The First Cut is The....

Wow... I opened my inbox this morning and found a plethora of information on the results of the National Institutes of Health (NIH) Consensus Development Conference on Vaginal Birth After Cesarean: New Insights

The conclusions (per their draft statement) are shown below, although you can follow the above link and read the complete study, as well as additional information:
Given the available evidence, TOL is a reasonable option for many pregnant women with a prior low transverse uterine incision. The data reviewed in this report show that both TOL and ERCD for a pregnant woman with a prior transverse uterine incision have important risks and benefits and that these risks and benefits differ for the woman and her fetus. This poses a profound ethical dilemma for the woman as well as her caregivers, because benefit for the woman may come at the price of increased risk for the fetus and vice versa. This conundrum is worsened by the general paucity of high-level evidence about both medical and nonmedical factors, which prevents the precise quantification of risks and benefits that might help to make an informed decision about TOL versus ERCD. We are mindful of these clinical and ethical uncertainties in making the following conclusions and recommendations.

One of our major goals is to support pregnant women with a prior transverse uterine incision to make informed decisions about TOL versus ERCD. We urge clinicians and other maternity care providers to use the responses to the six questions, especially questions 3 and 4, to incorporate an evidence-based approach into the decisionmaking process. Information, including risk assessment, should be shared with the woman at a level and pace that she can understand. When both TOL and ERCD are medically equivalent options, a shared decisionmaking process should be adopted and, whenever possible, the woman’s preference should be honored.

We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL. Given the level of evidence for the requirement for “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement relative to other obstetrical complications of comparable risk, risk stratification, and in light of limited physician and nursing resources. Healthcare organizations, physicians, and other clinicians should consider making public their TOL policy and VBAC rates, as well as their plans for responding to obstetric emergencies. We recommend that hospitals, maternity care providers, healthcare and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to TOL.

We are concerned that medico-legal considerations add to, as well as exacerbate, these barriers. Policymakers, providers, and other stakeholders must collaborate in the development and implementation of appropriate strategies to mitigate the chilling effect of the medico-legal environment on access to care.

High-quality research is needed in many areas. We have identified areas that need attention in response to question 6. Research in these areas should be prioritized and appropriately funded, especially to characterize more precisely the short-term and long-term maternal, fetal, and neonatal outcomes of TOL and ERCD.
The LA Times reports on these findings as well in Panel urges more choice in birth after C-section.
A National Institutes of Health panel says vaginal birth after caesarean is reasonably safe and should be more widely available. Many hospitals ban the practice as a matter of policy or liability. Vaginal birth after caesarean, or VBAC, is reasonably safe and should be more widely available, a National Institutes of Health advisory panel concluded Wednesday.

Such deliveries once accounted for 25% of U.S. births among women with a previous caesarean delivery, but have now fallen to less than 9%. Many women would like to attempt a vaginal delivery, however, and the panel's consensus statement is expected to increase their access to the option.
But women who might want to give labor a try very often don't get a chance. That's because of so-called "VBAC bans" -- hospital policies that forbid a vaginal birth after a cesarean (VBAC) unless fully equipped and staffed surgical and anesthesia services are readily available. These policies align with current guidelines set by gynecology and anesthesia professional societies.

Not all hospitals are able to comply with this standard, so many women who have had a C-section have no choice in the matter. In fact, 30% of hospitals stopped offering women this choice after the professional-society guidelines went into effect.
Denise Grady of the New York Times wrote on this subject in her article Panel Urges New Look At Cesarean Guidelines:
A panel of medical experts on Wednesday recommended steps to reverse a trend that has dismayed many pregnant women: the increasing difficulty of finding doctors and hospitals that will let a woman try to give birth normally if she has had a Caesarean section in the past.

The new recommendations came at a conference held in Bethesda, Md., by the National Institutes of Health to examine why the rate of vaginal birth after Caesarean, or VBAC (pronounced VEE-back), has plummeted, to less than 10 percent from 28.3 percent in 1996. The repeat operations are feeding the nation’s overall Caesarean rate of 31.8 percent, which has been rising steadily for the last 11 years.
Lauran Neergaard, AP Medical Writer, covers that Women Need A Chance to Avoid Repeat C-Sections
Too many pregnant women who want to avoid a repeat cesarean delivery are being denied the chance, concludes a government panel that urged doctors to rethink litigation-spurred policies that have swung the pendulum back toward the days of "once a C-section, always a C-section."

Fifteen years ago, nearly 3 in 10 women who had a first C-section were able to deliver their next baby vaginally, a trend called VBAC for "vaginal birth after cesarean."

Now that rate has dropped to 1 in 10, in part because a third of hospitals and half of physicians ban women from attempting VBAC, a panel of specialists convened by the National Institutes of Health said Wednesday.

But VBAC remains a safe alternative for the right candidates, and when those women try labor, between 60 percent and 80 percent of the time they do give birth vaginally, the NIH panel concluded. It urged that doctors offer mothers-to-be an unbiased look at the pros and cons, so they can decide for themselves.
Lolita Carico writes, at Mama Gloss, in her article Why Are C-Sections on the Rise,
Cesarean sections are the #1 most performed surgeries in the United States, with 1 in 3 pregnant women giving birth via c-section. That figure is up significantly since 1996, when the rate was 1 in 5.... The debate rages on, but a new report being released today by the NIH (National Institute of Health), has determined that VBAC’s are just as safe as normal births. The findings could lead to a decline in c-sections.

I have high hopes that this exposure will change (over time) the unethical ban of VBACs in hospitals across this nation (and two in my own area) and create an uproar by consumers over insurance companies dropping women seeking VBAC or even women who have had prior cesareans and find themselves pregnant again - and force change.

As the results of this conference snowball across the birth community news, blogs, Facebooks, and Tweets, I anticipate and joyfully expect more women to seek out alternatives, vocally so, and hospitals/practices to be urged to make changes to accommodate these options.

Additional Blogs of Note:
The Feminist Breeder (along with more coverage of the conference) concludes in Once a Cesarean, Rarely a Choice :
Time will only tell if the more positive points made by NIH consensus will have an impact on access in this country. From a birth activist’s point of view, the statements made by many of the conference speakers were a huge leap in the right direction. However, our cesarean and VBAC rates will not be reversed overnight, and in the interim, scores of women are left without a choice but to either fight the system for their VBAC, or submit to a surgical birth. To these women and their families, this is really no choice at all.
The NIH press release about the VBAC Consensus Meeting includes only a single instance of the phrase “uterine rupture.” Having spent 2 1/2 days watching the streaming webcast of the event, my strong sense is that this was by design. During the expert testimony, we heard over and over again that uterine rupture is the most feared outcome of a VBAC. We heard in gripping detail what happens when a uterine scar ruptures in labor, and even saw photographs of the devastation. We heard about deaths and hysterectomies and hypoxic injury to newborns that occurred with uterine ruptures. But after all of that, we heard a rather consistent message that uterine rupture itself is not the issue.
Courtroom Mama ruminates, over at The Unnecesarean, NIH VBAC Consensus Development Conference: Gift Horse or Trojan Horse?
There are a lot of wonderful things to say about the recent NIH VBAC Consensus Development Conference. Hopefully it will expand access to VBAC by urging ACOG to reconsider the “immediately available” standard, and end the practice of banning VBAC rather than working to lessen the risks through physiological management of labor and other techniques. I’m happy to see that they are finally acknowledging that there is no way to reduce infant mortality to zero, and that the risks inherent in VBAC are no different from the risks of catastrophic outcome in any other delivery, making singling out of VBAC nonsensical. I applaud the panel for that.
But, as a law geek and a birth geek, I have to look a gift horse in the ass here.

When the draft statement first came out, I was a little bit troubled by the part that is now the end of page 14 and top of page 15.

Along these same lines, the 1999 ACOG guideline urged, “After thorough counseling that weighs the individual benefits and risks of VBAC, the ultimate decision to attempt this procedure or undergo a repeat caesarean delivery should be made by the woman and her physician.” Presentations at the conference suggested that this important recommended practice is not uniformly followed, but there are no strong data documenting the extent of this problem.

In my opinion, this portion of the recommendation didn’t strongly address some of the concerns raised in the prior two days about what happens to women who aren’t ideal VBAC candidates and who nevertheless don’t want to have surgery. Surely I wasn’t the only one worried…
Stand and Deliver posted a great review on her blog, along with much more linkie love on the whole event.

Doula-la talks about what Shrimp and the NIH Panel have in common.

Karen The Pittsburgh Doula covers a small blip and privies us to her 'shell shockedness' of the whole communication-sphere of the US going abuzz with the news.

Academic OB/Gyn writes about a possible solution through Micro Tort-Reform. Very good read.

VBAC in the News is covered by Your Best Birth.

Momotics talks about what wasn't covered at the conference.

And, to close, Refuse to Be A Womb Pod writes I know what you did last summer
I did something last summer.
Actually, I did it for the second time.
Most professionals think what I did is dangerous.
I was told I shouldn’t do it. Many institutions have banned it.
I meet women very often who have never even heard of what it is I did.
Sometimes women say they wish they could do what I did
but they aren’t allowed.
Or brave enough.
Or wide enough or thick enough.
Or, it’s just not convenient
Sometimes the very law itself doesn’t allow women to do what I did....
Go to her blog to read the rest.


academicobgyn said...

Thanks for the link!

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