Discussing the new RCOG VBAC Guidelines

2591900916_70d17cd7f2Earlier 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.


RCOG (2015). Birth After Previous Caesarean Birth (Green-top Guideline No. 45). London: RCOG. October 2015
photo credit: Birth! via photopin (license)

4 comments for “Discussing the new RCOG VBAC Guidelines

  1. Helen Eatherton
    November 3, 2015 at 9:55 pm

    Hi Sara

    i am surprised that you say ‘ units do not have to consent to letting women get into the water for labour’. I have been arguing this point at work now for some time. As far as i can see, the infrastructure doesnt belong to the staff, its NHS and therefore it belong to the public and that of course includes the users. Hence, women have the right to give birth in the water if that is their choice. As health care professionals, it is our role to discuss the ads and disads of a plan, but ultimately if the woman choses to take those risks then surely that is up to her. Do we have the right to refuse? By denying certain women a water birth in an along side MLU, some women chose to give birth at home. Can you see a possibility when a Trust or lead professional may be prosecuted for a bad outcome at a home birth if that woman had been refused her choice at an MLU? Your thoughts?

    • November 5, 2015 at 10:00 am

      Hi Helen 🙂

      This is a brilliant point and a really interesting debate, and I have to say that I don’t know what the answer is legally, but maybe someone else who knows more about that will see this and join in. As we both know, staff (and I realise units don’t have agency lol) are frequently telling women they can’t get into the pool, citing ‘health and safety’ etc, and the sad reality is that I can’t see a way around that, because even though the infrastructure doesn’t belong to the staff, the staff are tasked with actioning the care and applying the rules within the building. I guess, by the logic you’re using (and how I wish that this hadn’t occurred to me, because I like your solution better and agree with you that women should have all of these rights and more) if NHS property belongs to all of us who pay UK taxes then that means that, when my bathroom gets replaced in a few month’s time, I can nip over to RUH and have a nice soak in one of theirs? 😉

      I’m going to look into this more and will look at writing another blog post which is more in depth, e.g. about how asking a woman to leave a pool could be considered assault.

      We need a way of having these debates over skype or something. With cups of tea 😀


  2. JH
    May 2, 2018 at 12:45 pm

    It’s disappointing that HBAC doesn’t get a mention at all on the Green Top, despite the benefits of labouring at home, where intervention is minimal and a calm relaxed environment would improve the chances of a spontaneous labour and delivery.

    Whilst I appreciate the risk of a uterine rupture, if a woman and her partner are fully aware, then with adequate support a HBAC can be a safe option. Taking into account the reason behind the first CS, obviously, and the individual woman.

    I have known, in my time as a midwife in a busy inner city teaching hospital, for uterine rupture to occur on a P1 G2 labouring woman with previous vaginal delivery and no one suspected it until the emergency CS was required due to fetal distress and the fetus was in the abdominal cavity.

    I have hunted and just cannot seem to find any research on HBAC at all.

    • May 3, 2018 at 12:02 pm

      Great points; thank you for sharing. And you’re right, home birth after caesarean isn’t getting research attention but, given the benefits of home birth and the increasing number of women who are seeking to birth at home, it ought to.

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