VBAC Policies In-Depth

Resulting from the increased promotion of and positive knowledge around VBAC, there has been much discussion of the policies and recommendations that have been

introduced as best practice guidelines for VBAC in various countries, for example the US, the UK and Australia. However, even with best practice guidelines for VBAC being produced worldwide, there still appears to be a missing element to this equation. Many of the institutes that have created guidelines for VBAC in their region have noted that there have been no randomised controlled trials (RCT‟s) that have investigated VBAC and compared the results with ERCS (Royal College of Obstetricians and Gynaecologists, 2015; Royal College of Physicians of Ireland and the Health Service Executive, 2013; The American College of Obstetricians and Gynecologists, 2010). However, even in the absence of a RCT, the VBAC policies that are being implemented globally portray this method of birth positively and as a real and viable option for women with a previous CS. Nonetheless, this is often overshadowed by the notion of

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risk in what undertaking a VBAC entails, compared to the relative perceived straightforwardness of CS.

This can be related back the notion of RCTs as being the gold standard of research and the privileging of knowledge that pertains to RCTs. The use of evidence-based medicine can become exclusionary and medical science is now only seen as valid “by an all- encompassing scientific research paradigm – that of post-positivism – but also and foremost in showing the process by which a dominant ideology comes to exclude alternative forms of knowledge” (Holmes et al, 2006, p.181).

As well as this, it can be easy for clinicians to assume that the outcomes of a RCT are related to best practice for the patient (Walker, 2003). While this may be true with RCT outcomes, this method can omit the fact that healthcare professionals may have their own personal knowledge of their patient. Due to the rigid approach of an RCT, this type of knowledge may not be seen as valid or appropriate when considering patient and hospital outcomes (Winch et al, 2002; Bonell, 1999). Therefore, while RCTs can prove very influential in guiding clinical decision-making and practice with regards to

medical/healthcare outcomes and policy formation, the lack of alternative designs can also have a negative effect on these outcomes. This can be seen in relation to risk perceived with VBAC and CS, where there are few RCTs conducted in this area. However, the alternative knowledge that is provided by healthcare professionals and their intimate experience with VBAC has allowed for the formation of policy globally as well as carefully designed experiments and the use of qualitative inquiry. This alternative knowledge can also encompass the women that partake in the trial and

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highlight their experiences of looking for information around VBAC and trying to access this mode of birth (Lundgren et al, 2012). It is this form of knowledge that can lend itself to the formation of an RCT and help to design an intervention that is suitable for the prospective research population.

Many countries globally provide guidelines for recommended practices in supporting a woman to attempt a VBAC, including Canada (Society of Obstetricians and

Gynaecologists Canada, 2005), Australia and New Zealand (The Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2010), the UK (Royal College of Obstetricians and Gynaecologists, 2015), and Ireland (Royal College of Physicians of Ireland and the Health Service Executive, 2013).

The Canadian Society of Obstetricians and Gynaecologists published their guidelines in 2005 and stated that a woman who has had a previous CS should be offered a TOL, provided that she has no further complications during her pregnancy. The guideline also recommends that a woman should only be offered a TOL if the hospital can provide a CS if it is needed as well as continuous electronic foetal monitoring for women who are attempting a TOL. Australia and New Zealand guidelines were similar to those of Canada, with a focus on the risks of UR and the morbidities related to TOL and labour management. These guidelines, while stating that VBAC is an option, also warn that it carries multiple risks such as need for blood transfusion, fever, and thromboembolic disease. In all of the guidelines that were examined, VBAC was compared to ERCS and it was stated in the UK guideline that “there is virtually no risk of uterine rupture in women undergoing ERCS” (Royal College of Obstetricians and Gynaecologists, 2015,

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p.8). However, when looking at the guidelines for best practice for VBAC, it was interesting to note that all of the guidelines focused mainly on UR and the risks with allowing women to attempt a TOL. An example of a guideline focusing on UR is the one from Ireland, wherein UR appears repeatedly in the guideline as an adverse outcome or risk of TOLAC. The guideline does not highlight the risks and benefits of VBAC, but rather how to monitor, prepare, and handle UR when attempting

VBAC,despite the guideline stating that in one Irish maternity hospital, the “UR rate was 2 per 1000 overall” (Royal College of Physicians of Ireland and the Health Service Executive, 2013, p.6).

Even though the majority of these guidelines present similar recommendations for VBAC, Bujold (2010), found that, through a comparison of three of the countries mentioned (US, Canada and the UK), evidence about the risks and benefits of VBAC were limited and that potential bias could have occurred in these guidelines. This may be due to the fact that there are no RCT‟s of VBAC and that the main adverse outcomes that are associated with VBAC are rare. The debate surrounding VBAC is furthered by Foureur et al (2010) who investigated the similarities and differences between six national guidelines concerning birth after CS, and explored the evidence each guideline used in its informed creation. Similarly, they found differences in UR rates in each guideline and overall indicated that “the guidelines create difficulties for clinicians and women” (2010, p.9). This evidence, or the lack thereof of high-quality evidence on VBAC and the variability among VBAC guidelines, may lead to confusion and a lack of understanding on the part of women and clinicians when considering the decision to

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undertake a VBAC and ensuring that they are knowledgeable of both the risks and benefits of VBAC.