In 1999, ACOG revised the position it had adopted in 1988 on VBAC. Its recommendations became more restrictive:
VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.
American College of Obstetricians and Gynecologists (1999)
The association noted that these recommendations were based on level C evidence, therefore implying that they were not really supported by scientific studies but rather by opinions of experts. While continuing to support the concept of VBAC, ACOG is now more cautious in its approach and puts the focus on individual risk factors.
SOGC did not change its guidelines on VBAC until 2004, when it replaced those of 1999. And the following year, the Society of Obstetricians and Gynaecologists of Canada (SOGC) (2005) modelled its own recommendations on those of ACOG, and suggested that
For a safe labour after caesarean section, a woman should deliver in a hospital where a timely caesarean section is possible.
Only one study, that of Leung et al. (1993), addressed the interval from the beginning of prolonged decelerations of the baby’s heart rhythm to delivery by caesarean section and achieving a healthy outcome for a baby following uterine rupture. According to this study, the delay should be of 17 minutes, whereas the recommendations of ACOG state that it should not exceed 30 minutes, as for any obstetrical emergency. In Flamm’s (2001b) opinion, it is impossible for most hospitals to achieve a 17-minute interval.
Why do medical associations as influential as ACOG and SOGC make rec-ommendations based, as ACOG admits, on opinions of experts instead of on serious studies? Why do they strongly recommend conditions for VBAC that are not deemed necessary for all deliveries, when it is known that complications requiring an emergency operation are present in 2–3% of them. Enkin et al. (2000) noted the following:
To put these rates in perspective, the probability of requiring an emergency caesarean section for other acute conditions (fetal distress, cord prolapse, or antepartum haemor-rhage) in any woman giving birth, is approximately 2.7% or up to 30 times as high as the risk of uterine rupture with a planned vaginal birth after caesarean.
They conclude that if hospitals are unable to furnish an adequate solution for problems arising during a VBAC, they are equally unable to meet emergencies liable to occur in any delivery.
Dissident voices: the American Academy of Family Physicians (AAFP) and the American College of Nurse-Midwives (ACNM)
One medical association, however, disagreed with ACOG’s position adopted in 2004 on the necessity for proceeding with a caesarean delivery immediately after the uterine rupture (which meant having a surgical team present, an unoccupied operating theatre, etc.). This was the American Academy of Family Physicians (AAFP) who, in 2005, after conducting their own literature review, concluded that the recommendations of ACOG were not based on convincing data and that there was no study on the necessity or not of having in place a medical team able to act ‘immediately to protect the health of mother and baby’. They recommended that
Trial of labor after caesarean 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.
(The American Academy of Family Physicians 2005)
As to nurse-midwives, the American College of Nurse-Midwives (ACNM) strongly supports the practice of VBAC, stressing the fact that VBAC offers significant benefits to women and their babies and entails fewer risks than a caesarean delivery. According to this association, midwives can help women have a VBAC if appropriate arrangements for medical consultation and emergency care have been made. It also believes that the help of a midwife increases a woman’s chances of succeeding with her VBAC and lowers the caesarean rate.
Conclusion. The VBAC decline: over and above clinical risks, medico-legal risks?
Currently, a crisis in malpractice rates is decreasing the availability of maternity care providers and raising concerns that patients may have limited options, less access to care, and perhaps be at increased risk for complications.
(Agency for Healthcare Research and Quality (AHRQ) 2003)
We have seen that the debate regarding VBAC was acutely concerned in the past with the risks for the health of mothers and their babies, but that this debate was based on low-level scientific studies or on opinions of experts. We also learned that the most talked-of study on VBAC was published years after the VBAC rate had begun to decline. Other factors have perhaps contributed to this reversal of the situation concerning VBAC in North America.
In the 1990s, cases of uterine rupture were often reported in medical pub-lications. It could be assumed that some physicians, during this period, had witnessed catastrophic uterine ruptures related to inconsiderate use of drugs to
induce labour. These experiences may have frightened health professionals who, from then on, associated VBAC with catastrophic uterine rupture.
This could also be related to a type of risk not often discussed in obstetrics and which has not been a part of the subject matter of studies, namely, medico-legal risks for health professionals. It is possible that clinical risks of VBAC are emphasised for medico-legal reasons, but this is seldom mentioned. However, after the emergence of legal proceedings following VBAC that had negative outcomes, one physician commented on this factor in a publication intended for his colleagues (Phelan 1996). To illustrate this point of view, Dr Zinger, vice-president of ACOG, wrote that
Defendant physicians are in a better position from a liability perspective if they were present at the time of the complication.
(Zinger 2001)
The recommendations of ACOG and SOGC on this subject seem to follow the same line of thought. And, in Canada, a physician told me about a conversation he had with a lawyer who, referring to legal proceedings concerning VBAC, said that
You have begun to practise VBAC? It’s our turn now.
Since that time, associations preoccupied with the lack of access to VBAC, such as the Northern New England Perinatal Quality Improvement Network, have come to recognise the fact that the huge sums awarded by American courts to families who have experienced ‘bad’ VBAC have had an important impact on insurance companies. Physicians’ insurance premiums have risen astronomically and pressure has been put on hospitals and directors to refuse VBAC for their clientele.
For example, in 2001, a few years after the first legal proceedings involving VBACs took place, a couple whose baby had suffered damages during a VBAC delivery, was awarded USD3.5 million following an out-of-court settlement (Anonymous 2002). The publication Birth (Anonymous 2002) reported that an important Des Moines hospital in the state of Iowa had decided to no longer perform VBAC. The spokeswoman of the hospital explained that concerns about both legal liability and patients’ health led to this decision, the anaesthetists being unable to assure their presence at an emergency caesarean delivery following uterine rupture.
In Canada, lawsuits linked to VBAC started to happen in the first half of the 1990s (Me M´enard, personal communication, 2007). It is this issue, namely the possible impact of medico-legal factors on obstetrical practices, which is the growing concern of consumers’ groups (organisations such as the International Caesarean Awareness Network) fighting excessive caesarean rates and defending women’s rights to choose how they want to give birth.
The midwives’ organisations are also concerned about VBAC. Individual mid-wives and associations of midmid-wives have had to decide whether they accept among their clientele women who wish to give birth vaginally after a prior caesarean. In Quebec, VBAC can be practised by midwives. The Quebec College of Midwives has decreed that midwives are qualified to take care of women who have had a prior caesarean, and that a VBAC had more chances of success when a midwife attended it. Many factors have influenced these organisations in their desire to help their members evaluate the risks for themselves if they want to be responsible for a VBAC taking place outside a hospital. Amongst these factors are reversal of opinion on VBAC in medical milieux, fear of litigation on the part of physicians and hospitals involved in VBACs that have had difficult outcomes and the pub-lication of the Lieberman study on VBAC in birth centres. The Seattle Midwifery School recently pointed out that in the controversy concerning VBAC – which deals with the health and security of mothers and their babies – practically no attention is paid to medico-legal risks for health professionals (Hugues 2005).
The fact remains, as noted by consumers’ groups in North America, that those who have borne the brunt of this change of attitude in medical circles are the women who have not been able to make the choice of a vaginal birth. In the context of the current available evidence that has been discussed above, I am convinced that it has to essentially be the prerogative of each woman to decide whether she wants to give birth to her baby vaginally or to have a caesarean, without any constraint linked to the place where the baby is born, be it a hospital or a birth centre. As for any medical intervention, the fact that a practitioner has given – or not – adequate information to his or her client seems to make the difference in case of legal proceedings following bad outcomes.
References
Agency for Healthcare Research and Quality (AHRQ) (2003) Vaginal Birth After Caesarean (VBAC). Evidence Report/Technology Assessment Number 71.
The American Academy of Family Physicians (2005) Trial of Labour After Caesarean (TOLAC). Formerly Trial of Labor Versus Elective Repeat Caesarean Section for the Woman with a Previous Caesarean Section: A Review of the Evidence and Recommendations by the American Academy of Family Physicians.
American College of Obstetricians and Gynecologists (1999) Vaginal Birth After Previous Caesarean Section. Practice Bulletin No 5.
Anonymous (2002) Vaginal birth after a previous caesarean. Birth 29(4): 292.
Baptisti Richards L (1987) The Vaginal Birth After Caesarean Experience–Birth Stories by Parents and Professionals. Bergin & Garvey, New York.
Beckett VA and Regan L (2001) Vaginal birth after caesarean: the European experience.
Clinical Obstetrics and Gynaecology 44: 594–603.
Blanchette H, Blanchette M, McGabe J et al. (2001) Is vaginal birth after cesarean safe?
Experience with a community hospital. American Journal of Obstetrics and Gynaecology 184(7): 1478–1484.
Brill Y, Kingdon J, Thomas J et al. (2003) The management of VBAC at term: a survey of Canadian obstetricians. Journal of Obstetrics and Gynaecology Canada 25(4): 300–310.
Bujold E (2006) Uterine rupture and labour after a previous low transverse caesarean section. BJOG 113(11): 1337–1337.
Bujold E, Bujold C, Hamilton EF et al. (2002a) The impact of a single-layer or double-layer closure on uterine rupture. American Journal of Obstetrics and Gynaecology 186(6):
1326–1330.
Bujold E, Bujold C, Hamilton EF, Harel F, and Gauthier RJ (2002b) The impact of a single-layer or double-layer closure on uterine rupture. American Journal of Obstetrics and Gynaecology 186: 1326–1330.
Bujold E, Mehta SH, Bujold C, and Gauthier RJ (2002c) Interdelivery interval and uterine rupture. American Journal of Obstetrics and Gynaecology 187(5): 1199–1202.
Canadian Institute for Health Information (2004) Giving Birth in Canada. A Regional Profile.
Chauhan SP, Martin JN Jr, Henrichs CE et al. (2003) Maternal and perinatal com-plications with uterine rupture in 142,075 patients who attempted vaginal birth after cesarean delivery: a review of the literature. American Journal of Obstetrics and Gynaecology 189(2): 408–417.
Cohen NW and Estner L (1983) Silent Knife–Cesarean Prevention and VBAC, Bergin &
Garvey, New York
Craigin EB (1916) Conservatism in obstetrics. New York Medical Journal 104(1): 1–3 (quoted by Vadeboncoeur 1989, p. 118).
Enkin M, Keirse MJNC, Neilson J et al. (2000) A Guide to Effective Care in Pregnancy and Childbirth. Oxford University Press, Oxford.
Enkin MW and Wilkinson C (2001) Single versus two layer suturing for closing the uterine incision of caesarean section. Cochrane Database of Systematic Reviews 2.
Update Software, Oxford.
Flamm B (2001a) Vaginal birth after caesarean and the New England Journal of Medicine: a strange controversy. Birth 28(4): 276–279.
Flamm B (2001b) Vaginal birth after caesarean: reducing medical and legal risks.
Clinical Obstetrics and Gynaecology 44: 622–629.
Goer H (2003) Spin doctoring the research. Birth 30(2): 124–129.
Guise GM, McDonagh MS, Osterweil P et al. (2004) Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section.
British Medical Journal 329(7456): 1–7.
Guise J-M, McDonagh M, Hashima J et al. (2003) Vaginal Birth After Cesarean Evidence-Based Report/Technology Assessment No 71. Agency for Healthcare and quality, Rockville, MD.
Hoyert DL, Matthews TJ, Menacker F et al. (2006) Annual summary of vital statistics:
2004. Paediatrics 117(1): 168–183.
Hugues W (2005) Out-of-Hospital VBAC: Assessing the Risks for Midwives. Seattle Midwifery School, Seattle, WA.
Johnson KC and Daviss BA (2005) Letter to the editor. Results of the national study of vaginal birth after caesarean in birth centers. Obstetrics and Gynaecology 105(4):
897–898.
Kieser KE and Baskett TF (2002) A 10-year population-based study of uterine rupture.
Obstetrics and Gynecology 100(4): 749–753.
Koehler N (1985) Artemis Speaks–VBAC Stories & Natural Childbirth Information. Jerald R Brown Inc, Occidental, CA.
Kremer DF, Berlin M, and Guise GM (2004) The relationship of health care delivery system characteristics and legal factors to mode of delivery in women with prior caesarean section: a systematic review. Women’s Health Issues 14(3): 94–103.
Leung A, Leung E, and Paul R (1993) Uterine rupture after previous caesarean delivery:
maternal and fetal consequences. American Journal of Obstetrics and Gynaecology 169:
945–950.
Lieberman E (2001) Risk factors for uterine rupture during a trial of labor after a caesarean section. Clinical Obstetrics and Gynaecology 44: 609–621.
Lieberman E, Ernst EK, Rooks JP et al. (2004) Results of a national study of vaginal birth after caesarean in birth centers. Obstetrics and Gynaecology 104(5, Part 1):
993–942.
Lydon-Rochelle M, Holt VL, Easterling TR et al. (2001) Risk of uterine rupture during labor among women with a prior cesarean delivery. The New England Journal of Medicine 345: 3–8.
Martin JA, Hamilton BE, Sutton PD et al. (2003) Births: final data for 2002. National Vital Statistics Re 52: 2–224.
Massachusetts Department of Health (2000) Use of hospital discharge data to monitor uterine rupture – Massachusetts 1990–1997. Morbidity and Mortality Weekly Report 49(12): 245–248.
McMahon MJ, Luther ER, Bowes WA Jr, and Olshan AF (1996) Comparison of a trial of labor with an elective second cesarean section. New England Journal of Medicine 335: 689–695.
Mozurkewich EL and Hutton EK (2000) Elective repeat caesarean delivery versus trial of labor: a meta-analysis of the literature from 1989–1999. American Journal of Obstetrics and Gynaecology 183(5): 1187–1197.
O’Connell, WT (1966) Vaginal delivery following caesarean section. Pacific Medicine and Surgery 74(6): 343–345.
Phelan JP (1996) VBAC time to reconsider? OBG Management 11: 62–68 (cited in Mozurkewich and Hutton 2000).
Pruett KM, Kirshton B, Cotton D et al. (1988) Is vaginal birth after two or more cesarean sections safe? Obstetrics and Gynaecology 72(2): 163–165.
Ravasia D, Wood S, and Pollard J (2000) Rupture during induced trials of labour in women with a previous caesarean delivery. American Journal of Obstetrics and Gynecology 182(10): 1176.
Rosen MC, Dickinson JC, and Westhoff GL (1991) Vaginal birth after caesarean:
a meta-analysis of morbidity and mortality. Obstetrics and Gynaecology 77: 465–470.
Rubin R (2005) Study backs natural birth after C-section. USA TODAY. 29/6/2006.
Sakala C (2003) New resources for evidence-based practice. Journal of Obstetric, Gynae-cological and Neonatal Nursing 32(5): 630–635.
Society of Obstetricians and Gynaecologists of Canada (SOGC) (1990) Declaration of Principles. Caesarean.
Society of Obstetricians and Gynaecologists of Canada (SOGC) (1997a) Vaginal Birth After Previous Caesarean Birth. SOGC Policy Statement No 68.
Society of Obstetricians and Gynaecologists of Canada (SOGC) (2005) Guidelines for Vaginal Birth After Previous Caesarean Birth. No 155.
Vadeboncoeur H (1989) Une autre c´esarienne? Non merci. ´Editions. Quebec-Am´erique, Montreal.
Wen SH, Rusen ID, Walker M, et al. (2004) Comparison of maternal mortality and morbidity between trial of labor and elective cesarean section among women with previous cesarean delivery. American Journal of Obstetrics and Gynecology 191:
1263–1269.
World Health Organization (1985) Appropriate technology for birth. The Lancet 326:
436–437.
Zelop CN, Shipp TD, Repke JT et al. (1999) Uterine rupture during induced or augmented labor in gravid women with one prior caesarean delivery. American Journal of Obstetrics and Gynecology 181: 882–886.
Zinger, S (2001) Vaginal delivery after previous caesarean delivery: a continuing controversy. Clinical Obstetrics and Gynaecology 44(3): 561–576.
4. Midwives
and Maternity Services in Greece – Historical Context and Current Challenges
Olga Arvanitidou
Introduction
This chapter presents a historical perspective of the health system in Greece and the creation of the maternity services. It also seeks to explore the philosophy underpinning the maternity services, the use of practice guidelines and the impact of these factors on midwifery.