VBAC assistance due to hospital regulations and some might even state to the patient that they are not safe so as to avoid confrontation. Statistics prove much differently.”  Michelle believes more women should make a clear statement to health care providers and insurance companies regarding their preference  to deliver their babies in a safer, healthier manner.

Michelle’s OBGYN, Dr. Amy D. Sarver, explained her rationale regarding Michelle as a good candidate for VBAC saying that Michelle knew her body very well, was very familiar with the process and physical stages of labor and delivery and that she (Michelle) would be at a medical facility staffed with  an anesthesiologist and appropriate medical personnel if an emergency situation presented.
The choice for VBAC should be one made after discussion and careful consideration of both Mother and Physician, with the primary goal to promote the safest environment for labor and delivery for both Mother and Child.

Laura Lamp King