ACOG Releases New Guidance Aimed at Making VBAC Available to More Women

October 24, 2017

Washington, DC—Vaginal birth after cesarean delivery (VBAC) should be attempted at maternal care facilities that typically manage uncomplicated births if they are capable of performing emergency deliveries, according to updated guidance from the American College of Obstetricians and Gynecologists (ACOG).

Currently, women who attempt trial of labor after cesarean delivery (TOLAC) have a 60 to 80 percent success rate of achieving a vaginal birth. The latest Practice Bulletin states that VBAC allows women to avoid major abdominal surgery and lowers their risk of hemorrhage, blood clots and infection. It also shortens the recovery period and reduces women’s risk of experiencing maternal morbidity or mortality during delivery in a future pregnancy due to repeated C-sections.

“Despite a 23 percent increase in VBACs from 1985 to 1996, that number has since plummeted as the cesarean delivery rate has continued to trend upward,” said Mark Turrentine, MD, chair of ACOG’s Committee on Practice Bulletins-Obstetrics. “This is the opposite of what we want to see happening, and it’s because there is still a great deal of misunderstanding regarding the safety of TOLAC and VBAC and a reticence to consider this a viable option due to medical liability concerns.”

In 2010, ACOG supported VBAC as a safe and suitable choice for women who have had a prior cesarean delivery and are appropriate candidates, including for some who have had two previous cesareans. Achieving a vaginal birth depends on individual circumstances, and the decision to attempt trial of labor should be made through shared decision-making between the patient and the ob-gyn.

“The best circumstance for a woman to labor after having had a prior C-section is when the balance of risks and chances of success are acceptable to both the patient and the physician, and that will be different in every case,” said Turrentine. “There are certain conditions that can make VBAC less likely if TOLAC is attempted, including advanced maternal age, a high body mass index, a high birth weight and a previous C-section that resulted because the cervix failed to dilate.”   

There can be a risk of uterine rupture and other complications, therefore home birth is contraindicated for all women undergoing TOLAC. ACOG recommends TOLAC and VBAC only be attempted at Level I facilities or higher. This ensures that emergency care is available if the life of the mother or fetus are in jeopardy and an emergency C-section needs to be performed.

ACOG and the Society for Maternal-Fetal Medicine developed uniform designations for maternal care facilities—from a “birth center” to a “Level IV” regional facility equipped to handle women with high-risk pregnancies. Level I facilities provide care to women who are expected to have an uncomplicated birth; however, they should have obstetric providers with privileges to perform emergency cesarean available to attend all deliveries.

“ACOG’s recommendation is not meant to increase restrictions but instead ensure all women who want to attempt to undergo labor after a cesarean are in the appropriate facility to achieve positive outcomes,” Turrentine said. “If the necessary resources aren’t available, obstetric care providers and patients need to discuss alternative options early in the course of antenatal care, including a transfer to another facility. However, this absolutely should not result in women having limited access to VBAC.”

The Practice Bulletin #184, “Vaginal Birth After Cesarean Delivery" will be published in the November issue of Obstetrics & Gynecology.

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Other recommendations issued in the November Obstetrics & Gynecology:

Committee Opinion #724, “Consumer Testing for Disease Risk”

With the increased emphasis on patient-driven health care and readily available access to patients through the internet and media, many genetic testing companies have begun to market directly to consumers. Direct-to-consumer genetic testing raises unique concerns and considerations, including limited knowledge among patients and health care providers of available genetic tests, difficulty in interpretation of genetic test results, lack of oversight of companies that offer genetic testing, and issues of privacy and confidentiality. When undergoing any direct-to-consumer genetic testing, the consumer should be apprised of risk from screening or susceptibility test results that can neither prove nor eliminate disease potential. Because ordering an appropriate genetic test and interpretation of genetic test results are complex, an obstetrician–gynecologist or other health care provider with knowledge of genetics should be involved in ordering and interpreting the results of any genetic test with medical implications. When an individual presents test results to a health care provider from a direct-to consumer genomic test that putatively assesses the risk of specific diseases, the patient should be referred to an obstetrician–gynecologist or other health care provider who is skilled in risk assessment for the diseases of interest and interpretation of genetic testing results in the context of the individual’s relevant medical and family history. Because of these considerations and in view of the fact that the interpretation of the results requires specific training and medical knowledge, direct-to-consumer genetic testing should be discouraged because of the potential harm of a misinterpreted or inaccurate result.

Committee Opinion #725, “Vaginal Seeding”

Vaginal seeding refers to the practice of inoculating a cotton gauze or a cotton swab with vaginal fluids to transfer the vaginal flora to the mouth, nose, or skin of a newborn infant. The intended purpose of vaginal seeding is to transfer maternal vaginal bacteria to the newborn. As the increase in the frequency of asthma, atopic disease, and immune disorders mirrors the increase in the rate of cesarean delivery, the theory of vaginal seeding is to allow for proper colonization of the fetal gut and, therefore, reduce the subsequent risk of asthma, atopic disease, and immune disorders. At this time, vaginal seeding should not be performed outside the context of an institutional review board-approved research protocol until adequate data regarding the safety and benefit of the process become available.

Practice Bulletin #185, “Pelvic Organ Prolapse”

Pelvic organ prolapse (POP) is a common, benign condition in women. For many women it can cause vaginal bulge and pressure, voiding dysfunction, defecatory dysfunction, and sexual dysfunction, which may adversely affect quality of life. Women in the United States have a 13% lifetime risk of undergoing surgery for POP. Although POP can occur in younger women, the peak incidence of POP symptoms is in women aged 70–79 years. Given the aging population in the United States, it is anticipated that by 2050 the number of women experiencing POP will increase by approximately 50%. The purpose of this joint document of the American College of Obstetricians and Gynecologists and the American Urogynecologic Society is to review information on the current understanding of POP in women and to outline guidelines for diagnosis and management that are consistent with the best available scientific evidence.

Practice Bulletin #186, “Long-Acting Reversible Contraception: Implants and Intrauterine Devices”

Intrauterine devices and contraceptive implants, also called long-acting reversible contraceptives (LARC), are themost effective reversible contraceptive methods. The major advantage of LARC compared with other reversible contraceptive methods is that they do not require ongoing effort on the part of the patient for long-term and effective use. In addition, after the device is removed, the return of fertility is rapid. The purpose of this Practice Bulletin is to provide information for appropriate patient selection and evidence-based recommendations for LARC initiation and management. The management of clinical challenges associated with LARC use is beyond the scope of this document and is addressed in Committee Opinion No. 672, Clinical Challenges of Long-Acting Reversible Contraceptive Methods.

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org