ACOG Issues Less Restrictive VBAC Guidelines

• 8/10/2010
• Author: Audrie Bretl Roelf
• Category: Benchmark Blog
• 6091 Views
• 0 Comments
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Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery—including for some women who have had two previous cesareans—according to guidelines released by The American College of Obstetricians and Gynecologists (ACOG).

Note: The Joint Commission’s Perinatal Care Core Measure Set, part of the National Quality Core Measures, includes the following measures:
• Elective delivery
• Cesarean section
• Antenatal steroids
• Health care–associated bloodstream infections in newborns
• Exclusive breast milk feeding
• This measure set is now available for selection for hospitals beginning with April 1, 2010, discharges.

ACOG states that, in keeping with past recommendations, most women with one previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about VBAC and offered a trial of labor after cesarean (TOLAC). In addition, ACOG guidelines now say that women with two previous low-transverse cesarean incisions, women carrying twins, and women with an unknown type of uterine scar are considered appropriate candidates for a TOLAC.

Both repeat cesarean and a TOLAC carry risks including maternal hemorrhage, infection, operative injury, blood clots, hysterectomy, and death. Most maternal injury that occurs during a TOLAC happens when a repeat cesarean becomes necessary after the TOLAC fails. A successful VBAC has fewer complications than an elective repeat cesarean while a failed TOLAC has more complications than an elective repeat cesarean.

According to ACOG, the risk of uterine rupture during a TOLAC is low—between 0.5% and 0.9%—but if it occurs, it is an emergency situation. A uterine rupture can cause serious injury to a mother and her baby. ACOG maintains that a TOLAC is most safely undertaken where staff can immediately provide an emergency cesarean, but recognizes that such resources may not be universally available.

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.

ACOG states that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC. On the other hand, if, during prenatal care, a physician is uncomfortable with a patient's desire to undergo VBAC, it is appropriate to refer her to another physician or center.

Practice Bulletin #115, "Vaginal Birth after Previous Cesarean Delivery," is published in the August 2010 issue of Obstetrics & Gynecology.