Acog’s 1999 VBAC guidelines: a survey of western massachusetts obstetric services

Abstract

Objective: ACOG Practice Bulletins provide management standards for obstetric and gynecologic services. The recent ACOG guidelines for vaginal birth after cesarean (VBAC) (Number 5, July 1999) are controversial concerning hospital VBAC policy. We surveyed all western Massachusetts obstetric services regarding their VBAC policy.Methods: A survey regarding procedure rates and VBAC policy was presented to chiefs of western Massachusetts obstetric services and the data summarized.Results: All services completed the survey. Of the approximately 8,000 annual deliveries performed in western Massachusetts, 18.5% are cesarean. From 1994, all services reported a decline in overall cesarean rate and an increase in VBAC rate. All institutions reported an unchanged primary cesarean rate, except for the only level 3 center surveyed, where it rose slightly. Regarding recent ACOG VBAC guidelines, five of six services were aware of the new guidelines. Fifty percent describe “immediately available” as cesarean delivery initiated within 30 minutes and 50% as within 15 minutes. Sixty-seven percent describe “physician availability for cesarean delivery” as anesthesia coverage in-hospital and 33% as anesthesia coverage on labor and delivery. The only service mandating an obstetrician’s attending presence during VBAC trials is the tertiary care center due to residency training. Five of six services have anesthesia availability in hospital, but not specific to labor and delivery.Conclusions: The recent ACOG VBAC guidelines were inconsistently interpreted among the services surveyed. At these institutions, declines in cesarean deliveries are due to the increase in VBAC trials. While failure to incorporate guidelines could increase liability for institutions, strict implementation may discourage VBAC trials and increase cesarean deliveries by as much as 50%. In our opinion, closer review of data regarding VBAC complication rates is necessary to develop workable guidelines applicable to institutions of all levels.