The American College of Obstetricians and Gynecologists has loosened up its recommendations regarding women who've previously given birth via ceserean section but want to deliver vaginally the next time around.
As the WSJ reports, now women who have already had two C-sections and those who are pregnant with twins following a C-section delivery are candidates for so-called VBACs, so long as their operations included a low-on-the-abdomen, horizontal incision.
While ACOG still recommends that women attempt vaginal delivery only if they're in a facility that has "staff immediately available to provide emergency care," the group says that if those resources aren't available the woman should "be allowed to accept increased levels of risk" if they are informed about the potential dangers and availability of facilities and staff. There are risks associated with all variations of childbirth, including vaginal birth and C-section.
Will the guidelines do anything to budge the C-section rate, which stood at more than 31% in 2007, according to ACOG? After the last set of guidelines were released, that same "immediately available" language led some hospitals to refuse to allow women with a history of C-section to make an attempt at delivering vaginally by allowing labor to progress.
William Grobman, a co-author of the guidelines and an associate professor of obstetrics and gynecology at Northwestern University's medical school, says that's the wrong question to ask. "We are culturally very focused on outcomes -- the C-section rate, the VBAC rate," he tells the Health Blog. "But we aren't trying to achieve arbitrary rates. There's as much focus on process as there is on outcomes," he says, which is why the guidelines emphasize "autonomy, shared decisionmaking and the provision of information."
If there were a metric to track, says Grobman, it would be the percentage of medical charts that show "there was a clear discussion about the risks and benefits" of an attempt at labor by women with a history of C-section.
He says it's not clear how many women have wanted a VBAC but have been unable to get it due to hospital or physician policy, but that there were enough people speaking out at a recent NIH consensus conference on the topic to suggest "it's a problem of some importance."
Grobman says the new clinical guidelines won't be "the start and finish" of a shift in physician behavior and hospital policies, since those things are also shaped by personal experience and professional liability concerns. "That being said, there's no doubt the guidelines are an important foundation," he says.