Saturday, July 31, 2010

VBAC statement from RANZCOG

A new College Statement on Planned Vaginal Birth after Caesarean Section (Trial of Labour) has been issued (July 2010) by the College of O's and G's, RANZCOG. 

Midwives who are monitoring the current state of maternity reform in Australia are aware of increasing pressure on both women and midwives to comply with RANZCOG's professional guidelines.

In this statement RANZCOG has summarised its statement of risks to mother and baby, of both 'Trial of labour' and repeat elective caesarean surgery, and its recommended plans of care. 

Recently I was with a woman who was planning vbac at home in my care, as an obstetrician was reviewing my client whose pregnancy had progressed to 11 days past 40 weeks.  The doctor listened with empathy as the young woman explained that she felt severely traumatised by the caesarean birth after induction of labour for her first baby.  The doctor considered that a trial of labour was a good plan, but was adamant in objecting to the plan for home birth. 

The doctor's explanation of risk was:
"One in 200 women who attempt vbac will experience uterine rupture.
"One in 10 of those who have uterine rupture will experience serious consequences - either serious (maternal) haemorrhage or still birth."

These risk figures are consistent with the references quoted in the College Statement on Planned VBAC.  Multiply 200X10, and according to this doctor there is a risk of 1 in 2000 that an attempted vbac will have an adverse outcome.

The doctor did not mention to my client that elective repeat caesarean increases the risk to her, particularly in her chance of serious haemorrhage, leading to hysterectomy, and even death.  Her risk of abnormal placenta implantation (previa and accreta) was increased in subsequent pregnancies.

Pregnant women are often faced with many risk calculations.  In early pregnancy when they have screening for Down Syndrome they are greeted with risk ratios that would be more familiar to bookmakers than to most mothers-to-be.   Many feel bullied by the use of statistical reckonings that seem to have been pulled out of thin air.

Here are a few other statistics to consider:
Despite impressive advances in technology and treatments Australian parents experience the tragedy of loss of a baby in approximately 10 in 1000, or 1 in 100 births (perinatal mortality rate in 2006, from the National Perinatal Statistics Unit).

The rate of babies born with Apgar scores less than 7 at 5 minutes in 1.5 in 100 births or 15 in 1000 births (PDCU 2007) in Victoria.

Women giving birth in hospitals have approximately a 30%, or 30 in 100 chance of caesarean birth.  Women having their FIRST baby in certain private hospitals have a 50%, or 50 in 100 chance of caesarean birth. 

Comparing these risks with the 1 in 2000 risk of adverse outcomes for vbac makes vbac sound relatively safe.

Midwives advising women who are intending to give birth physiologically will encourage minimal interference as labour establishes and progresses.  If their plan is to go to hospital for the birth, the transfer will usually occur after the labour has established.  Key features of midwife care for planned vbac include:
.trust: the woman and midwife establish a partnership based on reciprocity and trust
.the woman calls the midwife to be with her at her home when her labour has established
.the midwife carries out basic assessments of fetal and maternal wellbeing, and progress, in an unobtrusive way
.the woman is able to proceed to home birth vbac, or to make an informed decision to go to hospital when and if needed

The RANZCOG College Statement sets out advice on TOL (trial of labour), including:
.admission to hospital relatively early in labour
.intensive maternal and fetal surveillance intrapartum, including continuous electronic fetal monitoring.

Clearly there is a huge difference in the way independent midwives and obstetricians approach vbac.   There is no evidence of poor or worse outcomes when women plan vbac at home.  Some go to hospital; some proceed to vaginal births in hospital and some proceed to another caesarean birth.

1 comment:

  1. Midwives are not alone in our expression of concern over the escalating rate of caesarean surgery, and the declining rates of VBAC.
    The following statement is from Medscape

    Could We Increase Rates of Vaginal Birth After Cesarean? ACOG Weighs In

    Andrew M. Kaunitz, MD
    "Hello. I'm Andrew Kaunitz, Professor and Associate Chairman in the OB/GYN Department, University of Florida College of Medicine in Jacksonville. Today, I'd like to discuss increasing rates of vaginal births after cesarean. ACOG [American College of Obstetrics and Gynecologists] weighs in.

    "Almost one third of births to US women are currently by cesarean delivery. Over the last 10 to 15 years, many obstetricians as well as hospitals have become reluctant to offer women with a prior cesarean a trial of labor, with the percentage of vaginal births among women with prior cesareans dropping from 24% in 1999 to less than 9% in 2006. The declines in vaginal births after a cesarean delivery (or VBAC) represent a major factor contributing to the growth of cesareans in this country.

    "In stating that hospitals offering a trial of labor to women following prior cesarean should have a surgical and anesthesia team immediately available, and I quote, "to perform an emergency cesarean," ACOG's 1999 guidelines likely contributed to a rapid decline in trials of labor and VBACs, pushing overall cesarean delivery rates higher in US women. In March of 2010, the National Institutes of Health convened an expert panel to examine the decline in VBACs.[1] This panel concluded that VBAC is safe for many women following prior cesareans and encouraged ACOG to revisit its recommendations.

    "Filled with a wealth of clinical detail and references regarding trial of labor and vaginal birth after cesarean, ACOG's new guidelines are now available as a practice bulletin on the organization's Website and also in the August 2010 issue of the organization's Green Journal.[2] The bulletin continues to recommend that trials of labor be offered in facilities with staff members immediately available to provide emergency care. ACOG, however, then goes on to state, and I quote, "When resources for immediate cesarean delivery are not available, the College recommends that healthcare providers and patients considering trial of labor discuss the hospital's resources and availability of obstetrics, pediatric, anesthetic and operating room staffs."

    "Our current rate of cesarean delivery clearly is excessive. And ACOG's updated practice bulletin is a step in the right direction. I am concerned, however, that these revised guidelines may do little to increase VBACs or lower our currently sky high rate of cesarean births. Thank you."


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