Does the ACOG VBAC Stance Matter?

I was just chilling on facebook and one of my awesome birthy friends posted a link to a post I have wanted to write, but didn’t have the words.

So without further ado, the perfect post:

The Itinerant Laborer: 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 working under 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 our hospital, so you 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 I was floating on the postpartum unit, I encountered a woman at the end of the hall who was recovering from her second cesarean section.

She was a chatty one, so I got to hear her story. It made me 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 to me 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.”

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. I was appaled. 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 we have people sign when they are coming in for a regular labor and deliver, or even a planned section.

The first thing I 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 me.

But let me remind you that a natural (without inducing agents) VBAC is safer than a cesarean section. This is not mentioned. It also is 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.

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 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, who I believe had no reason to lie to me:

“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 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 nurses comment “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 where I work. 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 an attending physician approach 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.


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