Thursday, March 11, 2010

NIH VBAC recommendations

I was thrilled to hear that the NIH Consensus Conference on VBAC recommended increasing access to VBAC! Here is a link to the preliminary draft of the consensus statement; the final statement will come out in a few weeks. Here are the conclusions of the conference (emphasis mine):
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.
I anticipate a flood of articles and blogs in response to this statement. Please post links in the comments section to any you find interesting. In the meantime, here are two that I enjoyed reading:

Draft NIH Consensus Statement Released on Vaginal Birth After Cesarean Delivery by Laurie Barclay, MD from Medscape News

Panel urges more choice in birth after C-section from the LA Times

New links:
Once a Cesarean, Rarely a Choice at RH Reality Check by Gina Crosley-Corcoran, aka The Feminist Breeder 

Over at The Unnecesarean, Courtroom Mama commented how the NIH panel was unwilling to confirm a pregnant woman's right to refuse surgery--the right that every other adult has without question. She included a transcript from Susan Jenkins' questioning the panel. Be sure to read this.

Amy Romano at Science & Sensibility asks: Do women need to know the uterine rupture rate to make informed choices about VBAC?

Dr. Fischbein, an OB/GYN in southern California, weighs in on his experience attending the conference.

PinkyRN, a L&D nurse currently taking some time off and going to midwifery school, doesn't think that access to VBAC will actually increase.

WebMD: Let More Women Give Labor a Try, Experts Urge

A 7-time VBAC mama calls for VBAC mamas to unite

Dou-la-la thinks the NIH VBAC Conference could have used more shrimp (read to find out what she means!)

And lots more links at Bellies and Babies: The First Cut is The...

Nicholas Fogelson, aka Academic OB/GYN, argues that the problem is liability, and that liability is not rational. So no matter how rational all arguments for VBAC all, liability ends up winning anyway. He proposes micro tort-reform as a potential solution to the VBAC liability issue.
The problem is that liability is not rational.  Its based predominantly on completely irrational ideas that every bad outcome is somebody’s fault and that compensation must somehow be made.

The discussion at NIH is very rational, as are most of the arguments being made for VBAC availability.  The problem is that our history of lawsuits for uterine ruptures is completely irrational, as is the current situation with liability insurers.  The sad but simple reality is that many doctors and hospitals can’t provide VBAC because their liability carriers refuse to cover them if they do them, and without liability coverage medicine cannot be practiced in this country.  This is irrational, but it is real.

On one side we have lots of very rational arguments we can all get around, and on the other we have a completely irrational but very real issue that is the actual cause of the problem.
He proposes a national, uniform informed consent document that is federally protected. Really interesting idea. While I think it's not fair that someone would have to sign this kind of form for a VBAC and not for every other possible labor complication, I recognize that it's pragmatic.

The Well-Rounded Mama argued why VBAC bans are a violation of human rights

11 comments:

  1. This is wonderful news!

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  2. hi rixa -
    love your blog and am VERY interested in hearing more about this topic as i hope to try for a vbac. anyways, just wanted to let you know that your link to the draft NIH statement by Dr Barclay didn't work for me.

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  3. Sometimes you have to register with Medscape (free registration) to view their articles. This morning I didn't have to log in to view it, but now I do. Strange!

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  4. ps--if you google the title of her article and click on the first link that shows up, it doesn't make you log in first (at least not for me on this computer).

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  5. Thanks so much for this post and for the links. I have been anxiously awaiting news.

    Unfortunately, I feel more confused than ever and I don't have much time to make a decision. I'm 35 weeks pregnant. I had a c-section 18 months ago. I had pre-e, which lead to an induction at 38 weeks, which after 24 hours of drugs and contractions failed (I hadn't even dilated a single centimeter - I was closed tight), which lead to a c-section. Soon after the c-section I developed HELLP and had severe hemorrhaging that required several transfusions. So it was pretty scary to me.

    Anyway, now I am 35 weeks. I don't have pre-e at this point (knock on wood) but I do have PIH. I'm on methydopa to control my bps. My doctor scheduled a c-section for 39 weeks. I've been having a lot of contractions, so it is possible my little girl wants to make an early appearance. If I do go into labor on my own before 39 weeks the doctor left it up to me if I wanted to try for a vaginal birth or go right to c-section.

    I don't know what to do!! I was hoping the NIH press releases would have some magical answers. I'm terrified of another failed attempt at a vaginal birth and what that could lead to... but who wants major surgery either?? I almost wish my doctor would take a clear stand, but I appreciate that she is leaving it up to me.

    Sorry to leave such a long comment. But how would you advise someone in my shoes? I've recently developed pitting edema on my hands and swelling in my face, but my bps are holding steady at around 140/90 (with methydopa).

    --Scared and Confused Mama

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  6. Wow, tough situation for you! How would I react to your situation? Well, I would not agree to the arbitrary 39-week deadline for going into labor. There's no reason to say a VBAC is okay before 39 weeks, but after 39 weeks you have to have a c-section. Unless your situation with PIH is so dire that it necessitates an early delivery (whether via induction or c/s), your best bet is to wait for labor to begin on its own. I see no reasons why you'd be unable to give birth vaginally per se--you had a classic failed induction. Of course, that induction might have been necessary at the time--but still, your body wasn't ready to give birth.

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  7. Thanks so much for the response! I don't know why 39 weeks was given as "the time" to deliver. I do know my doctor said I couldn't do an induction, do to the previous section. So I have to go into labor naturally or not at all.

    I'm hoping things hold steady, health-wise, for at least a few more week!

    Is there any info out there on VBAC risk factors - like hypertension? I'd love to know if my high blood pressure increases my risks associated with VBAC - but I don't think such a study exists.

    Thanks again for your response - and for your blog!
    --Scared and Confused Mama

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  8. Scared and Confused Mama - Please ask your doc why the plan for 39 weeks, and find out exactly why that is the recommendation for your specific case. There is some recent evidence that PIH and mild pre-e has fewer maternal and infant complications if delivery is planned earlier, generally 37 weeks and your provider may well be thinking of this. I know this is a scary and confusing time, but it's better to get advice from the providers who know your actual situation than more general sources. Call and ask for an extended appt so you can get your questions addressed more appropriately. If you aren't satisfied with what your provider says, than get a second opinion, but please get specific medical advice from someone who has access to your specific history and situation.

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  9. On a more general note - I'm glad that the VBAC issue at least is getting more national attention due to the NIH. I'm also not a fan of the VBAC consent including giving up your ability to sue. In general, waivers of liability haven't held up anyway.
    I know there have been specific cases where suits have been successful despite no evidence of malpractice and adequate informed consent, but I think those cases were fairly rare. At least in my state, many of the VBAC suits have involved medical care way outside accepted standards (the one I read most recently that involved a large plaintiff award involved a doctor not arriving to the hospital until multiple hours and multiple calls from nursing concerned about the fetal heart rate tracing.) I think the fear of unwarranted litigation is out of proportion to how likely it is (where someone sues despite adequate medical care and good informed consent.) I don't know how to change that fear, however.

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  10. I got into a big debate with a guy on facebook about this in a link to the story NPR did on VBACs. He was saying that people reporting on VBACs are being "biased" and saying that c/s are inherently bad birth experiences and making people who have had c/s feel bad. But I didn't let that stand! This is a great step towards better birth policy even if there are (serious) problems in the statement.

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  11. Wow, funny reading that I did not think that VBAC attitudes would change. The place I am at now does a lot of VBACS. I just put together the statistics for the year 2012 for which docs did how many VBACS. Looks like some regulatory agency is looking at those numbers.

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