Category Archives: Florida

“Maternally Yours” Radio Interview Show Notes 7/31/12

microphone-1007154_1280On July 31, 2012, I was interviewed by Maternally Yours, a radio program on WSLR 96.5 LPFM, a Community Radio station in Sarasota, Florida.  Below are the show notes with links to more information.  I went off my notes for a bit, so be sure to listen to the podcast to get the full interview.  Also check out Maternally Yours’ blog post about the show.


Which women at good candidates for VBAC? Which are not?

Per the American Congress of Obstetricians and Gynecologists’ aka ACOG’s latest VBAC recommendations released in 2010, VBAC is a “safe and appropriate choice for most women” with one prior low transverse cesarean and for “some women” with two prior cesareans. Being pregnant with twins, going over 40 weeks, having an unknown or low vertical scar, or suspecting a “big baby” should not prevent a woman from planning a VBAC per ACOG.

ACOG also says,

Conversely, those at high risk for complications (eg, those with previous classical or T-incision, prior uterine rupture, or extensive transfundal uterine surgery) and those in whom vaginal delivery is otherwise contraindicated are not generally candidates for planned TOLAC [trial of labor after cesarean].

Reviewing your personal medical history with a VBAC supportive care provider is the best way to see if you are a good candidate.  I recommend getting a copy of your medical record(s) and operative report(s) from your prior cesarean(s), get the names of VBAC supportive providers, and ask the right questions.

It’s really important to qualify your care provider to ensure that they are supportive of VBAC, before you get their opinion on whether you are a good candidate.  There is a great range of practice styles from one care provider to another.

What are some of the risks and benefits of VBAC vs. repeat cesarean?

There are real risks and benefits to both VBAC and repeat cesarean. A mom can only make an informed choice when she is aware of the risks and benefits to herself, her baby, and her future fertility, pregnancies, and health.

According to the 2010 National Institutes of Health VBAC Conference, the risk of a mom dying during a elective repeat cesarean section (ERCS) is significantly increased in comparison to a trial of labor after cesarean (TOLAC).  However, the risk is still quite low in either scenario: 13.4 maternal deaths per 100,000 ERCS vs. 3.8 maternal deaths per 100,000 TOLAC.

The NIH also found that the rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between TOL and ERCS.  The risk of uterine rupture during a TOL was 4.7 per 1,000 vs. 0.3 per 1,000 in a ERCS.

2.8% – 6.2% of uterine ruptures were associated with an infant death within 28 days of birth. However it’s important to note that “the strength of evidence on perinatal mortality [the number of babies who die during the first 28 days of life] was low to moderate” due to the wide range of rates reported by the studies included in the Guise 2010 Evidence Report.  (Guise was the basis for the NIH VBAC Conference. ) The NIH identified this topic as an area for future research.

It’s important for women to understand the long term implications of multiple repeat cesareans.  A 2006 study of 30,000 women (Silver, 2006) undergoing up to six total cesareans found,

The risks of placenta accreta, [surgical injury of the bladder, bowel, and ureters],… the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units,… significantly increased with increasing number of cesarean deliveries.

Unfortunately, many women don’t think about these future risks until they are pregnant again.  According to the CDC, 49% of pregnancies are unintentional, so women really need to consider the fact that how they birth their current baby has implications for their future pregnancies and health.

[Dr. John Sullivan Jr. of Sarasota Memorial Hospital, another guest on the show, made mention of how I lead with maternal morality.  I did so for two reasons.  One, the Guise 2010 Evidence Report, when discussing the risks and benefits of VBAC versus ERCS in it’s Structured Abstract (page v), also discussed maternal mortality first.  I think this is because it is one of the primary questions moms have: what is my risk of dying?  Second, one of the ways that unsupportive care providers coerce women into a repeat cesarean is by misleading them on the risks of VBAC including uterine rupture and mortality rates.  So, I wanted women to know from the get go what the risks were.]

If evidence shows (and ACOG supports) that most women with one or even two or more prior Cesareans should be allowed a trial of labor, why are so many hospitals and physicians still banning the practice?

This is primarily due to the 1999 and 2004 ACOG recommendation that a doctor be “immediately available” to perform a cesarean.  Yet ACOG did not clarify if they meant an obstetrician or an anesthesiologist nor did they provide a standard for where the obstetrician and/or anesthesiologist should be or what they could be doing.

As a result, hospitals developed their own definitions producing differing VBAC protocols and requirements.  The most severe variety was the institution of VBAC bans in one-third of all American hospitals per the International Cesarean Awareness Network’s 2009 survey.  These bans disproportionally affect women living in rural areas as they may have to drive hundreds of miles in order to birth at a VBAC supportive facility.  The 2010 ACOG guidelines acknowledged that the interpretation of the prior recommendations were limiting access to VBAC and clarified that was not their intention.  ACOG even says,

Importantly, however, none of the principles, options, or processes outlined here should be used by centers, health care providers, or insurers to avoid appropriate efforts to provide the recommended resources to make TOLAC as safe as possible for those who choose this option.  In settings where the staff needed for emergency delivery are not immediately available, the process for gathering needed staff when emergencies arise should be clear, and all centers should have a plan for managing uterine rupture.  Drills or other simulation may be useful in preparing for these rare emergencies.

These same policies and procedures would also enable hospitals to respond rapidly to the increasing complications we see with multiple prior cesareans including placenta accreta. Read more here.

If women want to learn more about how hospitals without 24/7 anesthesia can provide VBAC safely, they can watch Dr. David Birnbach’s presentation from the 2010 NIH VBAC Conference or read his presentation abstract.

What can a mom do if she wants to birth at a VBAC ban hospital?

Dr. Stuart Fischbein, a Southern California OB, has talked extensively about his struggles as a VBAC supportive OB who worked at a VBAC ban hospital.  For a while, he told his patients that they could just show up in labor, refuse surgery, and he would attend their VBAC.  When hospital administrators got wind of this, they made him put in writing that he would not longer advise his patients of their legal right to refuse surgery.

Women have VBACed at ban hospitals. The problem is when an obstetrician is under tremendous pressure from hospital administrators to only perform repeat cesareans.  So with this pressure in mind, if a mom is told her baby is in distress, how does she know if her OB is telling the truth or succumbing to the pressure of hospital administrators?

Further resources:

Tell us about the legality of VBAC

Hospital-based VBAC is legal in all 50 states.  In some states, it is illegal for a midwife to attend a VBAC either at home or in a birth center.

What are some of the myths of VBAC?

So many persistent yet very false myths!  First, women should know that you can induce a VBAC.  Without medical indication, the increased risks are generally not worth it.  But for those women who have a medical reason, such as preeclampsia, severe fetal growth restriction, diabetes, chronic pulmonary disease, etc, an induction can be a nice alternative to a repeat cesarean.  Of course, every mom should review the risks and benefits of her options with her care provider.  ACOG says that Pitocin and Foley catheter induction is acceptable in a VBAC whereas Cytotec is contraindicated due to the high rates of uterine rupture with which it is associated.

Another myth is that your risk of uterine rupture doesn’t increase much after a cesarean or that your risk is the same or similar to an mom who has never had a cesarean.  One study from the Netherlands (Zwart, 2009) including over 350,000 births found the risk of uterine rupture in an unscarred uterus to be very, very small: about 1 in 14,000.  That same study found risk in a scarred uterus to be about 1 in 156 (this figured included induced and augmented TOLs).

Uterine rupture in a scarred uterus occurs at a rate similar to placenta abruption, post-partrum hemorrhage, and cord prolapse.  It’s not that the risk is so high in an scarred mom, it’s just that it’s so very, very, very low in an unscarred mom.

Another myth is that the risk of uterine rupture in a scarred uterus is similar to the risk in an induced, unscarred uterus.  This is also false.  The risk in an induced, unscarred uterus is still about 1 in 4,500.  It is very rare for an unscarred uterus to rupture induced or not.

Another myth is that you can compare the risk of birth to the risk of non-birth activities like dying in a car accident or choking on a pretzel.  However, you can’t accurately compare the risks of a daily activity like driving or eating because those risks are measured on a annual or lifetime basis.

Your annual or lifetime risk of something happening will often be higher than your risk of a birth related complication.  This is because one’s annual risk measures their risk over the course of 365 days.  A lifetime risk is often based on 80 years which is over 29,000 days.  You are likely to be in active labor for one day, maybe two.

To compare the risk of something that happens over 1-2 days to the aggregate risk of something that could happen any time over 365 days or 29,000 days is unfair and confusing.  I think it’s more helpful for post-cesarean women to focus on the choice they have, VBAC vs. ERCS, and compare those risks to each other.  Don’t get bogged down in comparing the risks of birth to the risks of non-birth activities.

Finally, a special myth for Floridans.  One mom told me that since Florida had the most lightning strikes hit the ground in the nation, she was more likely to be struck by lighting than have a uterine rupture.  This is false.  The National Weather Service says, based on the number of reported lightning strike deaths and injuries, your risk of being struck by lightning is about 1 in 700,000.  This is a lot lower than the risk of uterine rupture in a scarred or unscarred uterus.

Lightning - Tucson, AZ

Lightning strikes, shark bites & uterine rupture

Lightning - Tucson, AZWhen someone understates the risk of UR, I think it’s just as important the clarify as it is when someone overstates the risk. How else are women to make an informed decision? Just as it’s plain wrong for an OB to tell a woman with one prior low transverse cesarean that she has a 20% risk of rupture, it’s equally wrong when VBAC advocates say the risk is virtually non-existent.

Over the years, I have heard the statement: “You are more likely to be struck by lightning or bitten by a shark than experience uterine rupture!”

Today I’m going to get the statistics and run the numbers so you can see for yourself how the risk of these events compare.

Uterine Rupture

For this exercise, we will use the uterine rupture (UR) rate based on one prior low transverse (bikini) cut cesarean in a spontaneous labor determined by Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery (Landon 2004):

Risk of uterine rupture: 1/240 or 0.4%
Risk of infant death or oxygen deprivation: 1/2000 or 0.05%

Lightning Strikes

Using the faulty theory I’m going to calculate the number of Floridians, since it is the “lightning strike state,” who would be struck by lightning.

Let’s assume that the risk of getting struck by lightning in Florida is the same as uterine rupture (even though the saying goes the risk is greater): 1 in 240 or 0.4% or 0.00416

With 18,328,340 people living in Florida, that would mean that 76,368 people are struck by lightning every year in Florida. According to the CDC, that is more than the number of Americans who die annually from diabetes (72,449), Alzheimer’s disease (72,432), and influenza and pneumonia (56,326).

Using the National Weather Service stat that 10% of people struck by lightning die, we would have 7,636 people dying in Florida every year from lightning strikes. At that rate, you would have 209 people struck by lightning and 20 of those people dying every day in the state of Florida.

Now, I don’t live in Florida and I’m not an expert in lightning strikes, but that sounds like a lot of people dying.

Now let’s switch our assumptions and use the National Weather Service’s stats.

Odds of being struck by lightning in a given year (reported deaths + injuries) 1/700,000
Odds of being struck by lightning in a given year (estimated total deaths + injuries) 1/400,000

When we turn that fraction into a percentage, we get the following risk of being struck by lightening: 0.00025% – 0.00014%.

Using the National Weather Service’s statistics, we get 26 – 46 annual lightning strike related deaths or injuries in Florida.

Which sounds more reasonable to you? 26-46 Floridians struck annually by lightning or 76,368?

And that is assuming that the rate is the SAME as uterine rupture, but the rumor is that the rate of lightning strikes is HIGHER which means MORE than 76,368 Floridians are struck by lightning every year and more than 20 Floridians are dying daily from lightning strikes.

Now, does that pass the smell test? Does it seem reasonable in the least? It doesn’t to me.

Some would argue that in order to make the comparison, we need to eliminate the number of non-birthing people in Florida, but you really don’t because the lightning strike doesn’t know whether you are a man, woman, child, or menopausal. A Floridian women with one prior cesarean in spontaneous labor has the same risk as everyone else to be struck by lightning: 0.00025% – 0.00014%.

Shark Bites

From the Florida Museum of Natural History:

What are the chances of being attacked by a shark?

The chances of being attacked by a shark are very small compared to other animal attacks, natural disasters, and ocean-side dangers. Many more people drown in the ocean every year than are bitten by sharks. The few attacks that occur every year are an excellent indication that sharks do not feed on humans and that most attacks are simply due to mistaken identity. For more information on the relative risk of shark attacks to humans click HERE.

How many people are attacked each year by sharks?

Worldwide there is an average of 50-70 shark attacks every year. The number of attacks has been increasing over the decades as a result of increased human populations and the use of the oceans for recreational activity. As long as humans continue to enter the sharks’ environment, there will be shark attacks. For more information on shark attack statistics click HERE.

We have about 6.5 billion people on the world and 50-70 get bit by a shark annually which works out to 0.00000077% – 0.00000108%.

But this whole discussion is moot because it’s poor statistics to even compare these events (UR & lightning strikes or shark bites) because they are totally different types of occurrences.

The Actual Figures

This is a great chart from the Floria Museum of Natural History website entitled “A Comparison of Unprovoked Shark Attacks with the Number of Lightning Fatalities in Coastal United States: 1959-2008” where they show even in the state of Florida, over the past 49 years, there have been a mere 453 lightning fatalities and 585 shark bites. Remember that over 7,600 Floridans would be dying annually if the rate of uterine rupture was the same as the rate of lightning strikes.

Comparing Risks

There are some major problems when one is trying to compare risks of differing events.

One problem is when one uses a lifetime risk statistic as a means for comparison. You simply cannot take a statistic, like your lifetime risk of being struck by lightning (1 in 5000 which is significantly lower than one’s annual risk,) and compare that to your one-time risk of uterine rupture. If anything, using the annual risk of lightning strikes would be more accurate, but it still would be a false comparison.

An article by Andrew Pleasant entitled, Communicating statistics and risk, elaborates:

An oft-reported estimate is the lifetime breast cancer rate among women. This rate varies around the world from roughly three per cent to over 14 per cent.

In the United States, 12.7 per cent of women will develop breast cancer at some point in their lives. This statistic is often reported as, “one in eight women will get breast cancer”. But many readers will not understand their actual risk from this. For example, over 80 per cent of American women mistakenly believe that one in eight women will be diagnosed with breast cancer each year.

Using the statistic ‘one in eight’ makes a strong headline but can dramatically misrepresent individual breast cancer risk.

Throughout her life, a woman’s actual risk of breast cancer varies for many reasons, and is rarely ever actually one in eight. For instance, in the United States 0.43 per cent of women aged 30–39 (1 in 233) are diagnosed with breast cancer. In women aged 60–69, the rate is 3.65 per cent (1 in 27).

Journalists may report only the aggregate lifetime risk of one in eight because they are short of space. But such reporting incorrectly assumes that readers are uninterested in, or can’t comprehend, the underlying statistics. It is critically important to find a way, through words or graphics, to report as complete a picture as possible.

Take away message: Be extra careful to ensure your readers understand that a general population estimate of risk, exposure or probability may not accurately describe individual situations. Also, provide the important information that explains variation in individual risk. This might include age, diet, literacy level, location, education level, income, race and ethnicity, and a host of other genetic and lifestyle factors.

The second major problem is often the two things you are comparing are so different that the comparison is worthless. Again, I defer to Mr. Pleasant:

Try not to compare unlike risks. For instance, the all-too-often-used comparison ‘you’re more likely to be hit by a bus / have a road accident than to…’ will generally fail to inform people about the risks they are facing because the situations being compared are so different. When people assess risks and make decisions, they usually consider how much control they have over the risk. Driving is a voluntary risk that people feel (correctly or not) that they can control. This is distinctly different from an invisible contamination of a food product or being bitten by a malaria-carrying mosquito.

Comparing the risk of a non-communicable disease, for example diabetes or heart disease, to a communicable disease like HIV/AIDS or leprosy, is similarly inappropriate. The mechanisms of the diseases are different, and the varying social and cultural views of each makes the comparison a risky communication strategy.

Take away message: Compare different risks sparingly and with great caution because you cannot control how your audiences will interpret your use of metaphor.

Going Forward

It can be hard when wading through the (mis)information available on the internet about VBAC, but here are some tips to help you out.

1. Always find the source – If you find some great statistic, but there is no source referenced, be wary.

2. Verify the statistic – If there is a source listed, read through it. If there is no source listed, do a quick Google search. It didn’t take me long at all to find all the statistics in this article and run the math.

3. Leave a comment – If you find something on the internet that doesn’t pass the smell test, leave a comment on the blog or email the author asking for the source.

4. Be careful about forwarding things – There is so much misinformation on the internet, so do your friends a favor and don’t forward them emails or articles unless you have verified the information to be true. That is one way to quickly nip falsehoods in the bud!

For further reading on using statistics, check out, Correlation and Causation:Misuse and Misconception of Statistical Facts and Risk Communication, Risk Statistics, and Risk Comparisons: A Manual for Plant Managers

The cost of getting your medical records

When considering your post-cesarean birth options, it’s good to know what type of uterine incision you have.  The only way to verify this is by getting a copy of your operative report from the hospital where you had your cesarean.  I recommend bringing copies of your operative report when interviewing care providers as most will want to confirm your uterine incision type.

Sometimes women have a different incision on their skin than their uterus, so just because you have a low transverse (“bikini cut”) incision on your skin, doesn’t necessarily mean you have the same incision on your uterus.   Low transverse incisions are the most commonly used method in America and come with the lowest uterine rupture rare.

You may also want to get a copy of your medical records from your care provider to complete the picture of your prior pregnancy/pregnancies.

Read more here: Medical Records Copying Charges by State

Last updated October 9, 2012

Florida law mandates that insurance covers homebirth

Found this blog where another woman uses Florida law to get her insurance to cover her homebirth.

Here is Florida Statute Number 627.6574, but it’s section 7 that spells it out very clearly.  I’ve bolded it for your reading pleasure….

1) Any group, blanket, or franchise policy of health insurance that provides coverage for maternity care must also cover the services of certified nurse-midwives and midwives licensed pursuant to chapter 467, and the services of birth centers licensed under ss. 383.30-383.335.
(2) Any group, blanket, or franchise policy of health insurance that provides maternity and newborn coverage may not limit coverage for the length of a maternity and newborn stay in a hospital or for followup care outside of a hospital to any time period that is less than that determined to be medically necessary, in accordance with prevailing medical standards and consistent with guidelines for perinatal care of the American Academy of Pediatrics or the American College of Obstetricians and Gynecologists, by the treating obstetrical care provider or the pediatric care provider.
(3) This section does not affect any agreement between an insurer and a hospital or other health care provider with respect to reimbursement for health care services provided, rate negotiations with providers, or capitation of providers, and this section does not prohibit appropriate utilization review or case management by an insurer.
(4) Any group, blanket, or franchise policy of health insurance that provides coverage, benefits, or services for maternity or newborn care must provide coverage for postdelivery care for a mother and her newborn infant. The postdelivery care must include a postpartum assessment and newborn assessment and may be provided at the hospital, at the attending physician’s office, at an outpatient maternity center, or in the home by a qualified licensed health care professional trained in mother and baby care. The services must include physical assessment of the newborn and mother, and the performance of any medically necessary clinical tests and immunizations in keeping with prevailing medical standards.
(5) An insurer subject to subsection (1) shall communicate active case questions and concerns regarding postdelivery care directly to the treating physician or hospital in written form, in addition to other forms of communication. Such insurers shall also use a process that includes a written protocol for utilization review and quality assurance.
(6) An insurer subject to subsection (1) may not:
(a) Deny to a mother or her newborn infant eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the policy for the purpose of avoiding the requirements of this section.
(b) Provide monetary payments or rebates to a mother to encourage the mother to accept less than the minimum protections available under this section.
(c) Penalize or otherwise reduce or limit the reimbursement of an attending provider solely because the attending provider provided care to an individual participant or beneficiary in accordance with this section.
(d) Provide incentives, monetary or otherwise, to an attending provider solely to induce the provider to provide care to an individual participant or beneficiary in a manner inconsistent with this section.
(e) Subject to paragraph (7)(c), restrict benefits for any portion of a period within a hospital length of stay required under subsection (2) in a manner that is less favorable than the benefits provided for any preceding portion of such stay.
(7)(a) This section does not require a mother who is a participant or beneficiary to:
1. Give birth in a hospital.
2. Stay in the hospital for a fixed period of time following the birth of her infant.
(b) This section does not apply with respect to any health insurance coverage that does not provide benefits for hospital lengths of stay in connection with childbirth for a mother or her newborn infant.
(c) This section does not prevent a policy from imposing deductibles, coinsurance, or other cost-sharing in relation to benefits for hospital lengths of stay in connection with childbirth for a mother or her newborn infant, except that such coinsurance or other cost-sharing for any portion of a period within a hospital length of stay required under subsection (2) may not be greater than such coinsurance or cost-sharing for any preceding portion of such stay.

Cesarean & VBAC Rates of Hospitals – AL, AK, CA, FL, ME, MA, NJ, NY, OR, TX

This article has links to cesarean and VBAC rates by hospital for the following states: Alabama, Alaska, California, Florida, Maine, Massachusetts, New Jersey, New York, Oregon, Texas, and Utah.  (For more information on California hospitals, go here.)

This is great info for women of those states! 

Compliments of Our Bodies Ourselves: Finding and Comparing C-Section Rates by Hospital

Physician Credential Verification by State

Want to know if your doctor has been subject to a board hearing or disciplinary note? 

Here is a link to the State Board sites for all 50 states.