AAFP's stance on VBACs

Thanks to VBAC.com, I just discovered that the American Association of Family has revisited their stance on VBACs. You can read the whole study here, but I am highlighting the part where they diverge from the American College of Obstetricians and Gynecologists on Trial of Labor after C-section (TOLAC.)



What management strategies influence outcomes? (Any emphasis added is mine.)

Recommendation 4: TOLAC should not be restricted only to facilities with available surgical teams present throughout labor since there is no evidence that these additional resources result in improved outcomes. (Level C)

At the same time, it is clinically appropriate that a management plan for uterine rupture and other potential emergencies requiring rapid cesarean section should be documented for each woman undergoing TOLAC. (Level C)

Much of the controversy on VBAC has centered on the management of labor, the timeliness of operative delivery, the risk of uterine rupture and its attendant consequences, and the potential for infant morbidity and mortality. Concerns have been raised about the impact of the immediately available policy on access to VBAC services. One consequence of the immediately available policy appears to be that some hospitals have discontinued VBAC services entirely, forcing women to present late in labor, to travel to another facility that allows VBAC, or to submit to a scheduled repeat cesarean delivery that they may not have wanted. This could result in adverse outcomes for women and babies beyond inconvenience. Some have questioned the assumptions that seem to underpin the immediately available policy. For example, the policy assumes that having a surgical team immediately available will reduce morbidity or mortality from uterine rupture. The AAFP TOLAC Panel felt this was a debatable assumption. Similarly, the ACOG policy suggests that one rare obstetrical catastrophe (e.g., uterine rupture) merits a level of resource that has not been recommended for other rare obstetrical catastrophes (e.g., shoulder dystocia, abruptio placenta, cord prolapse) that may actually be more common.

However, it may be argued that, while these other catastrophes are largely not predictable, permitting a TOL in a mother with a previous cesarean is a planned event that may demand a different degree of preparedness.

While adverse consequences of a TOLAC are distinctly uncommon and must be balanced against attendant risks associated with ERCD, current risk management policies across the United States restricting a TOL after previous cesarean section appear to be based on malpractice concerns rather than on available statistical and scientific evidence. The TOLAC Panel found no systematic evidence suggesting that improved outcomes for TOLAC patients resulted from restricting a woman’s ability to undergo a TOLAC based on the availability of resources not usually present for other women in labor, the institutional setting, or the timeliness of operative delivery.

Any effort to limit the accessibility of TOLAC by requiring restrictive conditions during labor is likely to limit access to vaginal delivery for many women. Given the potential negative impact on access to care and the absence of evidence, no recommendations can be made as to whether a difference in intensity of care should be required for patients attempting a VBAC until more definitive evidence is provided demonstrating the benefits of more restrictive services for women undergoing a TOLAC.

Our recommendation significantly differs from current ACOG policy 14 because we could find no evidence to support a different level of care for TOLAC patients. Without good-quality evidence, we believe that different levels of resources cannot be advocated because their potential for unintended harms cannot be evaluated against their purported benefits.



The pdf of this review that I read was published in July, 2005. I just stumbled across it, I certainly did not see it covered in any major news source, as ACOG policy frequently is.

I am not a physician, but if medicine is akin to other professional fields, it is a big deal when one group strikes a stake so significantly different from a peer group. This would be like a group of physics teachers indicating that their peers in the Mathematics department weren't teaching what they should be nor using the methods they should be.

I attempted to search the ACOG website to find reference to this AAFP statement, but was unsuccessful.

One other issue struck me in reading the AAFP paper. Much of the research they found to use was considered only fair-poor based on the criteria they set up to judge a study's value. Much of what I have read and heard has given me the belief that obstetrics is the least well reasearched/evaluated, most based on common practice rather than evidence, area of medicine. This review by ACOG's peers certainly did not alter that belief.