Tuesday, July 27, 2010

Why the ACOG's new VBAC guidelines don't matter. There. I said it.

I am not one of those people who loves to deliver bad news. Nor do I especially enjoy raining on somoene else's parade. Believe me, Im no Debbie Downer.
That's why I struggle to write what I am about to write. I don't want to say what I have to say. And yet, I feel I have to say it.

I should preface this post by admitting my prejudice against and, to some degree, cynicism about the American College of Obstetricians and Gynecologists. Anyone who has read anything historical about birth in America can probaby guess why. For those who have not, I can only say that there have been in the history of women's health care in this country a series of smear campaigns launced by obstetricians against midwives. Wildy successful campaigns. The kind of campaigns that only lots and lots of money can buy. So, when I read that the ACOG has revised its guidelines regarding vaginal birth after cesarean (VBAC), I can't say I breathed a huge sigh of relief and thanked the heavens that they have finally come around.

I seriously doubt that they have come around.

What I think, rather, is that there has been a major shift in attitude toward birth in America in the past few years, thanks, in part, to Ricki Lake's documentary The Business of Being Born, but also because women have been spreading the word amongst themselves that birth is not something we have to take lying down. I believe that this has had an impact on the profit margins of the members of the ACOG and that these new guidelines have more to do with convicing women that they can trust their OB and they are not going to be railroaded into a medicalized birth just because they had a cesarean birth previous to this pregnancy.
Much like the guided hospital tour that features cozy birthing rooms that you may only use if we decide you are low-risk enough to not deliver in the sterile operating room "just in case" and whirlpool tubs that are almost never used because the stars have to be aligned just so with staffing just right and your baby's monitor strip looking a certain way in order for us to feel it's safe for you to be in water, I believe that these guidelines are one more way that physicians and hospitals are attempting to manipulate women into a false sense of security over having their babies at their facility.

And if this sounds super cynical, it's probably because the few years I have spent learning about the medical model of childbirth have given birth to a super cynic.

As in many cases, I think an anecdote might best explain to you why I don't believe these new guidelines mean a damn thing.

Sometimes RNs from one unit "float" to another maternity floor in a hospital, so nurses not only have a chance to work with women who are in labor but also women who are trying NOT to go into labor as well as women who have just recently had their babies. While one nurse I know in a nearby hospital was floating on the postpartum unit, she encountered a woman at the end of the hall who was recovering from her second cesarean section.

She was a chatty one, so my friend got to hear her story. It made her cry.

First of all, she was one of the many women living under the impression that her first cesarean section was performed in order to save her baby's life. She believes that everything was going along just fine (as it was) when suddenly "the baby's heartbeat dropped and they had to do an emergency c-section". Never mind that she had time to get a spinal and a bikini cut. The baby's life was in danger and she had to have an Emergency Cesarean. She's so grateful to her doctor. He saved her baby.

Now, I was not present at her first delivery. Nor have I seen her medical chart. I will tell you right now, up front, that I have no idea what happened at her birth. But I've seen enough cesarean sections to know that we leave the impression with just about every woman that if we had waiting a minute longer, her baby was going to die.

She explained that she was "all set to try a VBAC this time". "My doctor told me all along that I was a good candidate for a VBAC and we really wanted to try. But then I went into labor and we got to the hospital and they asked us to sign that consent."

At this point in my friend's story, I knew which consent she was referring to. The VBAC consent. "We do so few VBACs that I actually only read it one night when it was slow and I stumbled upon it in a file drawer." my friend explained. "I was appalled." She said it read as if you were being asked to participate in some kind of unproven, experimental and highly dangerous act.

Now you might think, well, yeah, there are risks to every procedure and women have a right to know about them. And you would be right in thinking this. This document, however, looked nothing like the consents people sign when they are coming in for a regular labor and deliver, or even a planned section.

The first thing one would noticed about the consent was the font. It was several sizes larger than on the cesarean consent. Risks were indented and enumerated. Words like rupture and death to fetus and mother jumped out at the reader.

But let me remind you that a natural (without inducing agents) VBAC is safer than a cesarean section. This was not mentioned. It also was not mentioned that if this woman chose a repeat c-section, she risked damage to her uterus that might prevent her from having a normally implanted pregnancy in the future. Nor did it mention that cesarean sections also carry serious risks to mother and baby, as I said before, to a slightly greater degree than VBAC.

This nurse continued: "I remember looking at it and thinking 'There's no way Id have a VBAC if this was the only information I had about it'."

And that's what this mom she was now caring for said, too.

"We looked at the paper and we just thought. Woah. This is too risky."

They asked their nurse for her advice. And...this is the real clincher... here is what the nurse said, according to this woman, whom I believe had no reason to lie to my friend:

"Well, if it was me... I think that a one percent chance of dying might as well be a hundred percent chance. It's just too risky."

Forget the facts. Im offering you my fear-based opinion, instead. It's what I do.

And so, the woman said, "That did it for us."

Now, Im not suggesting this nurse had some kind of agenda. Or even if she did have an agenda that she herself knew it existed. But I want to know: Is this nurse offering this same advice to women who undergo the major abdominal surgery known as a cesarean section? I highly doubt it. Here is someone who apparently knows nothing about the relative risks of the two types of birth, offering "advice" to a frightened couple that is based on nothing but her own fear.

And she is not the only one. I have heard of a trusted physician, when asked about vaginal delivery of twins, tell a patient that the cesarean is a sure thing, but with the VBAC "you just don't know" because "we can't control it." (Never mind that trying to control vaginal birth is what obstetricians do.)

I have heard of nurses commenting "what time should we open the OR" when report is given including a woman who is attempting VBAC. They don't even call it VBAC in most hospitals today. They call it TOLAC. Trial of Labor After Cesarean. In other words, "We'll let you try it, honey, but meanwhile Im going to be scrubbing in the back."

I have heard of an attending physician who approached a woman whose baby was fine, but who unfortunately did not successfully produce a baby vaginally (after cesarean) in the alloted time and say "You tried, but now I think it's time for your section."

Your section. You know, the one we've had waiting for you.

Maybe Im Jaded. But it's not because I'd rather be.

The ACOG's new guidelines don't mean a damn thing because something very important has not changed: The medical model of childbirth does not assume that we should trust birth. Many obstetricians and labor and delivery nurses (probably the majority, but I can't prove it) don't trust birth. And as a result, women are not being given the support they need during prenatal care and labor to successfully VBAC.

And that is why The New Guidelines don't mean anything.

Oh sure, they look good on paper. But as long as fear and control dictate the course of labor for women who opt for obstetrical "management" in-hospital, they don't mean squat.

And no, you can't squat, either. It's not safe.


  1. "And no, you can't squat, either. It's not safe." Hahaha.

    Heather, this is an awesome post. I love it.

  2. OMG I LOVE YOU!! My friend posted the link to this on facebook, I can't believe I hadn't ever been to your blog before.

    You have said EVERYTHING I have been thinking. The guidelines don't matter. Sure they are out there, but it all comes down to your OB, your midwife, your providers. And the giant majority of them will cut you faster than anything I have ever seen.

    Incredible post! I am sharing this with EVERYONE!

  3. you have some great points and for the most part I agree with you. The one thing I think the new guidelines may be able to do is lift the VBAC ban for midwives. In many states where midwifery is regulated VBACs are not allowed under any circumstance. These guidelines give an argument for midwifery boards to allow TOLAC at home with a midwife.

  4. This is the same feeling I've had about the new VBAC guidelines and I don't even work in a hospital. Thank you for adding your perspective. I think ACOG changed their guidelines so fewer women would opt to birth in birth centers or at home in their attempts to VBAC. I don't have any proof, of course, but why suddenly is it an issue after ten years? Why is OHSU filing complaints about midwives here in Oregon who are legally attending VBACs, twins and breeches? They have caused enough troubles that the midwives have filed a class action suit against them. I hope the midwives win. ACOG is no different. They are still trying to control the entire childbirth field.

  5. Kayce you probably havent read it because Im really really horrible about writing on it. I am trying very hard to write regularly now. It is online that I have finally met like-minded people with whom I can discuss these important issues openly. Thank you for reading my blog and for sharing it. We CAN enact change.
    Babylady - you are right. I guess because the midwife I work with already does HBAC I never thought of it that way.

  6. This was my first thought when I saw the new guidelines. It's great and all, but it takes a whole lot more than a short statement from the ACOG to convince medical professionals to change what they're used to doing and what they're comfortable with.

  7. Well said, sista! The bottom line is that Obstetricians are surgeons who LOVE to do what they know best .... surgery! They may be generally nice people and extremely competent surgeons, but don't expect them to sit around, twiddle their thumbs & wait patiently for someting they can't "control," when, in the end, surgery is so much simpler.
    ... here' to squatting!

  8. Babylady, I am writing from a state where HBAC with a LM has been banned, so I sincerely hope you are right. However the Bulletin has this little recommendation about TOLAC occurring in "facilities capable of emergency deliveries." I hate to be cynical but I agree that this probably won't affect current practice. There are too many entrenched beliefs and systems that would need to change. We the Sheeple smile, nod, and sign on the dotted line.

  9. Thank you for this post. I have been a doula in the States for 10 years and I keep telling other people over and over again that these new guidelines everyone is so happy about just aren't going to change a darn thing! I still have clients in some hospitals confined to ice chips because they don't have a dedicated L&D anesthesia team so they have to follow THEIR protocol (nothing p.o., bicitrate before an epidural) it is madness. Doctors have lost the art of birth. They have no idea how to handle a breech vaginally or women who do not want medications or families that ask questions. The ACOG can publish until they are blue in the face but nothing is going to change.

  10. Fabulous post, fabulous blog, insta-follow. Brava and nice to meet you.

  11. it is true that their goal is probably not to increase the rate of VBAC. Nor are they suddenly comfortable with it. But, whilst it may not mean any much change for you guys in the states... It helps us, in other countries. countries where VBAC is already pretty normal, and where having the ACOG relax their stance, allows or even forces OUR equivalent organisations to relax their a little further. I am not recieving as much opposition to assisting VBAC mama's to saty home longer and the like since these guidelines. I hope that eventually, "everywhere else in the world" will be providing statistics that FORCE the ACOG to give up a little bit of that control. Cause thanks to t'interweb, we are now an international community, and butterfly theory really can happen, even in birth. old the hope ladies, we are trying to change it for you.

  12. I never thought of it this way, but you know what? Those are some serious bombs you're dropping. Thanks for sharing your point of view on this. It makes a lot of sense this way. (Unfortunately.)

  13. Amazing post! So great to hear that perspective. I hope that the attitude does change.

  14. This is exactly how I felt when I read the ACOG VBAC statement! Most OB's don't follow ACOG's guidelines anyway unless it suits their agenda.
    As someone who has been there when VBAC's were preferred to seeing the changes first hand over the years, I knew this didn't mean squat!
    Thank you for writing this!

  15. That is exactly why I switched OBs when I got pregnant with #2. I LOVED having my unmedicated VBAC and would definitely do it again....although I think I might labor a little longer at home than I did.

  16. Excellent post. Almost every day I hear from women, in the park, at the store, in mom's groups, about their cesareans that saved their babies. It is exhausting.

    We need more hospital workers to step up and voice their stories in the birth change movement. Yes, fear and control --and money and power-- are overarching attributes of hospital birth and we won't get anywhere until the dominant model is overturned and OBs are reinstated as surgical specialists responsible for high-risk moms and babies and not attendants of normal, low-risk births.

  17. Thank you all for reading my blog and for posting your thoughts about this issue. I am seeing people say things online like "ACOG is finally on our side!" I just don't know what to say about that. I wish I could be so enthusiastic but I don't believe this change in official position is going to trickle down very quickly, if at all, to change the way care is delivered to women who are laboring in hospitals. The system serves itself and the attitudes of even the youngest physicians coming into practice clearly reflect that control and fear still dominate practice. I agree that OB's are a godsend when a woman has medical issues that preclude normal pregnancy and delivery. Those that are really good at what they do should be doing it in cases where their exepertise is required, not in the case of every woman who walks through the door and happens to be pregnant.

  18. So interesting. It's great to hear your perspective on this -- it makes so much sense.

  19. ACOG issued new recommendations because the CDC (amazingly, for once) actually was honest about the results of their own research and basically told ACOG to quit refusing women VBAC's & get the C-section rate under control. That's the long and the short of the new recommendations. And the OB's will pull out ALL the stops to avoid actually allowing women to VBAC--but maybe this will give us a few more informed Mama's who will insist loudly and get their way.

  20. I am a mom of 4 with a successful VBA2C of twins from Canada. When the new guidelines came out my OB read them and said the exact same thing as you did. Saying it doesn't make you cynical - it makes you a realist. Until women stop fearing birth, start listening to their bodies and TALKING to each other about ALL parts of pregnancy and labour and postpartum it isn't going to change. Not knowing causes fear and right now there are a lot of women that just don't know what they don't know. Keep talking - I am now a follower of your blog and hopefully the more we talk the more people will start to listen.

  21. Thank you for your courageous and clear words. You are right on. ACOG changed some of the words in their policy in response to pressure from birth advocates. That's right. Amazing individuals, some representing organizations, some just plain folks, went to Washington DC and sat in on a committee to review VBAC and Cesarean section (I think it was the NIH who sponsored this). Mostly women. They spoke truth to power. They asked blazing follow up questions. They blogged, fb, tweeted, etc. I agree that the changes they made won't make any difference for most obstetricians or hospitals. BUT, they were pressed and they changed. I can't remember a time when WOMEN asked ACOG to change and ACOG did anything but ignore them. I think the changes are placating and patronizing, but at least they are changes and in the correct direction. Let's keep up the pressure and see where we go! Elizabeth Allemann, MD, Missouri USA

  22. Thank you for this important post...of course I was excited to see the new Bulletin, but instantly thought "Yeah, but going into labor before 39 weeks, having babies that are perfectly 7lbs, laboring with every single piece of technology the hospital owns strapped to you, and in the *right* amount of time will only end up *proving* that VBACing is a miserable failure!" This new bulletin will probably change things for highly motivated momma's who won't take NO for an answer...but many others will be scared by the consent form, discouraged by care-providers, and not-so-subtly sabotaged by the "system"...we MUST be teaching natural, normal childbirthing philosophy to every family!