ACOG | International Cesarean Awareness Network

ICAN Addresses ACOG Practice Bulletin 184: Vaginal Birth After Cesarean Delivery

November 3, 2017 by blog

announcement

We, the International Cesarean Awareness Network (ICAN), would like to address the recent publication of Practice Bulletin 184 from the American College of Obstetricians and Gynecologists (ACOG), titled: “Vaginal Birth After Cesarean Delivery”. ICAN is a non-profit organization whose mission is to improve maternal-child health by reducing preventable cesareans through education, supporting cesarean recovery, and advocating for vaginal birth after cesarean (VBAC).

ICAN is hopeful that ACOG’s new VBAC guidelines will enable more maternity care consumers to find the support and evidence-based care that they need and deserve. Multiple statements throughout Practice Bulletin 184, such as “Coercion is not acceptable”, and “Global mandates for TOLAC are inappropriate because individual risk factors are not considered”, lead us to believe ACOG is working to decrease the widespread hospital VBAC bans that currently exist in the United States. As ACOG states, “respect for patient autonomy also dictates that even if a center does not offer TOLAC, such a policy cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery”. While ACOG also expresses understanding that some facilities may still choose to mandate surgery for patients with a history of prior cesarean(s), they made sure to add that “patients should be allowed to accept increased levels of risk” (eg, make their own choice), and stated that “none of the principles, options or processes outlined here should be used by centers, obstetricians or other obstetric care providers, or insurers to avoid appropriate efforts to provide the recommended resources to make TOLAC available and as safe as possible for those who choose this option”.

While we are encouraged by ACOG’s apparent stance that VBAC bans should not limit a patient’s right to informed consent and informed refusal, we are discouraged that they also chose to continue their hard stance against out-of-hospital VBAC. In their “Summary of Recommendations”, ACOG cited their recommendations regarding out-of-hospital VBAC as stemming from “consensus and expert opinion”, which is “Level C”. Maternity care consumers choose out-of-hospital birth for a variety of reasons. For example, if a local hospital mandates surgery for all patients with a prior cesarean, some may feel their only option is to birth out-of-hospital. ICAN supports a person’s right to choose their preferred birth location.

We greatly appreciate ACOG’s clarification regarding Level 1 facilities. ACOG, along with the Society for Maternal-Fetal Medicine, described Level 1 facilities as those that “can provide basic care”. They also stated that although there is reason to think rapidly available cesareans can provide “small incremental benefit in safety”, there is no data available to compare “alternate systems and response times”. We are hopeful that this clarification may effect change among Level 1 hospitals with existing VBAC bans.

Possibly the most unexpected addition to this bulletin is the frequent mention of web-based VBAC calculators. In January of 2017, an article titled: “Validation of a Prediction Model for Vaginal Birth after Cesarean Delivery Reveals Unexpected Success in a Diverse American Population”, discussed the accuracy of the MFMU web-based VBAC calculator. The MFMU VBAC calculator appears to be the calculator that is most widely used among medical professionals. This study found that when using the MFMU VBAC calculator, predicted rates were “highly accurate” for those patients that received predicted “success” rates over 65%. However, for the patients that received predicted “success” rates of less than 35%, the study found the actual VBAC rates were nearly “twofold higher” than the predicted rate. In addition, ACOG clearly states that “no prediction model for VBAC has been shown to result in improved patient outcomes.” ACOG points to using individualized care several times in Practice Bulletin 184, but VBAC calculators do not take individual circumstances into consideration. For example, a previous diagnosis of ‘Failure to Progress’ can be attributed to many issues, one of which being simply a failure to wait. In ACOG’s Obstetric Care Consensus, titled: “Safe Prevention of the Primary Cesarean Delivery”, they stated that “studies that have evaluated the role of maternal characteristics, such as age, weight, and ethnicity, have consistently found these factors do not account fully for the temporal increase in the cesarean delivery rate or its regional variations”. We feel that by encouraging physicians to use web-based VBAC calculators, we may see a decrease in the rate of TOLAC, and subsequently a decrease in the rate of overall VBAC.

Multiple criteria are used in the development of web-based VBAC calculators, including maternal age, body mass index, prior vaginal delivery, and race, among others. The paragraph in Practice Bulletin 184 that discusses “obesity”, leaves a final sentence that states patients who have a BMI of “30 or greater may be candidates for TOLAC, depending on their other characteristics (eg, having had a prior vaginal delivery), and their care should be individualized”. If ACOG’s intention was not to limit options for people with a BMI over 30, we question why they chose to include the words “may be candidates” while adding an example of “having had a prior vaginal delivery”. We strongly feel this statement may lead some physicians and midwives to decrease access to TOLAC for those with a BMI over 30, that have not had a prior vaginal birth. According to ACOG, cesarean delivery poses a greater risk of “infection, bleeding, and other complications” for an “obese woman” than for someone with BMI in the normal range.

ICAN as an organization strongly opposes the use of a patient’s race in VBAC calculators. There is a lack of scientific evidence that offers an explanation of why race is included in the calculations. Until peer-reviewed research examining correlations between race and mode of delivery provides something other than results such as “possible physician bias”, or “cross-cultural differences”, race should not be part of the criteria used to estimate the probability of vaginal birth. Race has not been conclusively determined to be a causation versus correlation for higher risk of repeat cesarean, but instead appears to be due to societal issues, including systemic racism in the medical system. Our society is ethnically and racially diverse. We challenge ACOG to develop a culturally informed maternity care response to the rising cesarean rates among all people, but specifically among People of Color.

In December of 2016, ACOG clarified their stance on Vaginal Birth After Two Prior Cesareans (VBA2C), stating: “Most women with two previous low-transverse cesarean deliveries are candidates for and should be offered TOLAC and counseled based on the combination of individual factors that affect their risk and probability of achieving a successful VBAC”. With the amount of available data showing similar rates of attempted TOLAC turned VBAC between those with one prior cesarean, and those with two prior cesareans, and the studies showing similar, to a 1-2% increase in risk of uterine rupture, we are disappointed that Practice Bulletin 184 did not reflect the 2016 clarification wordage.

For maternity care consumers with Special Scars (classical, prior rupture, j-shaped, inverted T shaped, etc…), finding a care provider willing to accept the patient’s right to bodily autonomy can be extremely difficult. We feel Practice Bulletin 184 will not help these patients regain their right to “accept increased levels of risk”, or to exercise their right to give informed consent. As stated in “Safe Prevention of the Primary Cesarean”, childbirth “by its very nature carries potential risks for the woman and her baby, regardless of the route of delivery”. We agree with ACOG that pregnancy is “not an exception to the principle that a decisionally capable patient has the right to refuse treatment, even treatment needed to maintain life. Therefore, a decisionally capable pregnant woman’s decision to refuse recommended medical or surgical interventions should be respected”. We feel ACOG’s label of contraindication regarding people with special scars attempting TOLAC will limit the patient’s ability to exercise their right to give informed consent and informed refusal. We do, however, thank ACOG for their continued support of TOLAC for people with a prior low-vertical incision.

The International Cesarean Awareness Network supports a person’s right to choose their preferred birth location and mode, and to choose who will provide their prenatal and delivery care. We believe it is imperative that the public becomes educated on their rights and options in childbirth, and on the risks involved with each option. A person cannot give true informed consent without first being given unbiased counseling regarding the risks and benefits of all options. Patients should be their own best advocate, and that involves researching and studying childbirth, and human rights in the medical system. We greatly appreciate the time ACOG put into updating their VBAC guidelines, and we are extremely hopeful that this information will provide greater access to evidence-based care for most people. We challenge ACOG to reconsider its endorsement of web-based VBAC calculators by evaluating the effect it will have on all people considering a TOLAC, especially People of Color and People of Size, to publicly restate their previous clarification on VBA2C- that “most women with two previous low-transverse cesarean deliveries are candidates for and should be offered TOLAC and counseled based on the combination of individual factors that affect their risk and probability of achieving a successful VBAC”, and to reconsider their stance against planned VBAC for those with special scars.

International Cesarean Awareness Network

Board of Directors

Lindsey Seger, President

Justen Alexander, Vice President

Samantha Wall, Secretary

Ann Marie Walsh, Chapter Director

Brianna Barker, Advocacy Director

https://www.acog.org/Resources-And-Publications/Obstetric-Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery

https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Ethics/Refusal-of-Medically-Recommended-Treatment-During-Pregnancy

https://www.ican-online.org/huntsville/2016/12/15/should-mothers-be-denied-option-of-vba2c-acog-clarifies/

https://www.acog.org/Patients/FAQs/Vaginal-Birth-After-Cesarean-Delivery-Deciding-on-a-Trial-of-Labor-After-Cesarean-Delivery

American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins-Obstetrics, & Grobman, W., MD. (2017). Vaginal Birth After Cesarean Delivery. Clinical Management Guidelines for Obstetrician-Gynecologists, 130(5), practice bulletin 184.

Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:693–711.

Refusal of medically recommended treatment during pregnancy. Committee Opinion No. 664. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e175–82.

Vaginal Birth After Cesarean Delivery – Deciding on a Trial of Labor After Cesarean Delivery. Frequently asked questions. Labor, delivery, and postpartum care. FAQ070. American College of Obstetricians and Gynecologists. https://www.acog.org/Patients/FAQs/Vaginal-Birth-After-Cesarean-Delivery-Deciding-on-a-Trial-of-Labor-After-Cesarean-Delivery. 2011 August.

“ICAN of Huntsville » Should Mothers Be Denied Option of VBA2C? ACOG Clarifies.” ICAN of Huntsville, ICAN of Huntsville Leadership, 15 Dec. 2016, www.ican-online.org/huntsville/2016/12/15/should-mothers-be-denied-option-of-vba2c-acog-clarifies/.

Should a Woman’s Ethnicity Decrease Her Access to Birth Mode Options?

January 12, 2017 by Vice President

If you have ever wondered what the leadership of your local ICAN chapter does, the following is a good example of our work to promote ICAN’s mission of improving maternal-child health by reducing unnecessary cesareans through education, providing support for cesarean recovery, and advocating for vaginal birth after cesarean (VBAC).

Recently, in September 2016, an ICAN of Huntsville co-leader was made aware of a situation where a local office had interpreted ACOG’s Practice Bulletin 115 in such a way that did not favor offering a trial of labor after cesarean(s) to women of Non-White ethnicity. The table labeled “Selected Clinical Factors Associated With Trial of Labor after Previous Cesarean Delivery Success”, from ACOG’s Practice Bulletin 115, was cited as the source for the office’s decision. After several days of research, our team discovered many studies citing unknown sources for the decreased chance of VBAC success associated with being of Non-White ethnicity, and even some that cited possible “Physician Bias” as the source. Since we could not get definitive answers through published peer-reviewed research, the aforementioned co-leader contacted ACOG directly, in order to gain clarification on the intended use of the table titled “Selected Clinical Factors Associated With Trial of Labor after Previous Cesarean Delivery Success”. We would like to share their response with you, in order to ensure maternity care consumers are fully informed about Practice Bulletin 115.

The question our co-leader submitted to ACOG on September 7, 2016, is provided below:

Dear ACOG Medical Library,

My name is . . . , and I spoke with one of the Medical Librarians this afternoon. This email is in regards to an ICAN of Huntsville chapter member who is . . . pregnant and was told she would not be “allowed” a trial of labor at this practice because of her race and having two prior cesareans. Due to her situation, and that of one of the ICAN co-leaders of our chapter, the practice has created a new policy stating all . . . doctors MUST sign off on a trial of labor after two cesareans, before a mother is “allowed” to have a trial of labor with the assistance of a doctor from that practice. We are writing to get clarification on Practice Bulletin 115, since it was used as the reason for denying this woman access to a TOLA2C. This office has some form of “check-list” that is being used to determine ideal candidates for VBAC and VBA2C. Two of the items on this list are 1. Number of prior cesareans, and 2. Non-white ethnicity.

Were the tables showing decreased success rates for certain subsets meant to reduce access to TOLAC or TOLA2C to those subsets of women?

This paragraph lists factors that negatively impact likelihood of VBAC, but does not list “non-white ethnicity”.

“Most published series of women attempting TOLAC have demonstrated a probability of VBAC of 60–80% (4, 5, 12–14, 22, 23). However, the chance of VBAC for an individual varies based on demographic and obstetric characteristics (see box). For example, women whose first cesarean delivery was performed for an arrest of labor disorder are less likely than those whose first cesarean delivery was for a nonrecurring indication (eg, breech presentation) to succeed in their attempt at VBAC (37–43). Similarly, there is consistent evidence that women who undergo labor induction or augmentation are less likely to have VBAC when compared with those at the same gestational age with spontaneous labor without augmentation (44–47). Other factors that negatively influence the likelihood of VBAC include increasing maternal age, high body mass index, high birth weight, and advanced gestational age at delivery (44, 48–54). A shorter interdelivery interval and the presence of preeclampsia at the time of delivery also have been associated with a reduced chance of achieving VBAC (55, 56). Conversely, women who have had a prior vaginal delivery are more likely than those who have not to succeed in their TOLAC (44, 57).”

But, the box labeled “Selected Clinical Factors Associated With Trial of Labor after Previous Cesarean Delivery Success” DOES list “non-white ethnicity” as a factor leading to a decreased probability of VBAC success. What evidence led you to add “non-white ethnicity” to that list, and why was it not mentioned in the text? Were these meant to be items to counsel women on so they know their risks vs benefits, or were they meant to be exclusionary items used to decline access to TOLAC and TOLA2C?

If a woman seeking a TOLAC or TOLA2C is not an “ideal candidate” based on information in the above paragraph from PB115, should she still receive full counseling on risks and benefits of both VBAC or VBA2C, and also ERC (elective repeat cesarean), and then be allowed to give her informed consent or refusal, regardless of physician recommendation?

On September 27, 2016, ACOG replied with the following:

Hello,

The Practice Bulletin described clinical and other characteristics associated with a vaginal birth among those undergoing a trial of labor so that patients and providers can have an informed and shared conversation about plans. The list, in general, and non-white race, specifically, was not intended to be used at a facility level to decide if trials of labor would be supported. In this regard, the document does not suggest a specific chance for vaginal delivery above or below which a trial of labor should be planned or prevented. While studies have associated non-white race with a decreased chance of vaginal delivery among women undertaking a trial of labor, ACOG does not support using race to exclude any women from the option of a trial of labor.

We continue to monitor VBAC and TOLAC studies and literature. If there are any changes to ACOG guidance, it will be published in the Green Journal. Please reach out anytime you have any questions- happy to move it through our experts.

Have a great day!

American College of Obstetricians and Gynecologists

Thankfully, ACOG was quick to respond with their intended interpretation of Practice Bulletin 115, in order to end any confusion that may have occurred. We are so grateful for ACOG’s willingness to respond to our questions and are hopeful it will help the women in this country have greater access to evidence-based care.

Sincerely,

ICAN of Huntsville Leadership Team

* For privacy reasons, names, personal information have been removed. ACOG has reviewed and approved of this blog post.

Please follow these links for more information from ACOG on VBAC:

You can contact ACOG at Practice@ACOG.org if you have any questions or concerns regarding a trial of labor after cesarean.

Should Mothers be Denied Option of VBA2C? ACOG Clarifies.

December 16, 2016 by Vice President

In September, a member of the ICAN of Huntsville leadership team encountered two situations within our local community about Trial of Labor after Cesarean (TOLAC) access that she felt needed additional clarification. On behalf of ICAN of Huntsville, she contacted the American Congress of Obstetricians and Gynecologists (ACOG). The original email included two questions, regarding two separate, but extremely important issues. In the following paragraphs, we will share our question, and also ACOG’s response. At a later date, we will be sharing the other question, along with ACOG’s response.

One of the questions posed to ACOG involved a local OB/GYN office that had interpreted ACOG’s Practice Bulletin 115 in a way that did not favor offering women access to a trial of labor after two cesareans. The wording of this Practice Bulletin is written in a way that could be confusing for some. The following email was sent to ACOG regarding clarification on a woman’s access to a trial of labor after two cesareans:

Dear ACOG Medical Library,

My name is …, and I spoke with one of the Medical Librarians this afternoon. This email is in regards to an ICAN of Huntsville chapter member … [this part will be discussed in Part 2 of our blog].

We would also like to have clarification on the wording of these two sentences from PB 115 regarding access to VBAC and VBA2C:

“Given the overall data, it is reasonable to consider women with two previous low transverse cesarean deliveries to be candidates for TOLAC, and to counsel them based on the combination of other factors that affect their probability of achieving a successful VBAC.”

“Most women with one previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about VBAC and offered TOLAC. “

In #1, the phrase “reasonable to consider” is used, and in #2, “most”, “are candidates”, and “should be counseled” are used. The office in question is using the difference in terminology to say ACOG only recommends physicians “consider” counseling women on VBA2C, but that they don’t have to mention it at all since it says “consider” vs “should be counseled”. What is the true meaning of the difference in terminology in these sentences? Should all women, with one or two low transverse incisions, be counseled on the benefits and risks of VBAC or VBA2C?

We would appreciate clarification on these issues, as the new policy for the office in question is going to affect many women in our community, and cause an even greater lack of access to care, especially for women of Non-White ethnicity, and VBA2C patients. Thank you for your help!

Sincerely,

ICAN of Huntsville Leadership Team

The difference in wording between the recommendations for VBAC and VBA2C could be interpreted by some as the practice bulletin saying the physician should only “consider” offering a trial of labor to women that have had two prior cesareans. The issue here was surrounding the usage of “consider” for TOLA2C, versus “should be” for TOLAC. We received a formal response on December 5th, following a discussion at the ACOG Practice Bulletin Committee meeting in November. Here is their response:

We reviewed your email at the November committee meeting. The committee members were very engaged in the conversation.

The Practice Bulletin was written to describe clinical and other characteristics associated with a vaginal birth among those undergoing a trial of labor. The intention was not to create confusion among practices regarding TOLAC or TOLA2C. The Practice Bulletin was crafted so that patients and physicians can have an informed and shared conversation about delivery plans. Most women with two previous low-transverse cesarean deliveries are candidates for and should be offered TOLAC and counseled based on the combination of individual factors that affect their risk and probability of achieving a successful VBAC.

Although we cannot do anything to change the language of this published document right now, we will definitely consider your email in any possible future revision of the Practice Bulletin.

American College of Obstetricians and Gynecologists

Per the above email sent to ICAN of Huntsville from ACOG staff, ACOG has clarified the wording in Practice Bulletin 115 for us by saying “most women with two previous low-transverse cesarean deliveries are candidates for and should be offered” a trial of labor and counseled appropriately on their individual potential risks. In short, for most women, after two previous low-transverse cesarean deliveries, access to delivery mode options should be no different than those women with one prior low-transverse cesarean delivery. We are so thankful to ACOG for clarifying this extremely important matter for our community. We are especially grateful that the practice bulletin committee members were engaged in the conversation and that they appreciated the seriousness of this issue. We are hopeful that the clarification the Practice Bulletin Committee has provided will increase access to evidence-based care, open dialogue, and shared decision making between care providers and patients. We are including Practice Bulletin 115 here: ACOG-VBAC

ICAN of Huntsville Leadership Team

*For privacy reasons, names and personal information have been removed.

Please click the following links for more information from ACOG on VBAC:

You can contact ACOG at Practice@ACOG.org if you have any questions or concerns regarding a trial of labor after cesarean.

Antibiotics Before Cesarean?

August 26, 2010 by blog 3 Comments

ACOG has issued recommendations that all women scheduled for cesareans be given antibiotics an hour beforehand and “emergent cases” should be started on antibiotics “as soon as possible.” According to Medpage Today:

Although antimicrobial prophylaxis to reduce postoperative maternal infections is already common practice for C-sections, clinicians need to stop waiting until after clamping the umbilical cord to administer them, according to the statement.

According to ACOG, research shows the following benefits:

* Fewer wound infections (0.6% when given two hours before skin incision versus 1.4% within three hours after incision)
* Significantly lower endometriosis rates (1% when given 15 to 60 minutes before C-section versus 5% after clamping in one trial and 7.8% when given at incision versus 14.8% after clamping in another)
* Significantly lower total postoperative infection rates (4.5% when given 15 to 60 minutes before C-section versus 11.5% after clamping)

Although an additional small randomized trial showed no significant maternal benefit from preoperative antibiotics, it showed no harm.

The statement published by ACOG dismisses concerns about detrimental effects on the baby if antibiotics are given before the umbilical cord is clamped:

Concerns that exposure could have a negative impact on the baby by masking positive bacterial culture results or leading to antibiotic resistant infections are unfounded, the committee concluded.

Randomized trials have shown no difference in rates of neonatal sepsis overall or from resistant organisms or in rate of admission to a neonatal intensive care unit, although all were underpowered to analyze these secondary outcome measures.

In light of these recommendations, birthing women should discuss their concerns and wishes regarding antibiotics given before a cesarean with their care providers.

Mother-sized Activism at Work in Iowa

August 9, 2010 by blog 6 Comments

Have you contacted your local hospitals and OB providers yet to ask about their practices in light of ACOG’s new VBAC recommendations?

Stephanie Windgardner in Sioux City, Iowa has. She shares:

My [OB] office previously stated the ACOG guidelines as why I could not try for a VBAC with my next child. Since the guidelines changed, I emailed to see if their standard of care was going to change along with them. Here is my email to them, their reply, and after what they replied, I felt the need to reply back to them- just want to get awareness out there that in my city (Sioux City, Iowa) and the tri-state area of Nebraska, Iowa, and South Dakota, that there are two hospitals, and two OB offices, none of which will “allow” or attend VBAC. I will be going to Omaha or Sioux Falls when I have my next child likely, so that I can have a chance at VBAC! This is a good hour and a half drive for me.

Here is part of Stephanie’s first email to her OB’s office:

After a lot of research and other opinions, I have decided I want to pursue a VBAC with my next child. I am not pregnant yet, but my husband and I plan to begin trying to conceive early next year.

After the release recently of the new ACOG guidelines, I was curious if the physicians in your office would be taking on VBAC patients. I see on your website your practice seems to follow all of the ACOG guidelines, and refer to them for more information.

I really appreciate any information you can give me. If VBAC is not an option…then I want to seek out other options before my yearly check up this fall, so that I can become familiar with a new doctor.

Thank you for your time.

Stephanie Winegardner

And here is her OB office’s reply:

Good afternoon Stephanie, we hope your having a great day. I wanted to let you know that our office and the two hospitals in town do not do VBAC’s. I am very sorry that you had a horrible experience with your last child and we would be more then glad to see you but you would have to have another c-section.

If we can be of any more help, please let us know.

Thanks

Unsatisfied with this response, Stephanie wrote one more email, asking her OB’s office why they won’t be changing their standard of care in line with ACOG’s new guidelines. As of today, she has not heard anything back.

Kudos to Stephanie for taking a mother-sized step toward better maternity care in he community. If you have contacted your hospitals or OB practices since ACOG’s recommendations, share your stories with us!

To find out what hospital policies are in your area, check ICAN’s VBAC Policy Database.