I’m sitting here watching the
NIH Consensus Development Conference: Vaginal Birth After Cesarean: New Insights
From the NIH Website:
Background
Vaginal birth after cesarean (VBAC) is the delivery of a baby through the vagina after a previous cesarean delivery. For most of the 20th century, once a woman had undergone a cesarean (the delivery of a baby through an incision made in the abdominal wall and uterus), many clinicians believed that all of her future pregnancies required delivery by cesarean as well.However, in 1980 a National Institutes of Health (NIH) Consensus Development Conference panel questioned the necessity of routine repeat cesarean deliveries and outlined situations in which VBAC could be considered. The option for a woman with a previous cesarean delivery to try to labor and deliver vaginally rather than plan a cesarean delivery was thus offered and exercised more often from the 1980s through the early 1990s. Since 1996, however, VBAC rates in the United States have consistently declined, while cesarean delivery rates have been steadily rising.
The exact causes of these shifts are not entirely understood. A frequently cited concern about VBAC is the possibility of uterine rupture during labor, because a cesarean delivery leaves a scar in the wall of the uterus at the incision site, which is weaker than other uterine tissue. Attempted VBAC may also be associated with endometritis (infection of the lining of the uterus), the need for a hysterectomy (removal of the uterus) or blood transfusion, as well as neurologic injury to the baby.
However, repeat cesarean delivery may also carry a risk of bleeding or hysterectomy, uterine infections, and respiratory problems for the newborn. Having multiple cesarean deliveries may also be associated with placental problems in future pregnancies. Other important considerations that may influence decision making include the number of previous cesarean deliveries a woman has experienced, the surgical incision used during previous cesarean delivery, the reason for the previous surgical delivery, her age, how far the pregnancy is along relative to her due date, and the size and position of her baby.
Given the complexity of this issue, a thorough examination of the relative balance of benefits and harms to mother and baby will be of immediate utility to practitioners and pregnant mothers in deciding upon a planned mode of delivery. A number of non-clinical factors are involved in this decision as well, and may be influencing the decline in VBAC rates. Some individual practitioners and hospitals in the U.S. have decreased or eliminated their use of VBAC.
Professional society guidelines may influence utilization rates because some medical centers do not offer the recommended supporting services for a trial of labor after cesarean (e.g., immediate availability of a surgeon who can perform a cesarean delivery and on-site anesthesiologists).
Information related to complications of an unsuccessful attempt at VBAC, medico-legal concerns, personal preferences of patients and clinicians, and insurance policies and economic considerations may all play a role in changing practice patterns. Improved understanding of the clinical risks and benefits, and how they interact with legal, ethical, and economic forces to shape provider and patient choices about VBAC may have important implications for health services planning.
To advance understanding of these important issues, the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Office of Medical Applications of Research of the NIH will convene a Consensus Development Conference from March 8–10, 2010. The conference will address the following key questions:
- What are the rates and patterns of utilization of trial of labor after prior cesarean, vaginal birth after cesarean, and repeat cesarean delivery in the United States?
- Among women who attempt a trial of labor after prior cesarean, what is the vaginal delivery rate and the factors that influence it?
- What are the short- and long-term benefits and harms to the mother of attempting trial of labor after prior cesarean versus elective repeat cesarean delivery, and what factors influence benefits and harms?
- What are the short- and long-term benefits and harms to the baby of maternal attempt at trial of labor after prior cesarean versus elective repeat cesarean delivery, and what factors influence benefits and harms?
- What are the nonmedical factors that influence the patterns and utilization of trial of labor after prior cesarean?
- What are the critical gaps in the evidence for decision-making, and what are the priority investigations needed to address these gaps?
Invited experts will present information pertinent to the posed questions and a systematic literature review prepared under contract with the Agency for Healthcare Research and Quality (AHRQ) will be summarized. Conference attendees will have ample time to ask questions and provide comments during open discussion periods. After weighing the scientific evidence, an unbiased, independent panel will prepare and present a consensus statement addressing the key conference questions.
I’m excited about the findings and presenting the consensus statement to ANYONE and EVERYONE associated with birth in North Louisiana. VBAC should be encouraged and supported over repeat C-section for women who are seeking one. Women should be given the opportunity of informed choice when it comes to the way they want to birth their children.
More to come as the conference progresses.
Two very important press releases by: The Big Push for Midwives were issued this week. One dealt close to home with a bill in Mississippi that was killed after many concerned calls to the MS Legislature (a bill that would have made it nearly impossible to practice as a midwife) and another citing a report by the CDC that showed an increase in Out of Hospital (OOH) births on the rise even before the release of Ricki Lake’s documentary The Business of Being Born in 2008.
Below are the findings and statements issued by The Big Push for Midwives.
Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has. ~ Margaret Mead
CDC Report: Demand for Out-of-Hospital Midwife Births Sharply Increases
Research Debunks Physician Group Claims that Actress Ricki Lake is Responsible for Rise in Out-of-Hospital Births
Envisioning a safer, less-costly model of maternity care in the United States.
Advocates oppose bill to regulate Mississippi midwives
THE ASSOCIATED PRESS • MARCH 1, 2010
http://tinyurl.com/yj5w9n4
From an email recieved from Susan Jenkins forwarded to her by Katherine Prown. Both are representatives from The Big Push For Midwives.
For all of you who have expressed interest in what was happening in Mississippi, or who otherwise care about licensing midwives, here’s a message from Katie Prown, Campaign Manager of the Big Push for Midwives Campaign, attaching a newspaper article with up-to-date information. Please note how effective an onslaught of phone calls to a legislature can be as well as the importance of creating relationships with the press, both of which the Big Push has been working on.
Best regards, SusanWhat happened in Mississippi last week is a fantastic example of how much The Big Push for Midwives media outreach campaign is paying off in returns! The Associated Press is one of the outlets we’ve been consistently sending our press releases to and following up with, building relationships that culminated in a phone call to me when one of their reporters learned of the bill to restrict midwifery practice to nurse-midwives, thereby outlawing all other midwives in the state, as well as midwives from LA, TN and AL with practices in MS.
MS has so long been considered a “safe” state that no one has been keeping an eye on the legislature there. Had it not been for that phone call, it’s highly unlikely we would have learned about the bill until after it passed. Needless to say, this bill—which had sailed through the House and was on the fast track in the Senate until we caught wind of it—would have been disastrous for mothers and midwives in MS. Thanks to quick mobilization and the amazing powers of social networking, we dodged a bullet, so everyone who helped with this effort deserves many thanks.
Even better, advocates in MS not only organized quickly once our Push Alert went viral, but they’re building on the momentum to push for a substitute amendment to replace the bad bill with a good one and will come back next year should that effort fail. And they’ve definitely made an impression. The author of the bill, Rep. Holland, told one of the callers to his office that in all his years at the state house, he had never heard “such a ruckus” over a bill before. So nice work, everyone! And if you have a few minutes, click on the link and post a comment.
Many thanks! Katie
Katherine Prown, PhD | Campaign Manager | TheBigPushForMidwives.org | 414.550.8025
After an amazing 2 days at the CIMS forum in Austin, TX I am more determined than ever to do whatever it takes to make significant changes to our maternity care system in North Louisiana. As I put the final touches on the rest of my website I am anxious and excited to start really promoting “normal birth” in my area. I already have the support of at least one OB/GYN and several other organizations. I have made contact with at least 2 more doulas although one is 35 miles away and the other 70 miles away but it’s a start. I hope that in the next year I will be able to recruit and train a few more doulas for this area. My “big picture” goal is to recruit and train midwives for this area. As it stands now this is what it looks like for the state of Louisiana and licensed midwives and it’s just not acceptable!
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