Guidelines
for Hospital VBAC Get Tougher
By: Claudia E. Villeneuve
“Now what?” That was my first thought
at the news that the Society of Gynecologists and Obstetricians
of Canada, SOGC, was revising their 1997 clinical practice
guidelines for VBAC or vaginal birth after caesarean for
the spring of 2004, the 60 th anniversary of the SOGC.
Overall the guidelines have never been very supportive
of intervention-free VBAC birth, and in fact, a VBAC with
an obstetrician can be one of the most intervention-full
birth situations there is. If one understands that a cascade
of obstetrical interventions can increase the chance of
needing a caesarean, one is left with the impression that
the guidelines are not so much concerned with helping women
achieve a VBAC but rather are concerned with setting the
stage for a caesarean. This is unfortunate because VBAC-hopeful
mothers actually need extraordinary amounts of emotional
support and reassurance that their bodies haven't forgotten
how to give birth vaginally. These VBAC guidelines cannot
prevent problems but only respond to them. They might even
create new problems that can only be solved with another
surgery. For ease of reference, the following list summarizes
the changes for vaginal birth after caesarean care in a
Canadian hospital:
Woman's Participation in her Care
From 1997 Guidelines: Respect for the woman's autonomy is of paramount importance.
Updated 2004 Guidelines: If there are no contraindications a woman should be
offered a VBAC.
Comment: Offering a VBAC to a “good candidate” is not giving women autonomy
over their care. In Canada today, there are women being refused the chance
of give birth vaginally after caesarean. Even if a woman is ready to accept
her share of the risks (the biggest by far), her doctor and nearby hospital
might refuse accepting theirs. An “elective” caesarean sometimes is the only
option they are offered.
Contraindication to VBAC
1997 – A list of 5 contraindications, or situations that should
preclude a VBAC, were listed.
2004 – A new contraindication is added: patient refusal to try a vaginal birth.
Comment: A woman refusing a VBAC is usually given an elective caesarean without
question. Why not? Well, it is easier to schedule the staff and resources for
a quick caesarean, than it is to “babysit” a normal VBAC labour. A woman refusing
a caesarean is usually severely criticized for allegedly putting her baby in
danger. There are no contraindications to an elective caesarean, by the way.
Not very fair.
Birth Location for VBAC
1997 – Every hospital/health center capable of providing an emergency
caesarean.
2004 – Only in a hospital where an immediate caesarean is available.
Comment: The change was from emergency to immediate, a subtle change but one
that disqualifies the majority of community hospitals. Many hospitals are not
VBAC-friendly or outright ban VBAC. In Canada , policy changes have made VBAC
acceptable only where 24-hour operating rooms are found. Ironically, hospitals
with part-time operating rooms can still do elective caesareans. Not very fair
either.
Use of Induction Drugs:
1997 - Safety of the use of prostaglandin gels on VBAC women is
not established. Oxytocin should be used after careful consideration.
2004 - Prostaglandin E1 has high risk of rupture, should not be used. Prostaglandin
E2 increases uterine rupture rates, therefore use in rare circumstances. Oxytocin
can be used.
Comment: Induction of labour should not have a place in VBAC labour. Some reasons
include: risk of uterine rupture, risk of needing a caesarean for failure to
progress, risk of needing a caesarean for maternal or fetal distress brought
on by the drug or the anesthesia that usually accompanies it, etc.
Continuous Electronic Fetal Monitoring:
1997 – EFM advised if induction and/or augmentation of labour is
used. Use intermittent otherwise.
2004 – Recommended for ALL women attempting a vaginal birth after caesarean.
Comment: Open any book on caesarean avoidance and you will find that overusing
the electronic fetal monitor has caused an increase in the caesarean rate.
It usually forces bed confinement on the woman's back, and makes the hospital
staff and the woman worry constantly and unnecessarily about the progress of
labour. Actually, EFM has not proven its usefulness over other methods, like
hand dopplers.
Twin Pregnancy
1997 - Twin vaginal birth is not contraindicated after one caesarean.
2004 – Multiple gestation (not just twins) is not a contraindication to VBAC.
Comment: If only this was always true in practice. M alpractice suits involving
VBACs have created a powerful motive for doctor bias, conscious or unconscious,
against VBAC and cast doubt over statements and policies dictating elective
cesareans. It is not only their medical opinion, then. Now add a multiple pregnancy
to the mix and you may have a guaranteed diagnosis for a required caesarean.
Breech After Caesarean
1997 - Breech vaginal birth is not contraindicated.
2004 - Breech caesarean birth has been adopted by the SOGC after the Hannah
study, and therefore a VBAC for a breech birth will be contraindicated.
Comment: The key flaw in the Hannah study is that women were randomly assigned
to planned cesarean section or planned vaginal birth, and only under obstetrician
care. The study did therefore not include women who were strongly motivated
to have a vaginal birth and had refused to be randomly selected for a caesarean;
and it did not include gentle birth choices that could greatly benefit the
breech baby's passage through the vagina such as waterbirth for weightlessness
and warmth, and midwifery.
Other situations
1997 – No mention of diabetes, scar layer closure, being overdue,
or spacing between pregnancies.
2004 – Neither is a contraindication for VBAC, but space between pregnancies
seems to be. A VBAC less than 24 months after the last caesarean requires counseling
for increased risk in uterine separation.
Comment: Most women with caesareans are told to limit the number of babies
they have because every consecutive caesarean surgery dramatically increases
the health risks for both. Women with caesareans are also told to space out
their pregnancies too or endure another surgery even if they don't want one.
If there is a reason to have a VBAC is to allow women autonomy over their family
size and their health.
If you wish to send a letter to Dr. Gerald
W. Stanimir, President of the SOGC, regarding the above guidelines,
send it to:
Daniel Morier, Public Education and Media
Relations Coordinator
Society of Obstetricians and Gynaecologists of Canada , SOGC
780, Echo Drive Ottawa ON K1S 5R7
(800) 561-2416 or (613) 730-4192 ext./poste 359
Fax / télécopieur: (613) 730-4314 Email: dmorier@sogc.com
Having a hospital VBAC is a personal challenge,
more than a physical one. Even these 2004 guidelines recommend
a devoted birth attendant to provide support. If you, after
consideration of your homebirth choices, decide to have a
hospital VBAC then convince yourself that you can do it alone
and that the hospital needs to give you the space you need.
Hire a midwife in hospital, get a doula also, borrow a birthing
ball, write a one-page birth plan, take caesarean avoidance
classes about avoiding obstetrical interventions, attend
VBAC support meetings, stay healthy, and trust your body
and your baby.
At last count (Journal of Obstetrics and
Gynecology of Canada, August 2004), the overall caesarean
rate had increased to 22.1%, the primary caesarean
rate increased to 16.3%, the elective repeat caesarean increased to
40.3% while the VBAC rate had decreased to 28.5%.
In a world where choosing an elective caesarean without medical
need is applauded as a time management skill, i.e. when People
Magazine reported the birth of Charlie Sheen and Denise
Richards' baby in March 2004, it is surprising that women
who wish to have a vaginal birth after caesarean would find
any obstacles at all. Reducing a woman's exposure to caesarean
surgery goes beyond the ideals of preserving the nature of
birth as something the woman does, not the surgeon. It is
a matter of reducing a woman's (and her baby's) exposure
to the immediate health risks of surgery, and the health
risks to her future reproductive health.
Article from Winter 2004 issue
of Birth Issues, published by ASAC in Edmonton .
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