Tuesday, June 15, 2010

NIH VBAC conference

In March, the National Institute of Health had a conference to assess the research in regards to VBAC and then made recommendations based on that assessment.

An AAMI student, Jessica, has separated the video that the NIH made available into easily watchable segments for anyone who might be interested:
VBAC New Insights Conference

I watched the entire conference. The presentations that I found most illuminating were Day 1 (#4) Overview of the Topic by Caroline Signore, MD and Day 1 (#12) Delivery after Previous Cesarean: Long- Term Maternal Outcomes by Dr. Cathy Spong.

NIH VBAC Conf, Day 1, #04 - Overview of Topic from Jessica, BirthAction Webmistress on Vimeo.

For those who may be unfamiliar with the issues surrounding VBAC- it is becoming increasingly difficult to find a care provider and/or institution that are willing to attend VBAC labors. Women are being forced to schedule repeat cesareans without being "allowed" a trial of labor. There are several reasons for this, the most cited is because of ACOG's recommendation that anesthesia be "immediately available" in case uterine rupture occurs. Many hospitals have instituted VBAC bans because of this policy, indicating it would be unsafe to attend VBACs because they didn't have anesthesia immediately available should something go awry.

There is no doubt that uterine rupture can be an obstetrical emergency. If it is caught too late, death or HIE can result. But, it is not the most common obstetrical emergency. Let's look at some numbers from Dr. Signore's presentation:

fetal/neonatal death following UR during TOL: 0.011-0.04%
HIE following UR during TOL: 0.046%
fetal death following midtrimester amniocentesis: 0.06- 0.5%
fetal death from cord prolapse: 0.01-0.06%
perinatal mortality from placental abruption: 0.7%

These other obstetrical risks are as high or higher than the risks involved in having a VBAC. And yet, there are not prohibitions against amnios. And there are no prohibitively stringent anesthesia policies for labors which are at risk of abruption or cord prolapse, which is to say, all labors. Hospitals tout themselves as the safest place to give birth, all the while saying they don't have adequate resources to deal with VBAC labors . If they aren't safe for VBAC, they aren't safe for any other labor in which an obstetrical emergency might occur.

The second presentation I mentioned, by Dr. Cathy Sprong, addressed the long term maternal outcomes of the various modes of delivery after a previous cesarean. The simplified version is this: the more cesareans you have, the higher the risk. For those women who are planning larger families, this is extremely important information. Too long the maternal risks of repeat cesareans (or multiple repeat cesareans) have been downplayed. It also makes a good case as to why the primary cesarean is a big deal and should not be taken lightly. The segment is 20 minutes long but it is so important.

NIH VBAC Conf, Day 1, #12 - Dr. Cathy Spong from Jessica, BirthAction Webmistress on Vimeo.