The American Congress of Obstetricians and Gynecologists has issued revised guidelines regarding when to offer a woman a vaginal birth when she had previously delivered a baby via cesarean section, aka VBAC. Nationally, less than one in ten women undergo VBAC; the rest undergo an elective c-section for births after previously having a c-section. Trial of labor after cesarean (TOLAC) is the planned attempt of VBAC. While the revised guidelines require the physician to discuss each procedure’s risks and benefits with the patient, there are subtle changes in the wording of the guidelines that patients will not notice that could impact the safety of the mother and baby.
The ACOG guideline states as follows in part: “Women and their physicians may still make a plan for a TOLAC in situations where there may not be ‘immediately available’ staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk. ‘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. And those hospitals that lack ‘immediately available’ staff should develop a clear process for gathering them quickly…”
VBAC carries a recognized but rare risk of uterine rupture which is a serious complication for the mother and the child. Uterine rupture requires emergency surgery and can threaten the life of the mother and the child. ACOG previously recommended that VBAC only occur in hospitals with emergency anesthesiologists and surgeons immediately available to deal with uterine rupture. In this revised guideline the language has changed, but what about the risks for the mother and the baby? Have those changed or is this relaxed new guideline a result of pressure on hospitals and physicians to allow this procedure to be performed in hospitals where trained anesthesiologists and surgeons are not physically present in the hospital. Are parents being told about this subtle but important change? How soon can the anesthesiologist get to the hospital? Minutes matter for both baby and mother in these rare but extremely serious circumstances.
ACOG attributes this change to “the onerous medical liability climate for ob-gyns”. However, there is only a claim for liability when a mother or baby are injured due to the negligence of the physician or hospital staff. In fact, if a physician adequately explains the risk of uterine rupture in VBAC including the alternatives and her delivery is appropriately managed then the physician is not liable for any uterine rupture that is beyond his or her control. What this new relaxed guideline does is allow hospitals without anesthesiologists and surgeons in the hospital at all times to perform VBAC. The question is whether families understand the risk that this provides and whether they are being allowed to choose to go where surgeons and anesthesia teams are readily available in the hospital. The goal of ACOG should be to educate physicians about when VBAC is clinically appropriate and also teach them how to counsel patients about their options. Of course parents should be completely informed of their options and the risks associated with those options, including whether the anesthesiologist and surgeon are immediately available. All of the risks need to be discussed with the patient or they have not been provided a fair chance to make the best choice for their family. Even if that means the safest choice for baby and mom is to deliver at another hospital.