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A letter from a hospital explaining why they banned VBAC

I was sent this letter by a mom from Southern California who wants to VBAC at her local hospital, but can’t since they have a VBAC ban.  She wrote a letter to them, which can be found here, and below is what she received in response.  She gave me permission to post both letters.

The letter was written on hospital letterhead.  I have included the entire letter here and it is typed exactly as it was written except for some identifying information that I have removed for the privacy of the OB who wrote the letter as well as the hospital’s name.  Who he is isn’t as important as what he says since he is speaking on behalf of the hospital.

After the letter, I include some commentary.

Also, please read: Two Doctors Respond to the Hastings Indian Medical Center VBAC Ban and Encourage Native American Women to VBAC! and A VBAC Supportive OB’s Response to the AMA’s Statement on Homebirth.

******************************************

March 10, 2008

Dear Ms. B,

I was asked to respond to your letter inquiring about Hospital’s VBAC policy.  Your letter is well written and asks some valid questions.  I will do my best to answer your questions by giving you a historical perspective as well as direct answers.

[....]

Although my primary role involves patient care and administrative duties, I continue to lecture across the country on a variety of obstetrical subjects, with the “Risks and Benefits of Cesarean Section” and “Risks of VBAC” being the two most requested talks I give.  I have personally delivered, or supervised the delivery of over 15,000 births, and continue to be involved in over 5,000 patient encounters per year.

Historically, when Cesarean sections were being performed 40 years ago they were performed through vertical uterine incisions.  These incisions were found to have a uterine rupture rate of 6% in subsequent labors, therefore the standard then was clearly “once a Cesarean, always a Cesarean”.  With the advent of transverse uterine incisions, it was found that women presenting in labor prior to their surgery had a much lower uterine rupture rate than previously documented, and hence the VBAC was born.  Unfortunately, the new uterine rupture rate was simply not known.

In the 70′s, Women’s Right’s groups as well as insurance companies trying to increase profits, pushed the VBAC fury to a point where many institutions began forcing women to VBAC against their wills.  Those of us who knew the procedure was not benign complained of inadequate consent for their patients, and women’s loss of autonomy.  It was not until almost 20 years later, that good modern VBAC data was available, and that the 1/200 (0.5%) uterine rupture rate was documented.

Once the data was available, questions were raised worldwide as to the appropriateness of the procedure.  Here at Hospital, our own obstetricians discussed for over 3 years the both the Ethics and logic behind the VBAC controversies.  The key question is simply whether or not a 1 in 200 risk of fetal death is “acceptable”, and whether or not a woman has a right to make that decision on behalf of an unborn term fetus.  Ultimately, the argument was made that most people would not board an airplane that had a 1 in 200 risk of crashing.  Moreover, we do not allow events to transpire that carry a much lower risk.  For example, it is illegal for a mother to take her newborn baby home from the hospital without a child protective seat (and most parents would not think of doing such a thing).  Yet, the risk of actually being in a car accident on the way home from the hospital is about 100 times less than the risk of a VBAC.  Discussion then took place regarding how good we are at saving mothers and babies that have catastrophic events such as uterine ruptures.  We concluded that “being good” at dealing with disasters was not a good reason for inviting them.  Moreover, in the airline analogy, if we were to invite mom’s to board an airliner that had a 1 in 200 risk of crashing, telling the passengers that only a small percentage of the people onboard would actually die because the hospital and the doctors are good at what they do, is not likely to change their original opinion of declining the flight.

Answering some of your other questions:

I am concerned that if [Hospital] can’t meet the staffing standard for VBACs, that means the hospital doesn’t have the ability to perform an emergency cesarean 23 hors [sic] a day/seven days per week.

[Hospital] is ready to perform emergency cesareans 24×7.  In fact, we are remarkably good at it, and can boast about some of the best outcomes in the world.  Not meeting some of the recommended requirements for VBAC does not infer a lower standard.  Even though we do not have ‘in-house’ anesthesia 24 hours per day, our surgical response time in many cases is better than larger institutions with “in-house” staff.  A large University setting may have in-house staff but simply walking from one side of campus to the other may take more time than driving in from home in our small community.  Moreover, the volume at some of these large centers and logistic delays often encumber those institutions and negatively impact on their response time, whereas [Hospital] has the ability to mobilize and act quickly when needed.

Nevertheless, being good at handling emergencies is not justification for inviting them.  There will always be emergencies in medicine that cannot be staffed or prepared for.  It is a sad fact of life that some women in labor will have heart attacks, and some will have brain tumors or brain aneurysms, and some will have emboli, but no system can have a Cardiologist, a Neurosurgeon, and a pulmonologist available on site 24 x 7 waiting for these things to occur.

We identify these challenges, and we set systems and protocols in place to efficiently handle these emergencies with available resources.  These systems work remarkably well, and fortunately in the majority of cases there is enough time for the mobilization of resources to result in the best possible outcome.

The cesarean rate in this country has risen well above the World Health Organization’s recommended rate of 10%-15%.. I am concerned that the cesarean rate in [our city] is so high…

The WHO recommended cesarean rate is not based on data.  In fact, there are no good published recommendations for cesarean rates that are based on data.  That is for a very good reason, and the reason is that the optimal cesarean rate depends on the goal desired.  If the goal is to optimize neonatal outcome, one can make a very clear and elegant mathematical argument that the cesarean rate should be almost 100%, and that is not a statement that appeals to many, therefore the issue is left mute.  When looking at the morbidity of cesarean sections at term, the majority of complications arise from surgical intervention after failed attempted vaginal delivery.  The actual equations get quite complicated, and depend on multiple factors including the health of the mother, and the planned number of Cesarean sections, and timing between pregnancies. 

When attempted vaginal deliveries are removed from the equation, such as in elective cesarean deliveries at term without labor, the outcomes are much better for the newborns than in vaginal deliveries and the morbidity to the mother can be equivalent or even lower than in attempted vaginal deliveries.  Although we do not consent women for vaginal deliveries, the risks of attempting a vaginal delivery are actually quite high, and carry many of the same risks, if not more, than cesarean sections.  Realize that Cesarean delivery virtually eliminates the risk of birth trauma.  The numbers you quote for fetal injury during Cesarean section are not accurate.  I can tell you the rates you report for newborn injury from Cesarean delivery would not be tolerated and would certainly be identified by quality assurance measures.

You quote statistics in this part of your letter, which are not accurate.  The complication rates for Cesarean sections in the last 20 years have dropped to levels that now are arguably safer than vaginal delivery, and although retained neonatal lung fluid is a very real increased morbidity to the newborns, it carries no long term sequelae in the absence of prematurity, and is more than compensated for by the benefits.

Delivering premature babies, whether by cesarean or vaginal delivery, both have the long-term implications you suggest but are not associated with the route of delivery.

I am concerned that [Hospital] is understating the risks of primary or subsequent cesarean surgeries yet exaggerating the risks of VBAC

The risks of VBAC are very real.  The 1 in 200 risk is an average risk of “catastrophic” uterine rupture taken from many studies across the country.  They do not count smaller ruptures whereupon the baby has not “fallen out” of the uterus yet, as these are often called “windows”.  This leads to the variations in the reporting of uterine rupture.  Those of us who provide care on a regular basis can tell you we see these ruptures frequently, even in the absence of VBACs.  I have seen 3 in the last 6 months at [Hospital].  All were handled well and had good outcomes, but even when trying to minimize these events they happen due to factors beyond our control.  The national death rate from Cesarean sections is less than 1 per 100,000 in most studies.  Unavoidable death due to pregnancy complications unrelated to route of delivery is 1 in 10,000.  When comparing these risks of uterine rupture in VBAC of 1 in 200, you see that the equation very much supports our decision to take the safest route and discourage these procedures.

In summary, the physicians at [Hospital] are very much aware of the dichotomy between what is safest for the unborn fetus and maternal preferences and autonomy.  These controversies are often complicated by lack of data, poorly understood data, and strong emotional components.

I can assure you that we strive to provide the safest medical environment while supporting as much of the autonomy and patient desires as possible.  Nevertheless, we ultimately have to be true to ourselves, and do what science tells us is best for our patients, even if sometimes we cannot please 100% of the clients.

You may find it interesting that since our decision to not offer VBACs, the majority of our patients responded very favorable, with a majority of women reporting a feeling of freedom in not having to justify to others their desire to not VBAC.  Although we expected a backlash of unhappy patients, we were pleasantly surprised to find the majority of women understanding the rationale and supporting our decision.  I now receive less than 2 complaints per year on our decision to not offer VBACs at [Hospital.]

In fact, the greatest increase in our Cesarean section rate the last few years has come from women demanding a Cesarean delivery and refusing vaginal delivery.  The acceptance of women’s autonomy and right to choose their mode of delivery has led to a significant number of women simply choosing Cesarean as the preferred mode of delivery.

If you continue to have strong desires to VBAC despite the risks involved, I am sure your obstetrical provider can help refer you to a University Center where the procedure is still being offered.  Although the risks may not be lower there, they may have chosen to offer the service both for patients and for training of their residents.

Sincerely,

OB

****************************************

This letter was so fascinating for me to read.  I want to make a few comments…

Note the names of his two most requested topics: “The Risks and Benefits of Cesarean Section” and “The Risk of VBACs.”  So interesting that cesareans have benefits, yet VBACs only offer risk.

He says, “If the goal is to optimize neonatal outcome, one can make a very clear and elegant mathematical argument that the cesarean rate should be almost 100%.”  So I wonder of the 15,000 births he has been involved with, how many of those women had cesareans?

He quotes a 6% uterine rupture rate in vertical incisions, which seems very high to me.  This is something I intend to research.  If you have studies you can quote, please leave a comment with that information.

He says, “Historically, when Cesarean sections were being performed 40 years ago they were performed through vertical uterine incisions.  These incisions were found to have a uterine rupture rate of 6% in subsequent labors, therefore the standard then was clearly ‘once a Cesarean, always a Cesarean’.”  Yet, that phrase, when coined 92 years ago, was not a anti-VBAC statement.  Here is the history of that phrase from ACOG themselves (Obstet Gynecol 1997;90:312-5. c 1997 by The American College of Obstetricians and Gynecologists):

The phrase, “once a cesarean, always a cesarean” dates back to an article by Edwin Cragin entitled “Conservatism in Obstetrics” published in 1916. Although cesarean delivery rarely was performed in that era, Cragin’s purpose was to urge physicians to avoid unnecessary cesareans. He termed the cesarean operation “radical obstetric surgery” and urged his colleagues to practice sound obstetrics to avoid having to resort to it. The famous “once a cesarean, always a cesarean” phrase came in the final paragraph of the article and clearly was meant to emphasize that one of the risks of a primary cesarean is that repeat operations might be required.  Interestingly, the author went on to point out that there are many exceptions to this rule and that one of his own patients had 3 vaginal births after cesarean without difficulty. This is remarkable given that vertical uterine incisions were standard at that time. The low transverse uterine incision would be championed by Kerr a decade later.

He says, “Once the data was available [on the risk of uterine rupture with a transverse scar,] questions were raised worldwide as to the appropriateness of the procedure.”  This is something I want to look into further.  I have done little research on VBAC philosophies outside of the USA.

He incorrectly states that 1 in 200 VBAC babies will die.  Landon 2004 stated, “Overall, our data suggest a risk of an adverse perinatal outcome at term among women with a previous cesarean delivery of approximately 1 in 2000 trials of labor (0.46 per 1000), a risk that is quantitatively small but greater than that associated with elective repeated cesarean delivery.” In other words, while the rate of uterine rupture in a spontaneous labor with one prior cesarean is approximately 1 in 250 (0.4%), 1 in 2000 (0.05%) VBAC babies will have a bad outcome.  I have more specific information on infant outcomes here

The OB who wrote our letter above then says, “The key question is simply whether or not a 1 in 200 risk of fetal death is ‘acceptable.’”   I find it ironic that the risk of miscarriage from an first-trimester amniocentesis is greater than the risk of uterine rupture yet that risk is acceptable when women want a diagnostic test. 

From the March of Dimes:

Serious complications from second-trimester amniocentesis are uncommon. However, the procedure does pose a small risk of miscarriage.  According to the Centers for Disease Control and Prevention (CDC), between one in 400 and one in 200 women have a miscarriage after amniocentesis. . . Studies suggest that the risk of miscarriage after first-trimester amniocentesis may be 3 times higher than the risk after second-trimester amniocentesis.

So the risk of miscarriage in a first-trimester amniocentesis is between one in 66 (1.5%) and one in 133 (0.75%), whereas the risk of adverse perinatal outcome in a VBAC labor is one in 2000 (.05%).  Miscarriage is death of a baby.  Rupture does not equal death, as Landon 2004 established.  Yet the March of Dimes describes the risk of miscarriage vis-à-vis amniocentesis as “small” while the number of VBAC-friendly hospitals decrease.  Why is it, when a woman wants a diagnostic test, this risk is ‘acceptable,’ yet when a woman wants a vaginal birth, the normal biological consequence of pregnancy, a smaller risk is unacceptable? I have yet to hear one person make a woman feel guilty about having an amniocentesis because she might kill her baby, yet it is quite common for women seeking VBAC to be treated as if they are accepting an excessive amount of risk.  Yet, I have met women who will not VBAC because the risk is to great, yet, when their OB suggested an amniocentesis, they consent.  (Read more here: Comparing Fetal Death and Injury: VBAC vs. Amniocentesis/CVS.)

He says, “We concluded that ‘being good’ at dealing with disasters was not a good reason for inviting them.”  Is an unnecessary miscarriage from an amniocentesis a disaster?  It certainly is for the mom.  And I have to wonder, does he induce labor?  Because that invites more risk as many hospital procedures do.  More on that later.

He says, “The WHO recommended cesarean rate is not based on data.”  Yet, he did not offer any medical studies that show that women and babies are benefiting from the USA’s 31% cesarean rate.  He only states that he believes babies would benefit from an almost 100% cesarean rate.  I think the burden of proof lies with the person wishing to impose surgery.  Show us how women benefit.  Show us how babies benefit.  Show us how you can ensure that my baby is ready to be born at 38 weeks via scheduled cesarean.  Prove to us that our babies won’t be in the NICU because they simply were not ready to be born and have problems breathing.  A quick google search led me to this commentary from the medical Journal Epidemiology published in July 2007 which states:

Twenty years ago, the World Health Organization recommended that no more than 15% of deliveries should be delivered by C-section, pending evidence that higher levels benefit either mothers or their offspring. Of 60 medium- and high-income countries reviewed in a recent study, the majority (62%) had national rates of C-section above 15%. If we assume, based on the World Health Organization recommendations, that C-section rates above 15% lack medical justification, then there are 3.5 million medically unjustified interventions performed among these countries yearly.

This article cited World Health Organization. Appropriate technology for birth. Lancet. 1985;2:436-437 as the source of the WHO recommended 15% cesarean rate.

The commentary continues: (emphasis mine)

What are the consequences of these trends for the health of women and babies? To the extent that high rates of C-sections are not medically indicated [this includes repeat cesareans], they unnecessarily expose the mother and child to consequences that are not fully understood.  In such procedures, the mother and her partner have no active participation in the birth of their child. The costs and benefits of this elective procedure, both physical and emotional, should be seriously explored before accepting the liberalization of its use.

Elective caesarean section may provide some benefits. A systematic review of 79 studies of elective C-sections versus vaginal deliveries, including observational and randomized trials, has shown that women with C-section have decreased urinary incontinence at 3 months and decreased perineal pain in comparison with those having a vaginal delivery.  On the other hand, C-section was associated with a higher risk of maternal mortality, hysterectomy, ureteral tract and vesical injury, abdominal pain, neonatal respiratory morbidity, fetal death, placenta previa, and uterine rupture in future pregnancies.  One limitation of observational studies is that the associations with poor outcomes could be due to the conditions that trigger the C-section rather than the C-section itself, despite statistical efforts to adjust for these confounders.  Consequently, the strength of this evidence should be considered with caution.

Two recent reviews of observational or ecological studies have examined the association of C-section rates with maternal and neonatal mortality and morbidity. One is the study mentioned above, using data on 60 medium- and high-income countries of all regions, and the other is based on data from Latin American countries.  Both reviews found no evidence for reductions in maternal and neonatal mortality and morbidity with increases in C-section rates to above 10%. In fact, higher rates of C-section were associated with higher rates of maternal and neonatal mortality and morbidity.  For example, Barros et al showed that, between 1982 and 2004, the C-section rate in one city in southern Brazil increased from 28% to 43%, whereas the preterm birth rate has increased from 6% to 16%. The increase in preterm births occurred despite improvements in socioeconomic and nutritional conditions in the population.  The increase in C-section rates and also an increase in elective induction of labor contributed to this trend.

Our doctor from the hospital then discusses recent uterine ruptures.  “Those of us who provide care on a regular basis can tell you we see these ruptures frequently, even in the absence of VBACs.  I have seen 3 in the last 6 months at [Hospital.]“  This is very odd.  Since the hospital does not ‘perform’ VBACs, we can imply that these 3 ruptures occurred to unscarred women.  If you look at this post of mine, you will see that Dr. Marsden Wagner states that the risk of uterine rupture in an unscarred uterus is 1 in 33,000.  We know from medical studies that inducing, especially with Cytotec, results in higher rates of rupture.  In VBACing women, the use of Cytotec to induce increases rupture rates to 1 in 20.  This hospital had 2800 births annually.  Using those numbers, approximately 1400 women gave birth during those 6 months.  If he has seen 3 uterine ruptures in the last 6 months, that means 1 in 467 unscarred, non-VBACing women are rupturing at this hospital.  That is an extremely high number – over 80 times greater than the 1 in 33,000 rate.

“You may find it interesting that since our decision to not offer VBACs, the majority of our patients responded very favorable, with a majority of women reporting a feeling of freedom in not having to justify to others their desire to not VBAC.  Although we expected a backlash of unhappy patients, we were pleasantly surprised to find the majority of women understanding the rationale and supporting our decision.  I now receive less than 2 complaints per year on our decision to not offer VBACs.”  Clearly, the VBAC seeking women need to let their local hospitals know that they are not happy with this policy.  I wonder, of the women seeking VBAC, what percentage went to the next closest hospital offering VBAC vs. had a home VBAC (HBAC) vs. had the repeat cesarean.

“In fact, the greatest increase in our Cesarean section rate the last few years has come from women demanding a Cesarean delivery and refusing vaginal delivery.  The acceptance of women’s autonomy and right to choose their mode of delivery has led to a significant number of women simply choosing Cesarean as the preferred mode of delivery.”  Women have the autonomy and right to choose their mode of delivery as long as it is not a VBAC.  They don’t have that right.

Ladies, this is what we are up against.  Reading this letter makes me wonder what is more likely: To convince hospitals like this to change their policy or to educate women on home VBACs?  I don’t think hospital with VBAC bans are going to change their policy.  Why should they?  Scheduled cesareans are easier for the OB and the hospital and it is certainly the fashion to not ‘do’ VBACs. 

If we are going to change VBAC bans, we need to identify how permitting VBACs are to the hospitals’ advantage.  And I think the best way of doing this is by affecting the hospitals’ pocketbook.  If all hospital birthing women, scarred and not, could ban together and birth ONLY at hospitals that permit VBACs, that would make an impact.  The question is, how do we accomplish this?

My local hospital instituted a VBAC ban just last week and there is a part of me that wants to ‘do something.’  But then I wonder, how many women will ‘discover’ homebirth/home VBAC/HBAC as a result of VBAC bans?  How many women will be forever changed by giving birth in their living room?  How many women will never have another hospital birth simply because their local hospital wouldn’t permit it and those women had to either expand their mind to homebirth or be cut once again? 

There is a part of me that sees these VBAC bans as a positive thing.  If we couple publicity of these bans with information on homebirth, we could turn this tide against VBAC around one woman at a time.  In looking at the stats for this website, one of the most common searches is on the legality of homebirth, VBAC, and HBAC.  I want women to know that it is legal to VBAC.  Just because you local hospital has banned it, or your local OB doesn’t ‘do VBAC,’ doesn’t mean that it is illegal in your state.  So many women are told by medical professionals and hospital personnel that VBACs are illegal.  I don’t know if these med pros are actively lying or have been mislead to think that VBACs are illegal, but they are not.  I want women to know that if their hospital has banned VBAC, you have options.  There are other ways to find VBAC supportive hospitals, OBs, and, of course, midwives. 

You do not have to have another cesarean.  You can birth your child.  A good place to start?  Join the ICAN email support group and start planning your VBAC.  Contact your local, county, and state representatives and tell them that you want VBAC available in your local hospitals, that you want midwives to be able to attend VBACs, that you don’t want to have surgery again.  Write your local hospital so they know that women are not happy with their VBAC ban.  And if you local hospital supports VBAC, send them a thank you note and let them know how much you appreciate the option. 

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24 comments to A letter from a hospital explaining why they banned VBAC

  • [...] A Letter From A Hospital Explaining Why They Banned VBAC [...]

  • Wow! Thanks for sharing this and providing your critique. I imagine that any number of women could read the OB’s letter and determine that it made sense (some or all of it). But you deconstructed the letter and interpreted it from a mother/baby-friendly perspective.

  • Kim

    “are arguably safer than vaginal delivery, and although retained neonatal lung fluid is a very real increased morbidity to the newborns, it carries no long term sequelae in the absence of prematurity, and is more than compensated for by the benefits”
    In response to this comment, he completely ignores the BENEFIT to mothers and babies by being able to be together and breastfeed! Yes bottlefeeding (or tubefeeding) pumped breastmilk is better than formula, he is saying it is ok to submit babies and moms to risks of not breastfeeding by having babies in NICU’s while moms are stuck in post op beds. Not only that but there is research that shows that the cs baby’s gut is absent the same good bacteria of vb babies that prevent illness for the first 6 months of life. Thats just from having a cs, add to that the practice of gastric suctioning to try to releive the baby of the retained fluid and diminish respiratory distress and you have a baby even more susceptible. Although so many things in the letter provoked a blood boiling response in me, the retained fetal fluid and time in the NICU separated from family being an acceptable risk compared to UR and whatever other benefits to baby he sees in RCS vs VBAC put me over the edge.

  • Stephanie

    I think as consumers go we have a RIGHT to know at least which hospital this is so we can avoid it!

  • If only I could see the person who wrote this letter. I’m sure the visual of loads of crap oozing out of his ears would be a sight to see!

    And, amazingly, this is not a form letter!! I am beyond shocked.

  • Jen,
    This is an interesting letter and a great rebuttal. While VBAC bans may encourage some moms to go the homebirth route, I am afraid that most moms will only hear that VBACs are dangerous and stop there. If the OBs were more supportive of VBACs than more moms would choose them, or at least know it was an option. I think most moms hear their OB say it isn’t an option and then think it really isn’t.

  • Jen:

    Thanks for the letter (I can’t believe you retyped it!) One thing that struck me immediately is the condescending tone. Not one of discussion but simply dismissing facts without consideration.

    I also noticed that he (I’m assuming here) equated uterine rupture with fetal demise, albeit subtly. Those types of maneuvers only feed fear amongst previous C/S moms, making it seem that any complication with delivery will lead to their baby dying.

    Keep up the strong work. I agree that mom’s sentiments can change but it will take continued hard work and discussion.

    Dr. Loveless

    “Oh you’re pregnant? Who is your midwife?”

  • Ute

    “The acceptance of women’s autonomy and right to choose their mode of delivery has led to a significant number of women simply choosing Cesarean as the preferred mode of delivery.”

    Well, goody then… let’s all have c-sections!!

    Ugh!

    Ute, who had a V2BAC!

  • Thank you for this article. It is extraordinary. I am posting a link to it on my blog.

    “Why is it, when a woman wants a diagnostic test, this risk is ‘acceptable,’ yet when a woman wants a vaginal birth, the normal biological consequence of pregnancy, a smaller risk is unacceptable? I have yet to hear one person make a woman feel guilty about having an amniocentesis because she might kill her baby, yet it is quite common for women seeking VBAC to be treated as if they are accepting an excessive amount of risk. Yet, I have met women who will not VBAC because the risk is to great, yet, when their OB suggested an amniocentesis, they consent.”

    This is but one of many, many such inconsistencies and incongruencies in obstetrics.

    I am a baby advocate and I believe that the baby is fully present and aware, experiences and remembers birth, and is profoundly impacted. 100% cesarean rate because it is safer for the baby!?!? This is so unscientific, illogical, and criminal.

    Keep up the great work.

  • This is amazing. I posted it on TrueBirth as well, in the Internet News section. Great work!

  • Cassia

    Wow. Now, I can’t remember my sources… but I seem to remember reading that hospitals can’t *legally* ban VBACs…. OK, found it: http://www.ican-online.org/vbac/your-right-refuse-what-do-if-your-hospital-has-banned-vbac-q

    I guess that applies to federally funded hospitals, at least.

    Oh, and I love how he completely ignores the risk a C/S puts on future pregnancies–no matter what the birth mode of “choice” may be.

  • Karen

    VBAC a procedure? You don’t do a VBAC to anyone! Mothers birth their babies, simple.

    Clearly this OB needs to update his anatomy knowledge as he obviously is not aware of the difference between his posterior and his elbow. *sigh*

  • [...] VBAC Facts post – A letter from a hospital explaining its ban [...]

  • Hey Jen, I know this is an old blog post, but you know me. I can’t leave a page asking for stats on risk of rupture after an unusual incision. :-) So here you go, from the Landon Study:

    Low Transverse – 0.7%
    Low Vertical – 2.0%
    Classical, Inverted T or J – 1.9%
    Unknown – 0.5%

  • The only thing I can say is… wow….

    The majority of women in this country would look at this letter, see that there are untold risks of rupture with a VBAC and instantly schedule their cesarean.

    The few remaining will fight the decision, and if even a little thing goes wrong, everyone is blaming the mother because she didn’t do what was best for her baby and have a cesarean.

    Sure, rupture is real. But you actually have a 99% chance of NOT HAVING ONE. Some doctors have never even seen a rupture, even a little one (and I’m talking about the VBAC doctors that still cover it).

    Our country is losing its mind, and it is beginning with birth…

  • Anthony

    Well written letter by the physician. VBAC’s are very risky. I’ve lived through the personal horror of a catastrophe. And trust me it was catastrophic. I nearly lost my wife and full term son. My son now lives his life as a quadriplegic with Cerebral Palsy. You can’t convince me it’s worth the risk. Not for the child, not for the mother, not for the family, and not for the doctor and hospital.

    Greedy insurance companies thought they could turn profits by forcing VBAC’s on mothers. The doctor’s letter is true to form and his statistics are on the money. If you care about people, mothers, babies, and family, “Don’t push for VBAC’S” do the opposite.

    • Jen Kamel

      Anthony,

      I am so sorry about your son. That must have been horrible.

      I agree that the policies in place during the 90s when insurance companies were pushing VBAC were entirely unsafe. VBAC became required in some places and some women were not given a choice about whether or not to VBAC. This resulted in women with contra-indications to VBAC experiencing bad outcomes. Women in crowded hospitals did not receive good care and had bad outcomes. Women desiring trials of labor after cesareans were induced and had bad outcomes. And all of this resulted in VBAC getting a bad name. “Instead of blaming the overuse of induction, mandatory VBACs regardless of suitability, and mismanagement of labor, doctors began saying that it was actually VBAC that was unsafe.” You can read more on the history of VBAC here.

      Fortunately, we know more know about the risks and benefits of VBAC and repeat cesareans than we did in the 90s. Like how rupture rates vary depending on the scar type (Landon, 2004), how the risks of cesareans increase with each surgery (Silver, 2006) and the risk of uterine rupture and other complications decrease after the first VBAC (Mercer, 2008). We know now that inducing increases the risk of uterine rupture (Landon, 2004). And we know that the risk of a baby dying or experiencing oxygen deprivation in a trial of labor after cesarean (0.05%) is similar to the risk of the mom dying during a repeat cesarean (0.04%) (Landon, 2004). So neither option is inherently safe or risky. Both offer a different set of risks. I think it’s important for women to understand these risks when considering their options. I wrote a summary here: Nervous About Planning a VBAC.

      Once again, I’m so sorry about your son and I thank you for taking the time to leave your comment.

      Warmly,

      Jen

  • Anthony

    I still agree with the doctor’s letter above. Why invite the risk? and it is way way too risky. How could the liability limits of a midwife, or small hospital possibly cover such a tragedy? Should that be handled by malpractice reform? By allowing our health professionals to be unaccountable? Recovery for even economic loss is nearly impossible today. The liability is tremendous. Childbirth is already risky enough. I agree that induction may be a contributing factor and maybe more research should be done on those drugs and their use. Cervadil was used to induce my wife, and it was contra-indicated at that time in women with a scarred uterus by “the Physicians Desk Reference”; but that didn’t stop it’s use. This catastrophe didn’t happen in a busy hospital. It happened because the hospital and physicians were not prepared to deal with the profound emergency. I see no benefit to anyone, by lobbying for VBAC’S. Thanks for the reply

    • Jen Kamel

      Anthony,

      There is about a 0.4% risk of having a uterine rupture with one prior low transverse cesarean in a spontaneous labor (meaning you weren’t induced or given Pitocin or other similar drugs during your labor) (Landon, 2004). One would think that with all the hoopla about uterine rupture, that this rate would be significantly higher than other obstetrical complications.

      You might be surprised to learn that uterine rupture occurs at a similar rate to other obstetrical complications such as post partum hemorrhage, cord prolapse or placental abruption! And when we look at infant outcomes, there is about a 6% chance of infant death or oxygen deprivation after an uterine rupture (Landon, 2004) compared to the 12% risk of infant death after a placental abruption (Ananth, 1999).

      Yet how many first time moms worry their entire pregnancies about any of those complications? How many considered an elective primary cesarean in an attempt to circumvent them? How many were offered, or even strongly pressured, to consider an elective cesarean by their friends, family, or OB? How many where made to feel selfish over their desire to plan a vaginal birth?

      Meanwhile moms planning a VBAC are often made to feel that having a repeat cesarean is the most prudent, conservative choice whereas only selfish women who wish to experience vaginal birth plan a VBAC. Only people who do not understand the statistics would make such a bold claim.

      And where are all the lawsuits resulting from the infant deaths as a result of placental abruption? Why aren’t people outraged that all these babies are dying as a result of selfish moms who should have been prudent and had scheduled cesareans to prevent this tragedy? We hold VBAC to such an impossible standard because the tolerance for risk has been reduced to zero.

      The problem is that most people don’t understand the rate of obstetrical complications in a first time mom. Conventional wisdom and rumor does not give your average individual enough information to adequately compare the risks of a primary vaginal birth, repeat vaginal birth, primary cesarean, repeat cesarean, primary VBAC and repeat VBAC. That is why we have medical studies because even doctors, who themselves attend thousands of births over their career, do not control for variables like researchers do. Doctors focus on practicing medicine whereas researchers, who are often medical doctors who still see patients, focus on constructing studies, maintaining records, and controlling for variables. All of this enables researchers to accurately detect and measure the incidence of complications and also identify larger patterns.

      One thing we have learned from medical studies is that the risk of infant death during a VBAC attempt is “similar to the risk” of infant death during the labor of a first time mom (Smith, 2002). Should all first time moms have cesareans because their labor is just to risky?

      Let’s not forget that while a cesarean could prevent a would-be uterine rupture, placental abruption, or cord prolapse, cesareans themselves introduce many serious risks. In the face of immediate death or damage to mom or baby, these risks are absolutely acceptable. However, when we are performing major abdominal surgery on the other 99.6% of women who will not have a uterine rupture, we are subjecting them to an unnecessary level of risk.

      There are several complications that occur during a second scheduled cesarean section at a rate similar to or greater than the risk of uterine rupture during a spontaneous trial of labor after cesarean after one prior low transverse cesarean (0.4%) (Landon 2004). These complications include hysterectomy (0.42%), any blood transfusion (1.53%), a blood transfusion of four or more units (0.48%), maternal intensive care unit admission (0.57%), maternal wound infection (0.94%), and endometritis (2.56%) (Silver, 2006). And while Silver (2006) found that the maternal death rate was “only” 0.07% during a second cesarean, this is 3.5 times higher than the rate of maternal death in a trial of labor after cesarean (0.02%) and 1.4 times higher than the risk of infant death or oxygen deprivation (0.05%) (Landon, 2004.) Keep in mind that all the cesareans included in the Silver (2006) study were scheduled. All the complications noted were a direct result of the surgery, not of any other medical complication.

      These are important facts for people to know before they make the judgment of which option is more “risky:” VBAC vs. repeat cesarean. It’s not enough to understand the risks of VBAC, one must also understand the risks of cesarean section. Only then can one see that neither are inherently safe or risky. They both offer a different set of risks. You can read more about the specific risks that cesareans pose in the article The risks of cesarean sections.

      Cesareans also have major implications for all future pregnancies and delivery options. The risks of complications increase with each cesarean section which make subsequent pregnancies more precarious which increases the likelihood of a bad outcome for mom or baby. According to Silver (2006), a four year study of up to six repeat cesareans in 30,000 women:

      Increased risks of placenta accreta, hysterectomy, transfusion of 4 units or more of packed red blood cells, [bladder injury], bowel injury, urethral injury, ileus [absence of muscular contractions of the intestine which normally move the food through the system], ICU admission, and longer operative time were seen with an increasing number of cesarean deliveries…. After the first cesarean, increased risk of placenta previa, need for postoperative (maternal) ventilator support, and more hospital days were seen with increasing number of cesarean deliveries.

      Because the risks of cesarean are so great, they conclude their study with the following statement, “Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery.”

      Additionally, scheduled cesarean section puts anyone else who experiences a medical emergency requiring surgery in danger because those operating rooms become unavailable. I wonder how often women with true obstetrical complications requiring immediate cesareans, such as your wife, or non-obstetrical emergencies such as car accident or gunshot victims, have been unable to receive that urgent, time sensitive care due to otherwise healthy moms and healthy babies undergoing scheduled elective repeat cesareans and tying up the operating rooms? With 92% of women having repeat cesareans (Martin, 2006), I’m sure it’s happened, especially in smaller hospitals, many of which only have one or two operating rooms. These routine repeat cesareans impact everyone and it’s only going to get worse.

      According to the CDC (Menacker, 2010), “The number of cesarean births increased by 71% from 1996 (797,119) to 2007 (1,367,049) [and] In 2007, approximately 1.4 million women had a cesarean birth, representing 32% of all births, the highest rate ever recorded in the United States and higher than rates in most other industrialized countries.” The latest data from the CDC shows that 92% of women have a repeat cesarean (Martin, 2009). So with 1.4 million cesareans, we can look forward to approximately 1.26 million repeat cesareans in the future. With primary cesarean rates growing, our repeat cesarean rate will grow, we will witness more of the complications identified by Silver (2006), including more maternal deaths, and more cases of people who really need emergency surgery dying because operating rooms are filled with otherwise healthy moms and babies undergoing scheduled cesareans.

      You said, “It happened because the hospital and physicians were not prepared to deal with the profound emergency.” I would gently suggest that the problem was more with your hospital than VBAC. They induced your wife with a drug that was contraindicated in a trial of labor after cesarean and then were unprepared for an obstetrical emergency. If your wife had a placental abruption or a serious complication from a repeat cesarean, it sounds like they would have been just as unprepared. That is an entirely separate issue than whether VBACs are excessively risky.

      Thank you again for your comments and I wish you the best.

      Warmly,

      Jen

  • Anthony

    Your statistics mean is nowhere near the mean quoted in the doctors letter. This doctor has performed how many births? and participated in many more. He travels around the country lecturing on this subject? His mean is 2.5% not .05%. .05% is risky too. But I believe 2.5% is more likely for for complications with VBAC.

    Accidental death from cesarean he pegs at .001%. That’s .00001

    • Jen Kamel

      Anthony,

      His statistics are wrong. That is why I posted the letter. I wanted to illustrate how important it is to educate yourself because some OBs just don’t know and give incorrect information. Please read my comment above on the differences between an OB’s opinion and medical research.

      There is not one large study on VBAC that shows a fetal mortality rate of 1 in 200 (0.5%.) Please check out my bibliography. I’ve read all these studies. If you can find a study on VBAC including over 5,000 women, controlling for scar type, induction method and dose that shows an infant mortality rate of 0.5%, I would love to see it.

      Warmly,

      Jen

  • Laura

    Thank you for creating this page. I am trying to understand why the majority of hospitals in my area have banned v-bac, no matter what the patient history is. The even scarier part of this issue, is the lack of support women offer each other! Even my friends are anti-supportive and claim I am being dramatic. Excuse me for being spirited enough to complain about being forced to undergo major surgery, when it is unnecessary. I guess my only choice is to deliver at a hospital 2 hours away or figure out how to home birth? I sort of don’t even trust a vbac acceptable hospital either. Maybe the claim is just a ploy to get you there and then they will do a c-section anyway? The home birth decision scares me because of the few what-ifs. I am glad I am not pregnant yet because I feel like I just walked into a mine field.

  • [...] article can be found here.  The author gives us access to an actual letter written by a doctor who delivers babies in a [...]

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