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Another VBAC consult misinforms

At the NIH VBAC Conference, I was happy to hear the draft Consensus Statement acknowledge that there were non-medical factors that affect women’s access to VBAC:

We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL [trial of labor after cesarean]. . . We are concerned that medico-legal considerations add to, as well as exacerbate, these barriers.

Many women assume that their local hospital has banned VBAC, or their OB doesn’t attend them, because VBAC is excessively dangerous.  Most women are unaware of the many non-medical factors that play into VBAC accessibility.

What disappointed me, however, was the panel’s surprise at the misinformation and bait & switch tactics to which many women are subjected.  I think when you are a VBAC supportive practitioner, it may be hard to believe that your colleagues practice in a manner like I describe below.

To give you an idea of the kind of advice that many, many moms seeking VBAC receive, here are excerpts of an email from Brooke Addley of northeastern Pennsylvania.  She decided to ask her OB about VBAC at her annual exam in March 2010.  This is what happened:

Once I brought the subject up stating that I really would not be open to a c-section unless it was medically necessary he said “they are all medically necessary” and then went on to mention that just within this last month there were two major ruptures at the local hospital.  From there he just talked about the risk of VBAC and how catastrophic it could be if there was a rupture.

A uterine rupture can be catastrophic, but it is rare and the incidence of uterine rupture is comparable to other obstetrical emergencies such as placental abruption which has a worldwide rate of 1%.  As Mona Lydon-Rochelle PhD, MPH, MS, CNM said at the NIH VBAC conference, “There is a major misperception that TOLAC [trial of labor after cesarean] is extremely risky” and George Macones MD who stated in terms of VBAC, “Your risk is really, really quite low.”  Additionally, 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).

One of the factors discussed at the NIH VBAC conference is that a practitioner is less likely to offer VBAC if they have experienced a uterine rupture, particularly if there is a bad outcome.  However, that ethically should not interfere with him providing his client with accurate information on the rate of uterine rupture as well as studies that substantiate the rate provided.

When I cited the low rate of uterine rupture [of 0.5% - 2% after one prior low transverse cesarean] he said “that information is incorrect and the rate is actually higher.”  Yet when I asked him to lead me in the direction of the study or studies where he found that out he said there isn’t any because many women have repeat [cesareans] and once in the OR it is discovered that they have a thin window in their uterus and if they labored/pushed it would have ruptured for sure.

The rate of rupture in a spontaneous labor after one prior low transverse incision is 0.4% (Landon, 2004). So not only did he give her an inaccurate picture about the rate of rupture, but he led her to believe that there are no studies on VBAC.  (I always wonder in situations like these: Is the OB really actively trying to mislead the patient or is he really so misinformed?)  This OB should read the NIH VBAC conference Program & Abstracts, or my VBAC Class bibliography, to see that in fact there are many studies on VBAC.

Then the OB gives her inaccurate information on VBAC success rates:

I asked the VBAC success rate and he said that most fail.

VBACs have a success rate of about 75% which has been the conclusion of many studies  (Coassolo, 2005; Huang, 2002; Landon, 2005; Landon, 2006; Macones, 2005).  Success rates vary based on a variety of factors, but to say that ‘most fail’ is absolutely false.  What this OB should say is, “Most women who attempt a VBAC with me as their care provider fail,” which is probably 100% true.

And then the OB gives her the line that many women fall for:

He did however say that although he really does not recommend it . . . he would allow me to try.

And there is the hook.  So many women are satisfied to simply be given the opportunity to VBAC.  Unfortunately, from what this OB has said already, I do not believe Brooke would have a genuine opportunity to VBAC.  Surely this OB would come up with some “valid medical reason” that she needs a cesarean sometime during her pregnancy or labor.  Here come the requirements to be granted a trail of labor:

…yet there are many things that would have to be taken into consideration, including my unproven pelvis. He mentioned that in the hospital I would have to have continuous monitoring and 18 hours after my water broke, if I was not progressing, they would want to use Pitocin to advance the labor.  He also mentioned that he does not allow any woman under his care to go past 40 weeks.

The unproven pelvis standard is bizarre.  Don’t all women pregnant with their first child have an unproven pelvis?  Do we offer them all of them an elective primary cesarean to prevent a “failed vaginal delivery?”

No stereotypical VBAC consult full of misinformation is complete without a healthy helping of repeat cesarean risk minimization:

He did not mention risks to repeat c-sections.  When I brought it up he said there aren’t any except the obvious risks that come with any surgery.

False, false, false.  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 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.

It is quite typical for a woman to receive inflated rates of uterine rupture while the practitioner minimizes the risks of repeat cesarean.  This OB goes one step further and claims there are no risks at all besides the general risks associated with surgery.

It is no wonder that most women ‘chose’ repeat cesareans and only 45% of American women are interested in the option of a VBAC (Declercq, 2006).  What kind of choice is it when you make major medical decisions without even a fraction of accurate information?

There is much discussion and debate about what constitutes informed consent.  However, there is no debate that informed consent fundamentally consists of understanding the risks and benefits of your options.  When a woman only hears the (inflated) risks of option one and the (inaccurate) nonexistent risks of option two, it is clear that her practitioner is trying to influence her final decision by skewing the information provided.

Finally, the OB suggests that the desire to have a vaginal birth and avoid medically unnecessary surgery warrants psychological help:

I flat out said to him that I just cannot have another c-section [without medical indication] and he told me that I need to see a therapist, [that] it’s not that big of a deal and it is the safest way to go!

It might be helpful for this OB, and others who think like him, to learn more about how women are impacted by their cesareans.  Cesareans performed on otherwise healthy babies and healthy moms are absolutely a big deal to many women.  Even when cesareans are medically indicated, there are women who still mourn the loss of a vaginal birth even as they celebrate their healthy baby and the technology that made their entrance into the world safe.  Read American Women Speak About VBAC for more personal stories.

Then the OB makes it sound like he’s the only game in town:

Oh and then at the very end he said I could always go with another provider but he is pretty much the most open to VBAC.  I flat out told him that he is not VBAC friendly at all and that if he is the most open in town I have quite the battle ahead of me.

The emotional fallout of the appointment:

The entire visit I just had to hold back tears and once I hit the street I lost it.  I just want to hit my head against a wall!! I’m just sad, sad that it has to be this way – sad that, as much as I want to have another baby, I dread getting pregnant.  Sad that women are told this shit and forced to believe it.  I’m just in such a funk now…..just a sad, sad funk.

But it’s not just Brooke.

Michelle was told by her OB that uterine rupture rates increase with each VBAC which contradicts a 2008 study that concluded the risk of uterine rupture drops 50% after the first VBAC (Mercer, 2008).  One of the women who attended the VBAC class this past Sunday said that her OB quoted a uterine rupture rate of 6-10% after one prior low transverse cesarean. Sarah was quoted a rate of 10% “after the first section.”  Karla was also quoted 10% and called “selfish” by her OB who was “appalled that [she] would risk the life of [her] baby.”  Once again, the correct rate for uterine rupture in a spontaneous labor after one prior low transverse cesarean is 0.4% (Landon, 2004) and these women are quoted rates 15 – 25 times higher.

Another way doctors lie is by circumventing the risk of VBAC issue entirely.  A friend told me that her doctor said her medical insurance wouldn’t pay for a VBAC.  So believing her doctor and thinking she didn’t have any other option, she had a scheduled repeat cesarean. Turns out, my friend had the same medical insurance as me and that same insurance reimbursed me for my homebirth VBAC.

And who can forget the irate mom who left a comment on the VBACfacts Facebook fan page expressing her disbelief that any “selfish idiot” would pursue a VBAC.  Her OB told her that there was a 10% infant and maternal mortality rate with trials of labor after cesarean.  When I emailed her with the correct rates of 0.02% for maternal mortality and 0.05% for infant death or brain damage (Landon, 2004) and requested she forward any studies supporting a 10% mortality rate, she didn’t reply.

VBAC consults that misinform are all to common and help contribute to the 90% repeat cesarean rate in American (Hamilton, 2009).  If you are a VBAC supportive practitioner, and would like to make it easier for women in your community to find you, please read: How to best connect moms with VBAC supportive practitioners?

Learn more about finding a supportive care provider:

______________________________________________________

Coassolo, K. M., Stamilio, D. M., Pare, E., Peipert, J. F., Stevens, E., Nelson, D., et al. (2005). Safety and Efficacy of Vaginal Birth After Cesarean Attempts at or Beyond 40 Weeks Gestation. Obstetrics & Gynecology , 106, 700-6.

Declercq, E. R., & Sakala, C. (2006). Listening to Mothers II: Reports of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection.

Hamilton, B. E., Martin, J. A., & Ventura, S. J. (2009, March 18). Births: Preliminary Data for 2007. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_12.pdf

Huang, W. H., Nakashima, D. K., Rumney, P. J., Keegan, K. A., & Chan, K. (2002). Interdelivery Interval and the Success of Vaginal Birth After Cesarean Delivery. Obstetrics & Gynecology , 99, 41-44.

Landon, M. B., Hauth, J. C., & Leveno, K. J. (2004). Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery. The New England Journal of Medicine , 351, 2581-2589.

Landon, M. B., Leindecker, S., Spong, C., Hauth, J., Bloom, S., Varner, M., et al. (2005). The MFMU Cesarean Registry: Factors affecting the success of trial of labor after previous cesarean delivery. American Journal of Obstetrics and Gynecology , 193, 1016-1023.

Landon, M. B., Spong, C. Y., & Tom, E. (2006). Risk of Uterine Rupture With a Trial of Labor in Women with Multiple and Single Prior Cesarean Delivery. Obstetrics & Gynecology , 108, 12-20.

Macones, G. A., Cahill, A., Pare, E., Stamilio, D. M., Ratcliffe, S., Stevens, E., et al. (2005). Obstetric outcomes in women with two prior cesarean deliveries: Is vaginal birth after cesarean delivery a viable option? American Journal of Obstetrics and Gynecology , 192, 1223-9.

Mercer, B. M., Gilbert, S., Landon, M. B., & Spong, C. Y. (2008). Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Obstetrics & Gynecology , 11, 285-91.

Silver, R. M., Landon, M. B., Rouse, D. J., & Leveno, K. J. (2006). Maternal Morbidity Associated with Multiple Repeat Cesarean Deliveries. Obstetrics & Gynecology , 107, 1226-32.

Smith, G. C., Pell, J. P., Cameron, A. D., & Dobbie, R. (2002). Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies. Journal of the American Medical Association , 287 (20), 2684-2690.

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25 comments to Another VBAC consult misinforms

  • Thanks so much for this wonderful post! This story is being repeated all over the country! I am immediately sharing this on facebook and with our local ICAN chapter! A hard read but so true!

    Sharon

  • Thank you for this BLOG! I will begin sharing this immediately on my FB page and with my Mothers that I work with. It is so frustrating. If OB’s are lying or misleading us with this….what else are we being mislead about.

    Sharon

  • This sounds almost *exactly* like the conversation I had with my original OB at my 36 week appointment. And even though I had the opportunity to switch care providers (and go on to have a successful VBAC four weeks later), I often wonder about all of those women who either didn’t know that they were being purposefully lied to or who just didn’t want to *fight* at the end of their pregnancy simply to give birth vaginally.

    Thanks for writing this post. Hopefully it helps lots of women out there turn away from the scare tactics and misinformation BEFORE they enter the third (or second…or first!) trimester!

  • Yes, unfortunately the environment that many physicians practice in does NOT encourage them to follow the tenets of Full Informed Consent. In Fact, many hospital policies, and apparently the malpractice insurance “rules” and pressures dictate what a physician can and can’t say. In our area, a physician that was actually telling the truth, and providing women with proper & full informed consent was told that unless he stopped “allowing” women access to VBAC that he would be put on medical review. It goes above the physicians. Medical schools, National organization, the State medical boards, and hospital administrators must DEMAND and implement policies that provide full informed consent and right to refusal of treatment for all woman, whether the woman wants a VBAC, a repeat cesarean, does not want an IV, refuses continuous EFM, etc.
    Full Informed Consent is every Womans right!

  • “I always wonder in situations like these: Is the OB really actively trying to mislead the patient or is he really so misinformed?”

    I think BOTH and unfortunately I have found a lot of the latter. Many OBs it seems graduate from school, complete their residency and never pick up another journal Green or otherwise. I have personally had numerous conversations with various providers about things such as inductions, hemorrhage, VBAC, skin to skin, breastfeeding, cesareans etc and find they are NOT up to date. They are not reading the research and if they are…. they don’t seem to “get it.” What’s just as bad…. they do not even use the recommendations put forth by their own ACOG! Its INSANE!! I have actually said to a provider…. Have you read your Green Journal lately LOL…. He didn’t think it was funny!

    THANKS a million times for this article. This is a GREAT piece and so true unfortunately so true…..

    Nicole

  • Birth in Eastern PA

    I am going to start a blog where women in eastern PA can share their experiences–good or bad–with peri-natal care providers (OB’s, midwives, doulas, lactation consultants, massage therapists…). I want women to be able to share NAMES of the providers. This blog is going to be a review site of sorts. PLEASE pass my e-mail address (birthineasternpa at yahoo dot com) along to Brooke and ask her to e-mail her story to me if she would like it to be included. I will need to keep a record of the names of the women submitting stories, though they do not have to have their names listed if they do not want to.

  • Someone I know was recently talking with the chief OB at a rather large OB/GYN practice in my area…and that OB did not know about the NIH VBAC conference AT ALL!

    I just find this completely shocking. I’m a doula, not making nearly the level of decisions that this OB makes…and I was AT the NIH conference because I wanted my voice to be heard, and I wanted to make sure I was aware of the latest research. In my professional life (pick one…childbirth, or my previous profession in Environmental, Health & Employee Safety), though I certainly can not attend every conference that is out there, I certainly knew about the “big” conferences like this and followed them.

  • Carrie Ballek

    Hi Jen K.,

    Please give Brooke my contact information for ICAN of Lehigh Valley. Although there is not currently an ICAN chapter in northestern PA (I’m working on it!), I have many VBAC moms contacting me (we’re about 1-2 hours south of her in Allentown). What is happening in her area is appalling (I have heard similar stories unfortunately) but I know of a few women who have had really wonderful HBACs and HBA2Cs in that area too.

    Carrie Ballek
    Chapter Leader, ICAN of Lehigh Valley
    icanoflehighvalley@yahoo.com

  • Naomi

    You know, I cannot help but wonder: How do the OBs that outright lie to women on a routine basis live with themselves?

    I think it should be 100% illegal to deliberately misinform your patients. That sounds like malpractice to me.

    What recourse do women have when they find that an OB is lying to them? It seems to me that there should be some sort of corrective mechanism for doctors lying to their patients to deliberately skew the process of “informed consent”.

  • stephanie

    Thank you for this post. Sadly, these same care providers are the ones making up the reasons for the unnecessary inductions and interventions that lead to the primary sections to begin with. And in our later years, the same ones who recommend hysterectomy for common problems when there are less invasive and just as effective treatments. Again, all without completely honest and open discussion regarding the risks and benefits of ALL the alternatives.

  • Megan

    I had an emergency C section with my first. Then I had an amazing VBAC with no complications what so ever with my second, and infact my doctor told me I should really try VBAC and im so glad. Now im pregnant with my third, and my doctor told me I have a 4-7% chance of rupture. And C-section should be first on my mind. I really want to do VBAC, it was great the first time. Im glad I read this, cause my doctor (who is really pushy and rude at times) had me in tears thinking I was gonna make the wrong choice.

  • [...] bans (Kamel, 2010); unsupportive health care providers, friends, and family (Kamel, 2009b & 2010b); or the misrepresentation of VBAC risks (Kamel, 2009b & [...]

  • momtobeagain

    Hi, I had a cs delivery last 2004 with out any warning. I had no labor pains or whatsoever but the OB decided to cs me. I was very young then and did not know any better so I just said yes. Now, I am expecting my 2nd child due on feb 2012 and really want a VBAC. my OB told me I only have 30-40% chance of success rate for vbac, and that is if I had a low segment type of CS and not classical cs (I will ask my prev OB what I had). because if I had been classically cs-ed then she said there is no way she will risk me into labor as there will be 99.9% uterine rupture chance. This is very scary but then I have read a lot about here and having trust issues on her. Now I do not know if I will believe her and just go with whatever she says coz she’s the doctor after all or should I still push thru with what I want, a VBAC that is? Is it true that if I had classical CS, there is no way I can have tolac? pls reply. thanks.

    • Jen Kamel

      Momtobeagain,

      You will almost certainly have another cesarean with this OB. The question is, are you ok with that? If you aren’t, it’s time to find another care provider. You can find more information here: .

      Your doctor has already given you some questionable and false information.

      The average rate of VBAC success is around 70-75%. Where is your OB getting this 30-40% number?

      Additionally, while the risk of rupture is certainly higher with a classical incision vs. a low transverse (“bikini cut”) incision, it is nowhere near 99.9%. That is just a flat out lie. According to this chart, the risk of rupture in a classical incision is 1.2% or 1 in 83 births. Now the Landon 2004 study found that the risk of rupture in a spontaneous labor after one bikini cut cesarean was 0.4% which means that the risk of rupture with a classical incision is much greater. But that is assuming that you have a classical incision. Can you contact your old OB to get your medical records to confirm? Here is information on how do to that: http://vbacfacts.com/2008/06/09/the-cost-of-getting-your-medical-records/.

      Warmly,

      Jen

      • momtobeagain

        Hi Jen,

        Thank you for your reply. I was able to get my old record from my prev OB. It says I had a low transverse cut cs with her signature on it. I am hesitant to look for another OB as I am very near my due (feb 11, 2012) and I will be full term this jan 21(37 weeks) already. I ams ure that I do not want another CS this time and I was kind of depressed upon realizing that she may eventually decide to CS me., coz from her tone, I think she just agreed to “try” labor but then discourage me on my most vulnerable time, in pain and distress. She said even if I am low transveresed CS, I had a big baby 7.1lbs before and it’s big for my built. She IEd me and said my pelvics are small (which was actually the indication in my prev CS – CPD). It is like she’s trying to find every excuse for me not to try VBAC. I have read a lot of articles here and suggests that having a big baby is not a factor for CS unless I had a 9lbs baby previously etc. So I guess I will just try to go to the hospital when I am in real labor, that way She can not meddle anymore. I hope I will achieve my goal and my baby will cooperate as well as my body.

        Thanks for the great articles…very informative and encouraging. :)

        • Jen Kamel

          Momtobeagain,

          The fact that you have a low transverse CS is good news!

          Can you get a doula? That might help.

          I wish you luck! Please keep me posted on how it went!

          Warmly,

          Jen

          • momtobeagain

            Hi Jen, me again. I will be due next week feb 14 but Ob is now trying to convince me to CS. I do have hi blood pressure of 130/100 and yesterday she was convincing me to have a CS asap this week and I said no. But my husband is trying to convince me too and do not want to put baby in risk.I am very confused. I already am under medication to lower my BP and it is now back to normal 110/80. If my BP rises to 130/100, is it adviseable already to give in to CS? she mentioned about preecmlapsia, fetal distress etc, not to mention I was CS before.In short, so many reasons for her to CS me and it is now me against everyone. would not want to end up with stillbirth baby, high hospital bill and blame is all on me. I am not sure If I still am being reasonable. The nearer my due date is, the more my vbac goal is getting blurred. thanks -momtobeagain

          • Jen Kamel

            Hi Momtobeagain,

            I addressed your question here.

            Warmly,

            Jen

  • momtobeagain

    hi Jen,

    I’m in the hospital right now and still in recovery(typing in one hand). just want to inform you that I had a successful VBAC with a very healthy baby girl!!! had it not been coz of all the resources I read here, i would have not known that vbac is possible. after all the scare tactics my OB told me, I still managed to achieve my goal coz I am well informed becoz of your site. thank u sooo much!

    details:
    - Bloody show at feb 15 @7:30am but did not go to hospital yet like what my OB told me. I tried laboring at home as long as I can. I got admitted 6cm already which was the next day Feb 16 @2:30am when my contractions are 5mins apart.
    - they augmented my labor with oxytocin coz contractions stopped when I had the epidural which I refused but they won’t listen and my dilation got stuck at 6cm for almost 2 hrs.
    - they gave me more epidural which I refused but gave me anyway(I was glad I had it or I would have quit, the pain was unbearable when I was 7cm, I almost wanted to faint). My wateer broke at 7cm, just few minutes after baby was out
    -They transferred me to delivery room at 8:05 am
    -I was pushing but can’t feel a thing but it took me just 5 pushes and baby girl was out @ 8:32 AM feb 16!!

    -got a tear and is painful right now, I asked OB not to cut me and just let it tear naturally but I think she still did.

    • Jen Kamel

      Momtobeagain,

      I am so thrilled for you! I have goosebumps! You did it!!! Congratulations!!!!!

      Thank you so much for updating me!

      Warmly,

      Jen

  • momtobeagain

    btw my baby was 6.13 lbs but I had a very big tummy which everyone assured me I can’t get it out coz it is big baby. well ha! they’re all wrong.

    • JQMD

      Congrats to you! Stories like these make me very happy. I’m also in the boat of many others (like mentioned in this article) where I’m scared to get pregnant again because of the daunting task of battling to even “try” to have a vaginal birth. The stories of other women really give me hope and courage. I’ve been pregnant twice since my first (delivered by cs), unfortunately, I miscarry before 7 weeks every time.

  • MomseekingVba3c

    OMG! Congratulations! I wish I had been more informed like @Momtobeagain… I am stil hopeful for a VBA3C :D

  • So wanting vba2c!!!

    Hello Ms. Kamel,
    I stumbled upon this website as I am searching desperately for vba2c info. around Philadelphia area. I had 2 low transverse c-sections. (both times breech) First time @ Abington Hospital, second time @ Montgomery Hospital. I am probably about 4~5 weeks into pregnancy and have plenty time to research and have my chance at vba2c. I have Valley Birth Place’s Barbara D’mato as my mid-wife, but they don’t do vbac. I am SOOOO
    desparate for an OPPORTUNITY to give birth naturally. Do you know of anyone around zipcode 19044? I live about 15 min. from Abington Hospital. I’m willing to travel to the care provider. Thank you so much!!!

    • Jen Kamel

      Dear so wanting VBA2C,

      I do not know of any health care providers in that area, but I will post your question on Facebook. Go here to follow comments.

      Warmly,

      Jen

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