American College of Nurse-Midwives Calls for Definitive Vaginal Birth After Cesarean Study

WASHINGTON, July 3 /U.S. Newswire/ -- In a statement released today, the American College of Nurse-Midwives (ACNM) responded to a recent New England Journal of Medicine article on vaginal birth after cesarean (VBAC). The ACNM urges caution, as over-interpretation of the findings may lead to diminished options for women seeking VBAC. The ACNM also calls for decreasing the number of primary cesarean sections performed while awaiting a more conclusive, prospective study.

The ACNM Statement reads as follows:

"The primary findings of this particular study are important and make sense. It is not surprising to find that medications used to induce labor by creating a pattern of strong and regular contractions, without any natural breaks, increase the risk of opening a previous scar. An overuse of any of these medications can be dangerous, even for a woman with no scar on her uterus. Therefore, women desiring a VBAC should not have their labor induced."

The article leaves the following questions unanswered:
bulletDid all of these women really have a uterine rupture? The authors did not review original records to confirm that the coding was correct, and the report of eleven ruptures in women who did not attempt a VBAC raises questions that only a chart review can answer.
bulletWere the reported postpartum complications a direct result of the uterine rupture?
bulletWere there other issues in labor management that increased the risk of rupture, and/or the severity of complications?
bulletAre there other variables related to the conduct of the previous cesarean section that would increase the risk of rupture?

Without answers to these questions, the data in this study should not be used to frighten women considering a VBAC.

The medical, legal, and economic responses to this and other studies on VBAC are a perfect example of apogean thinking. Such extreme thought led to the popular 60's and 70's approach, 'once a cesarean, always a cesarean.' The 1981 NIH Consensus Development Statement on Cesarean Section which reported that many women could have a safe vaginal delivery after a previous cesarean section, combined with the need to control rising health care costs, led to the opposite view, 'all women were expected to attempt a VBAC.' Since cesarean section is not without risk, and both the number and type of complications increase with each subsequent surgery, we cannot justify a leap backwards to the all or nothing approach.

"Health care must be guided by evidence-based outcomes-fear of litigation must not negate the evidence or unduly influence decisions made by health care professionals. Women need unbiased, individualized information and, if they desire, a safe and supportive place to attempt a VBAC. Health care professionals must choose candidates for VBAC carefully, monitor these women while providing an environment that is conducive to a vaginal birth, and must be prepared to intervene quickly if problems develop."

When speaking to women, the ACNM recommends:
bulletDo everything you can to avoid the an unnecessary first cesarean section. 
bulletDo not choose a cesarean without understanding the risks and benefits to mother and infant; minimize unnecessary interventions especially those that that keep you in bed during early labor; create an environment where you feel empowered to give birth; and believe that you can give birth vaginally until proven otherwise.
bulletFind a health care professional who will evaluate your situation based upon your personal health status and goals.
bulletIf you are attempting a VBAC, do not consent to an induction of labor.

For more information on the ACNM's VBAC position, contact Eric A. Dyson at 202-728-9876, e-mail [email protected], or visit

The American College of Nurse-Midwives' mission is to promote the health and well-being of women and infants within their families and communities through the development and support of the profession of midwifery as practiced by certified nurse-midwives and certified midwives. Midwives believe every individual has the right to safe, satisfying health care with respect for human dignity and cultural variations. ACNM is the oldest women's health care association in the U.S., with origins dating to 1929.

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