Earlier this month, the RCOG released the new version of their Green-top Guideline on vaginal birth after caesarean (VBAC). In introducing this document, they note that, “There is a consensus (National Institute for Health and Care Excellence [NICE], Royal College of Obstetricians and Gynaecologists [RCOG], American College of Obstetricians and Gynecologists [ACOG]/ National Institutes of Health [NIH] that planned VBAC is a clinically safe choice for the majority of women with a single previous lower segment caesarean delivery. Such a strategy is also supported by health economic modelling and would also at least limit any escalation of the caesarean delivery rate and maternal morbidity associated with multiple caesarean deliveries. This guideline provides evidence-based recommendations on best practice for the antenatal and intrapartum management of women undergoing planned VBAC and ERCS.”
I’ve been out and about meeting and talking to midwives and birth folk since the guideline was released and I have to say that there is disappointment in some circles at the continued tendency to state that VBAC is ‘offered’ by obstetricians, when actually VBAC is what would happen if a woman stayed at home and didn’t even consult an obstetrician. Some midwives are also disappointed that the RCOG have not addressed the question of the use of water in labour. I appreciate that there isn’t good evidence on this topic, but there isn’t good evidence on a number of other topics covered by the guideline either, but recommendations (supported by expert opinion) are still included. I also appreciate that the recommendation that women who have decided to have a VBAC should have their labours continuously monitored adds an extra challenge to the use of water, but it’s not impossible. And, of course, guidelines are, by definition, just a guide, so women do not have to consent to monitoring. (Sadly, as midwives will attest, units equally do not have to consent to letting women get into the bath or pool in labour either). But I don’t want to be wholly negative, as some midwives and birth folk who are working in less woman-centred areas welcome the guidelines, especially the continued recognition of the fact that induction and augmentation are not ideal for women who have decided to VBAC, as they feel that it gives them a platform from which to challenge practice.
These are just a few of the discussion points, and there is lots more to debate, of course. If you’d like to ponder the issues for yourself, you can find the full guideline here.