my hospital says that they will do a vbac but they aren’t set up for it because the labor side is far away from the c-section side so if i try to do a vbac and end up having a c section it will take a lot longer to get me to surgery. do you think this is a legitimate reason to consider not having a vbac? im too close to my due date ( 7 days left ) to change hospitals or doctors although i am beginning to wish i would have. ..
-NERVOUS in hagerstown maryland

Hi Virginia,

The short answer is: No, that is not a legitimate reason to deny you a VBAC.

The reality is, you are less likely to experience an uterine rupture than a complication that has absolutely nothing to do with your prior uterine surgery.  (Please read Scare tactics vs. informed consent and scroll down to the chart entitled “Risks far outweigh VBAC” to see for yourself.)

Since obstetrical complications arise during labor in women with no history of uterine surgery that require immediate surgical delivery, how can a hospital claim that they are fit to attend those births, but not yours?

Any birth (VBAC or not) could end in a medically necessary cesarean and any hospital (urban or rural) set up for birth should have a plan detailing how they will respond to those inevitabilities.

I have also often wondered how often women with true obstetrical complications requiring immediate cesareans or even car accident victims requiring surgery, have been unable to receive that care due to otherwise healthy moms and healthy babies undergoing  scheduled elective repeat cesareans occupying the operating rooms?  With over 90% of women having repeat cesareans, I’m sure it’s happened, especially in smaller hospitals (Martin, 2006).

The ability of rural hospitals to safely attend VBACs was extensively discussed at the March 2010 NIH VBAC conference.  One doctor spoke during the public comment period and stated that her rural hospital had a VBAC rate of over 30%!  It turns out, if a hospital is supportive of VBAC and motivated, they can absolutely offer VBAC safely.  (I also welcome you to read the commentary of two obstetricians and one certified nurse midwife who argued against the VBAC ban instated at their local rural hospital.)

As David J. Birnbach, M.D., M.P.H (2010), who presented on the impact of anesthesiologists on the incidence of VBAC asserted:

Lack of immediate available of anesthesia may not always be a key factor in outcome [during a uterine rupture], especially in cases where the obstetrician is not present. Many cases of uterine rupture can be stabilized while the anesthesiologists becomes available, and examples have been suggested of ways to reduce the risk associated with such a crisis. These include antepartum [prenatal] consultation of VBAC patients with the anesthesia departments, development of cesarean delivery under local anesthesia protocols, finding methods of improving communication on labor and delivery suites, practice “fire-drills,” and development of protocols matching resources to risk.

I highly recommend you read the Final Statement produced by the conference as it was the catalyst for the subsequent revision of ACOG’s (2010) VBAC guidelines in the Practice Bulletin No. 115 where they affirmed:

Women and their physicians may still make a plan for a TOLAC in situations where there may not be “immediately available” staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk.

This is a huge change.

The term “immediately available,” first introduced in the 1999 Practice Bulletin No. 5 and then reiterated in the 2004 Practice Bulletin No. 45, was the reason why many hospitals ultimately banned VBAC.  Hopefully the removal of that recommendation in this new Practice Bulletin will result in the reversal of VBAC bans and an overall greater support for VBA1C and VBA2C.  ACOG acknowledged that their prior recommendation was resulting in way to many cesareans and the increasing risks that multiple cesareans bring are significant and unacceptable.  (Please read the risks of multiple cesareans detailed by Silver 2006 in Another VBAC Consult Misinforms.)

The removal of the “immediately available” recommendation is supported by the NIH (2010) Final Statement which found it, if implemented in all hospitals, to be an impossible standard that could result in the closing of many Labor & Delivery units:

Would provision of an anesthesiologist standing by waiting for an emergency at every hospital that practices obstetric care increase patient safety?  In truth, that person would need to be doing nothing else clinically, so even being in the hospital might not qualify for “immediately available.”  Looking at the numbers of anesthesia staff currently available, the minimum requirement to provide immediate anesthesia [per the recommendation of the American Congress of Obstetricians and Gynecologist] care for all deliveries would be to have all deliveries accomplished at facilities with greater than 1,500 deliveries annually.  This would require that approximately three-quarters of all obstetric programs nationwide be closed (Birnbach, 2010).

I am excited and hopeful to see the ripple effects of this new Practice Bulletin especially for women in rural areas.  Hopefully the option of VBAC will become a reality for more women.

______________________________________________

American College of Obstetricians and Gynecologists. (2010, July 21). Ob-Gyns Issue Less Restrictive VBAC Guidelines. Retrieved July 21, 2010, from ACOG: http://www.acog.org/from_home/publications/press_releases/nr07-21-10-1.cfm

Kamel, J. (2010, July 21). ACOG issues less restrictive VBAC guidelines. Retrieved from VBAC Facts: http://vbacfacts.com/2010/07/21/acog-issues-less-restrictive-vbac-guidelines/

Birnbach, D. J. (2010). Impact of anesthesiologists on the incidence of vaginal birth after cesarean in the United States: Role of anesthesia availability, productivity, guidelines, and patient saftey. Vaginal birth after cesarean: New Insights. Programs and Abstracts (pp. 85-87). Bethesda: National Institutes of Health.

Martin, J. A., Hamilton, B. E., Sutton, P. D., Ventura, S. J., Menacker, F., & Kirmeyer, S. (2006). Births: Final Data for 2004. National Vital Statistics Reports , 55 (1), 1-102.

National Institutes of Health. (2010, June). Final Statement. Retrieved from NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights: http://consensus.nih.gov/2010/vbacstatement.htm

National Institutes of Health. (2010, March 8-10). NIH VBAC Conference: Program & Abstracts. Retrieved from NIH Consensus Development Program: http://consensus.nih.gov/2010/vbacabstracts.htm

Take the time to get and read your records.  You may find that your “emergency” cesarean was no rush at all.

Medical Records Copying Charges 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.

She links to another great website: “The Big Push For Midwives, launched on January 24, is a coordinated campaign to advocate for regulation and licensure of Certified Professional Midwives (CPMs) in all 50 states and the District of Columbia. The website includes a page with links to news articles related to midwifery-related legislative efforts, and a map of states [which I've copied below] where licensure is available or where legislation is pending. Licensure is currently available to CPMs in 22 states.”

There is also a page on The Big Push for Midwives website that lists birth resources for the following states: Alabama, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Maine, Michigan, Missouri, Nebraska, Nevada, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Dakota, West Virginia, and Wyoming.  (Might be a good place to look if you want a VBAC and are looking for a VBAC supportive provider.)

The relevance of CPM licensure to VBAC moms?  More legal options.

From Wikipedia:

No state prosecutes mothers for giving birth outside of a hospital. However, midwives who assist at such births may be prosecuted in some areas.

In the early and mid 1900s, physicians pushed to have midwifery banned throughout the United States. Childbirth became very clinical with the mother generally subdued with leather straps and ether. In 37 states it is once again legal to acquire the services of a midwife. Many midwives continue to attend mothers in states where it is illegal, while efforts are underway to change the law.

Practicing as a direct-entry midwife is still (as of May 2006) illegal under certain circumstances in Washington, D.C. and the following states: Alabama, Georgia, Hawaii, Illinois, Indiana, Iowa, Kentucky, Maryland, Missouri, North Carolina, South Dakota and Wyoming.^[12] However, Certified Nurse Midwives can legally practice in these areas.

People wishing to have a midwife-assisted home birth in the United States should always research the applicable laws in their home state.

I know homebirth sounds like a radical thing, but I have heard story after story of women who would have never considered a homebirth until they started looking for a VBAC supportive OB only to find none and then felt trapped, out of options, and scared.  And so now these women, who would have been quite happy to birth in a hospital, are hiring midwives, regardless of wether it’s legal in their state, and having a homebirth VBAC rather than face the alternative, an unwanted, unnecessary repeat cesarean in a ‘VBAC ban’ hospital.

I hope this is going to be one of the factors that swings the conventional wisdom back to supporting VBAC because when enough women start birthing at home and that an impact is felt in hospital revenues, hospital administrators and OBs might start paying attention.  Unfortunately, by the time that happens, it might be ‘to late’ for the hospitals.  Enough women would have experienced the joy, peace, privacy, and safety of homebirth to never want a hospital birth again.

For Maryland residents: Just click on this link and look up who your Maryland state delegates are. This bill is before the House so you are only writing to your delegates and not your senators.

For those living outside of Maryland, send your letter to the
Committee Health and Government Operations Committee (HGO)
Room 241, House Office Building, Annapolis, MD 21401-1912
(410-841-3770 Annapolis/Baltimore or 301-858-3770 Washington, D.C.)
Chair: Peter A. Hammen

Then, write them a letter. I have copied mine below. Make it your own
using portions of mine if you want to.

Address them properly and mention HB 1407 in the letter. You can send your letter today and/or copy your letter and fax it or email it to Mairi Rothman, CNM at 240-485-1818 so she can mail a copy of all of the letters out at the recommended strategic moment, about 3-4 days before the hearing of the bill (tentatively scheduled for 3/14).

Thank you!

=======================================================

Email Subject Line: Letter regarding HB 1407

February 21, 2008

The Honorable Put Delegate’s Full Name Here
Lowe House Office Building
Annapolis, MD 21401-1991

Dear Delegate Last Name Here:

This letter is to inform you that for the sake of Maryland women’s health care, you must support House Bill 1407, the Birth Options Preservation Act. This bill opens access for women to care by
Certified Nurse Midwives (CNM). Evidence demonstrates equal to superior care is provided by midwives. Women are consistently more satisfied with the clinical and holistic approach of their midwives.

As a childbirth educator and mother, I have used midwifery care both for well-woman care and in childbirth. I have very safe, happy and healthy pregnancies and childbirth experiences at a birth center. When there was any doubt that my first pregnancy might need medical assistance, I was referred to a perinatologist (high risk OB) for co-management and care. Fortunately, in the end, I did not need medical assistance but was grateful that my midwife referred me for medical monitoring to be on the safe side. CNMs are experts in women’s health care through the childbearing years and beyond. They are professionally bound by the Standards of Practice of the American College of Nurse Midwives. They are ethically and clinically prepared and qualified to collaborate and refer to medical care when appropriate.

The Maryland Board of Nursing in its requirement for physician signature to obtain a license has been a barrier to women’s access to midwives. Please support and pass this bill for the good of Maryland families. Show CNMs the same respect for our profession that the women we care for already demonstrate. Give Maryland women access to the health care that they desire and deserve.

I still remember the day you handed out information asking for my vote on the streets of Hampstead one warm summer day. I hope you will listen to my voice and the voice of others and fight for women’s rights to the best health care which must include midwives and better access to them!

Thank you for your efforts and thank you for listening.

Yours in birth,
Jessica Groves
Hampstead, MD

Bradley Method Childbirth Educator & Birth Doula
Trusting Our Bodies

How does HB 1407 change this? Certified Nurse Midwives (CNMs) must get an obstetrician to sign a form agreeing to essentially be available 24/7 for that midwife in order for that midwife to obtain a license. This is problematic for three reasons: 1) midwives’ careers should not be under the control of an obstetrician with whom they compete for clients! Obstetricians are trained in surgery and high risk pregnancies and should not control the well-woman care and the pregnancy care of a low-risk mother choosing a midwife as her care provider. 2) Some obstetricians really want to support CNMs but hesitate to sign this form because doing so makes them afraid they will be liable
for that midwife’s actions. This is not fair to the obstetrician either! 3) This law is redundant. The Standards of Practice that CNMs must abide by already requires them to have a written plan for consultation, collaboration and referral to medical care when appropriate.

Your presence at the rally gives women a voice and supports the House Bill that will change the current law!

What is the schedule for HB 1407?
Monday, Feb 25 – Rally
March 14 – Committee has hearing on HB 1407
March 17 – House delegates vote on HB 1407

What if I cannot attend the rally? Then, please read the next email coming that tells you how to write a letter to your delegate and send it either snail mail (preferred) or by email. Please copy all letters to Mairi Rothman.

For more info about the rally, see below…

===============================================================

CALLING ALL BIRTH OPTIONS ADVOCATES!
(especially those in Maryland)

We have a bill! The Birth Options Preservation Act is House Bill 1407.

This bill proposes to end the requirement that nurse midwives practicing in Maryland have a written agreement with a doctor. This will go a long way to ensuring greater access to nurse midwives throughout the state! Final language is now available on the web site, directly from
http://mlis.state.md.us/2008rs/billfile/hb1407.htm. That page will also throughout the process have up-to-date public information on the bill.

You have all been asking for some time now: what can we do to help ensure that practices like the Takoma Women’s Health Center and the Maternity Center stop closing? Well, here is something you can do right now: We need to all work together to make sure this bill passes! We have the sponsoring Delegates and their staffs all working hard, lobbying not only their colleagues, but
other interested organizations, and things are looking very positive, but without the VISIBLE and AUDIBLE support of midwives and their clients or would-be clients, legislators have no reason to listen.

LET’S GIVE THEM SOMETHING TO LISTEN TO!
Below are instructions and driving directions for attending a Nurse-Midwives Rally Night on Monday, February 25th, in Annapolis. Yes, it is a long drive for some of us, but the forecast is for sun and mild temperatures, and we urge you to try your very best to get there, to stand and be counted. This bill could make a huge difference for the women of Maryland ! If this law had been in affect 5 years ago, some of the midwifery practices which were forced to close over the past few years might still be open.

Here’s how you can help:

1. Come to the Rally! We will gather for inspirational speeches from legislators, midwives and clients, then go to visit our legislators, armed with talking points and other materials to make our case. We will try to send a midwife with as many groups of consumers as possible. They love hearing from constituents, and will be very welcoming!

2. Bring your family and friends to the rally! Post this announcement on any listserves you are on, put up a notice up at work, post it at your favorite coffee shop, nursery school, pediatricians, etc.

3. Write to your legislators! Whether you attend the rally or not, it is a good idea to write to your legislator and let them know you support HB 1407. Email your letter to your friends and family and encourage them to write to their legislator, too!

4. Volunteer to help the legislative committee! In the next ten days, we will be doing phone calls to members, and to legislators to set up appointments. We can use all the help we can get! Please contact Mairi Breen Rothman to let her know if you will come to the Rally, and how many friends you hope to bring with you. We can help you identify your legislator, so we can make appointments for you to visit your own delegates when you come to Annapolis . (Don’t worry—you’ll go in a group with a packet of information!) If you can’t come, you can still write to your delegate, and we would be happy to give you sample language, so contact Mairi even if you
can’t come! Please call Mairi or Tina with any questions (Mairi 301-674-9976,
Tina 410-937-5824)

Hope to hear from ALL of you in the next couple of days. If we all work together, we CAN make this happen!
Mairi Breen Rothman & Tina Fisher, Legislative Liaisons
American College of Nurse-Midwives , Maryland Chapter
============================================================
Nurse-Midwives Lobby Night in Annapolis
Where: Rally @ the Assembly Room (rm. 114) of the Office of the Comptroller
* Enter at the front door on Calvert Street
* All visitors are required to sign in at the front desk with the
Department of General Services Police. Be prepared to show identification
* Parking information listed below! 
* Rally begins @ 6:00 P.M (Please arrive by 5:45!)
* Please plan on being at the Assembly Room by 5:45 P.M. to begin the rally promptly
* Plan on arriving in the Navy-Marine Corps Memorial Stadium parking lot by 5:00 P.M. in order to arrive by shuttle on time
* Park: Navy-Marine Corps Memorial Stadium, 550 Taylor Avenue, Annapolis, MD 21401

Due to severe parking restraints in the area around the Maryland State Government Complex, we recommend that you park in the Navy-Marine Corps Memorial Stadium visitor’s parking lot. A shuttle service will pick you up in the visitor’s lot and bring you to the Complex, which is only a 2-3 minute ride. Please be prepared to pay a maximum of $5 for parking.

Directions (from Washington, D.C. metro area):
Take the Beltway and merge onto US-50 East towarAnnapolis. Get off at Rowe Boulevard South, exit 24, toward Annapolis. Stay in the far right lane as you exit Route 50 onto Rowe Blvd/Md-70 east. Make a right at the second traffic light onto Taylor Avenue/MD-435. The Navy-Marine Corps Memorial Stadium will be on your right before you turn. After turning onto Taylor Avenue, turn at the second entrance to the stadium lot, posted “visitor’s parking.”

Visitors are required to withdraw a ticket from the parking meter machine at the bus stop. If the machine is broken, do not worry about getting a ticket. Depending on when you leave the lot, you will most likely not be required to pay the parking fee. BE PREPARED TO, THOUGH! Take the shuttle bus to the Department of Legislative Services stop, the last one on the loop (do not hesitate to ask the driver for assistance). When you get off, you will be on College Avenue between the Department of Legislative Services Building and the Lowe House Office Building, adjacent to Bladen Street. Proceed down the left side of Bladen Street until you reach the corner of Bladen and Calvert Street. The Office of the Comptroller will be right in front of you! Enter at the front door.

Contact Information

Mairi Breen Rothman – Legislative Liaison, American College of Nurse Midwives Maryland Chapter (301) 674-9976
Patrick Metz – Legislative Director for Delegate Heather R. Mizeur (301) 858-3493