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