Birth Policy Resources

Birth Policy Resources: "Trial of Labor After Cesarean (TOLAC)
Formerly Trial of Labor Versus Elective Repeat Cesarean Section for the Woman With a Previous Cesarean Section
American Academy of Family Physicians

Executive Summary

The American Academy of Family Physicians Commission on Clinical Policies and Research convened a panel to systematically review the available evidence on trial of labor after cesarean delivery (TOLAC) using the Agency for Healthcare Research and Quality Evidence Report on Vaginal Birth After Cesarean (VBAC). The panel’s objective was to provide an evidence-based clinical practice guideline for pregnant women and their families, maternity care professionals, facilities, and policy-makers who care about trial of labor and maternity care for a woman with one previous cesarean. The recommendations are as follows:

Recommendation 1: Women with one previous cesarean delivery with a low transverse incision are candidates for and should be offered a trial of labor (TOL). (Level A)

Recommendation 2: Patients desiring trial of labor after previous cesarean (TOLAC) should be counseled that their chance for a successful vaginal birth after cesarean (VBAC) is influenced by the following: (Level B)

Positive Factors (increased likelihood of successful VBAC)

Maternal age <40 years
Prior vaginal delivery (particularly prior successful VBAC)
Favorable cervical factors
Presence of spontaneous labor
Nonrecurrent indication that was present for prior cesarean delivery

Negative Factors (decreased likelihood of successful VBAC)

Increased number of prior cesarean deliveries
Gestational age >40 weeks
Birth weight >4,000 g
Induction or augmentation of labor

Recommendation 3: Prostaglandins should not be used for cervical ripening or induction as their use is associated with higher rates of uterine rupture and decreased rates of successful vaginal delivery. (Level B)

Recommendation 4: TOLAC 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. (Level C) At the same time, it is clinically appropriate that a management plan for uterine rupture and other potential emergencies requiring rapid cesarean section should be documented for each woman undergoing TOLAC. (Level C)

Recommendation 5: Maternity care professionals need to explore all the issues that may affect a woman's decision including issues such as recovery time and safety. (Level C). No evidence based recommendation can be made regarding the best way to present the risks and benefits of trial of labor after previous cesarean delivery (TOLAC) to patients.

AAFP Policy Action March 2005 -- Printed July 2005
Copyright� 2005 American Academy of Family Physicians

Click here to read the complete document (PDF).

"New Study Leads State Attorneys General and Insurance Commissioner to Strongly Challenge Insurance Industry's Price-Gouging of Doctors"

"New Study Leads State Attorneys General and Insurance Commissioner to Strongly Challenge Insurance Industry's Price-Gouging of Doctors"

7/7/2005 1:29:00 PM

To: National Desk, Health Reporter

Contact: Joanne Doroshow of the Center for Justice & Democracy, 212-267-2801; Web: http://centerjd.org

NEW YORK, July 7 /U.S. Newswire/ -- In response to a new study released today by several national consumer organizations titled Falling Claims and Rising Premiums in the Medical Malpractice Insurance Industry, two state Attorneys General and one state Insurance Commissioner responded with strong statements condemning the actions by insurers to dramatically raise insurance rates for doctors while claims are dropping.

'The numbers underscore the need for much tougher, more aggressive oversight to prevent and punish profiteering,' Connecticut Attorney General Richard Blumenthal said. 'Federal and state regulators should thoroughly scrutinize recent rate increases and take appropriate corrective action. Affordable medical malpractice insurance is critical to public health. Expensive insurance rates become a matter of life and death when they drive doctors out of business - as is happening in Connecticut and nationwide. Insurance company greed can be hazardous to our health.'

'The data in the Annual Statements filed under oath with state insurance departments, which this Report discloses, call into question much of what the medical malpractice insurance industry has been saying publicly during the past several years,' said Missouri Attorney General Jay Nixon. 'There is no excuse for malpractice insurers doubling their rates while their claims payments decrease.'

more . . .

BirthPolicy Proposed NOW Resolution: Opposing Bans on Vaginal Births After Cesarean

BirthPolicy Proposed NOW Resolution: Opposing Bans on Vaginal Births After Cesarean: "NASHVILLE - 7/2/05: The following resolution is being considered by the National Organization for Women during the 2005 National NOW Conference in Nashville, TN from July 1-3.
As presented:


OPPOSING BANS ON VAGINAL BIRTHS AFTER CESAREAN

WHEREAS, the National Organization for Women (NOW) has a long history of supporting women's rights to make reproductive choices; and

WHEREAS, Vaginal Birth After Cesarean (VBAC) has repeatedly been shown to be a safe and reasonable choice for women; and

WHEREAS, studies published by the New England Journal of Medicine and research by the Maternity Center Association show that 588 women must undergo unnecessary cesareans to prevent one compromised perinatal outcome and 7100 women must undergo elective repeat cesareans to prevent one infant death; and

WHEREAS, VBAC labors proceed without the need for emergency surgical intervention 99.6% of the time; and

WHEREAS, elective repeat cesarean poses serious risks to mothers and infants, including two to four times greater chance of maternal death; increased risk of emergency hysterectomy; injury to blood vessels and other organs, chronic pain due to internal scar tissue; increased chance of re-hospitalization; complications involving the placenta in subsequent pregnancies; increased risk of prematurity and low birth weight; a 1-9% chance the baby will be cut during surgery; increased risk of respiratory distress syndrome; and increased risk of childhood asthma; and

WHEREAS, hospitals in every state have banned VBAC; and

WHEREAS, women seeking care in hospitals that ban VBAC have been forcibly anesthetized and sectioned when they tried to withhold consent to surgery; and

WHEREAS, the right to refuse unwanted and unnecessary medical treatment is a fundamental right; and

WHEREAS, the right to bodily integrity is a fundamental right;

THEREFORE BE IT RESOVED THAT, NOW opposes institutional and healthcare policies that deny women's access to VBAC; and

BE IT RESOLVED THAT, NOW's policy statements, brochures, and fact sheets concerning reproductive freedom include references to the need to protect women's access to VBAC; and

BE IT RESOLVED THAT, NOW will work with national maternity care reform organizations to call for Congressional hearings on VBAC bans and other threats to women's choices in childbirth; and

BE IT FINALLY RESOLVED THAT, NOW will work with state and national maternity care reform organizations to advocate for judicial challenges and public policy protecting women's access to informed choice in childbirth and their right to choose VBAC.

Submitted by: Katherine Prown
Issue Hearing: Health and Reproductive Rights
Chair: