VBAC Series: What Does ACOG Have to Say?

The American College of Obstetrics and Gynecology (ACOG) issued a practice bulletin in 1999 about Vaginal Birth After Cesarean.  Within this practice bulletin, providers were encouraged to counsel women regarding VBAC and the likelihood of their success, but that delivery should only occur in a setting where immediate emergency care can be offered.  While the first part of the recommendation is based on good scientific evidence, the second part of the recommendation is based solely on consensus and expert opinion. 

In 2010 a new practice bulletin was created, and this was reaffirmed in 2015.  The 2015 version starts by mentioning the large decrease in the number of women attempting a Trial of Labor after Cesarean (TOLAC).  In 1996 the number of VBACs reached 28.3% (that is the percent of women delivering vaginally after a prior cesarean), and now most sources put the VBAC rate around 10% nationally. 

Why the shift?  The ACOG bulletin states the increasing fear of uterine rupture and liability has led to the sharp decline.  However, they fail to mention their own statement about access to emergency care as part of the decline.  While there was a slow decline from 1996-1999, the decline steepened after the release of the 1999 practice bulletin.

In a 2007 paper in Birth journal, researchers called over 200 hospitals in their region, and found 30% had stopped offering VBACs based on the 1999 ACOG practice bulletin.  As a result access to VBAC has become far more limited in this area, and one could imagine this is also the case nationally. 

This report appears to have a great deal of information about VBAC and its safety, but I admit at 300+ pages, I have only begun to skim through it.  It also makes mention of this paper starting the decline of VBACs (check out the graph on page 12 of the report) in addition to the ACOG practice bulletin. 

The ACOG practice bulletin has MANY good points about VBAC and how the majority of women are good candidates for a trial of labor.  What is unfortunate, though, is how a single statement based on consensus and expert opinion, rather than scientific evidence, has done so much to shape access to a TOLAC.