Category Archives: An inside perspective

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:

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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.

Interview with Dr. Fischbein: An Inside Look at Hospitals and VBAC Bans

Stand and Deliver recently conducted an excellent interview with Dr. Stuart Fischbein, a Southern California VBAC and breech supportive OB.  It’s an excellent read and I’m including my favorite parts below.  You can read the entire article here: Stand and Deliver: Interview with Dr. Stuart J. Fischbein.

First, let’s do  quick review of ACOG’s Practice Bulletin #54, published in July 2004 and the reason why some American hospitals have banned VBAC, recommends, “a physician [be] immediately available throughout active [VBAC] labor who is capable of monitoring labor and performing an emergency cesarean delivery.”

Now that we are all on the same page, here are excerpts from Dr. Fischebin’s interview:

Don’t hospitals ban VBAC because it is dangerous?

They ban VBACs under the guise of patient safety. But patient safety is a euphemism for “we don’t have a good evidence-based reason to do it, other than we don’t want to get sued, it’s more expedient, and we make more money from c-sections—the hospital does, not necessarily the physician, but the hospital does—so we’re going to ban it because it’s easier for us, and we’re going to say it’s for patient safety because of the risk of rupturing the uterus.” But you know what? That risk should be something that the patient decides. Patients have a right to be given informed consent, free from misinformation or coercion, free from skewing information that benefits the practitioner or the hospital. And they have the right to consent or refuse to accept the treatment that’s offered. That right is frequently being denied.

What role does malpractice insurance play in VBAC availability?

The reason that a lot of hospitals ban VBACs anyway [despite meeting ACOG’s “immediately available” recommendation] —and this isn’t very well known to most people—is because their insurance carrier will tell them that if they allow VBACs, their premium will be much higher. Rather than pay higher premiums, they just ban VBACs and do so under the guise of patient safety. The hospital lawyers, the insurance company lawyers, the insurance company executives, and the hospital administrators are making decisions for patients and then lying about why they’re doing it.

Aren’t uterine ruptures the primary reason for repeat cesareans in women with a prior cesarean?

Most emergency c-sections, the ones that occur suddenly, have nothing to do with a uterine rupture.  They are for placental abruption, prolapsed cord, or prolonged fetal heart rate decelerations.  Far more often, it’s something unrelated to the VBAC that causes an emergency.  And somehow the hospital can manage to take care of those situations. If hospitals can take care of those things, why can they not take care of VBACs?

ACOG’s latest VBAC recommendation was based on consensus opinion, not scientific evidence.  Doesn’t that matter to hospitals when implementing VBAC bans?

Ultimately it won’t matter to the hospital. It’s not about evidence-based medicine. It’s very clear to me in discussing this with the committees that they don’t care. They’re being told by the risk managers, the lawyers, and the insurance companies that they cannot do VBACs. And that’s the final word. The anesthesia departments are also often behind VBAC bans. They talk about patient safety, but really it is that reimbursement is so bad and they don’t want to have to sit around in the hospital all day long and they are fearful of being sued.

Do hospital administrators impact how an OB counsels a woman on VBAC?

I’m supposed to tell patients that they have to go elsewhere if they want a VBAC, that they can’t stay in their own community, that they have to drive 50 miles. … I’m not supposed to tell them that they have the option of showing up in labor and refusing surgery. The hospital actually put in writing that I should avoid telling them that. They’re telling me to skew my counseling, and they have no shame in doing so.

How do OBs feel about working in hospitals with VBAC/breech bans?

For physicians who are not really committed to doing VBACs or breeches, it’s a lot easier to do a section. You get paid about the same. With a section, you can do the surgery at 7:30 am and you’re in the office by 9 am. If you have a breech or a VBAC, you have to cancel your day or spend the night at the hospital. It’s a lot more work, and you don’t get paid any more for it. So you really have to be either dedicated or crazy or somewhere in between. You have to keep your ethical feet well-grounded.

How do VBAC bans impact hospital revenues?

For hospitals, it’s easy. Does a hospital make more money off a practice that has a 5% c-section rate or a 25% c-section rate? That’s an easy question. Although they will never admit that; [the official reason for VBAC bans] will always be patient safety. Clearly, there’s no incentive for them to offer a VBAC to anybody.

How do VBAC bans impact women seeking VBAC?

A successful VBAC occurs about 73% of the time. If a hospital bans VBAC, they’re basically telling 73% of women that they have to undergo a surgical procedure that carries more morbidity than if they had a vaginal birth.

How could tort reform impact VBAC supportive OBs and birthing women?

[With] tort reform, you might be able to make changes by improving competition. If you get rid of some of the restrictions on businesses, you might see more competition start up. You might see more birth centers open, or birth centers that actually have operating rooms, little maternity hospitals. Just like we’ve seen specialty surgery centers open up recently. For years hospitals tried to squelch these things because they know they can’t compete with them. Some day, maybe the major hospital model will go out of business. And would that be so terrible? We have specialty hospitals that do heart surgeries, gastric bypass, or plastic surgery. Why not specialty hospitals that just do maternity? Run by doctors and midwives.

Hospital’s Oxytocin Protocol Change Sharply Reduces Emergency C-Section Deliveries

This article published June 19, 2009 demonstrates one hospital’s experience when they changed their oxytocin (Pitocin) protocol.

I’ve included the entire article below and have emphasized what I consider to be the most interesting parts.

Hospital’s Oxytocin Protocol Change Sharply Reduces Emergency C-Section Deliveries
By Betsy Bates
Elsevier Global Medical News
Conferences in Depth

CHICAGO (EGMN) – The modification of the oxytocin infusion protocol at a large university-affiliated community hospital nearly halved the number of emergency cesarean deliveries over a 3-year period, reported Dr. Gary Ventolini.

As oxytocin utilization declined from 93.3% to 78.9%, emergency cesarean deliveries decreased from 10.9% to 5.7%, Dr. Ventolini said at the annual meeting of the American College of Obstetricians and Gynecologists.

Other birth outcomes improved as well at an 848-bed community hospital that serves as the primary teaching hospital of the Boonshoft School of Medicine at Wright State University in Dayton, Ohio.

These included significant declines in emergency vacuum and forceps deliveries and a sharp reduction in neonatal ICU team mobilization for signs of fetal distress (P = .0001 in year 3 compared with year 1).

“More and more data are showing us that we are using too much oxytocin too often,” Dr. Ventolini, professor and chair of obstetrics and gynecology at the university, said in an interview.

“Our pivotal change was to modify the oxytocin infusion from 2 by 2 units every 20 minutes to 1 by 1 unit every 30 minutes. And we see the results,” he said.

Outcomes of 14,184 births from 2005, 2006, and 2007 were retrospectively analyzed to determine any impact of the change in an oxytocin protocol implemented in 2005. Patient characteristics were similar in all three calendar years.

The most profound changes were in emergency deliveries, including caesarean deliveries, vacuum deliveries (which dropped from 9.1% to 8.5%), and forceps deliveries (which fell from 4% to 2.3%).

The overall cesarean section rate remained unchanged, as did the rates of cord prolapse, preeclampsia, and abruption.

Dr. Ventolini cited a recent article in the American Journal of Obstetrics and Gynecology that suggests guidelines for oxytocin use, including avoidance of dose increases at intervals shorter than 30 minutes in most situations (Am. J. Obstet. Gynecol. 2009;200:35.e1-.e6).

Dr. Ventolini and his associates reported no financial conflicts of interest relevant to the study.

Subject Codes:
womans_health;
Elsevier Global Medical News
http://www.imng.com

June 19, 2009   10:04 AM EDT

Photo credit: http://healthmad.com/health/fetal-monitoring/

The Role of Interpretation – ACOG Refines Fetal Heart Rate Monitoring Guidelines

Photo credit: http://healthmad.com/health/fetal-monitoring/

Photo credit: http://healthmad.com/health/fetal-monitoring/

I remember when I was pregnant with my first.  The CNM I hired worked at multiple hospitals, so my husband and I toured each one to get a feel for each hospital’s standard policies and procedures.  A few people I knew questioned why we were bothering doing this since, aren’t all hospitals the same?  While I was expecting some differences, I was really surprised with what I found.

The standard procedures of the three hospitals we toured varied greatly – everything from the use of telemetry (wireless fetal) monitoring to how much bonding time a mom and baby were permitted before baby was whisked away for mandatory hospital procedures to where babies slept at night and whether babies were routinely given sugar water, formula or a pacifier.

I came away realizing how important it is to carefully screen which hospital you chose as well as your OB/midwife and the L&D nurse who will be caring for you during your stay at the hospital.

This June 22, 2009 press release illustrates ACOG’s (The American College of Obstetricians and Gynecologists’) efforts to help standardize the care women receive from OBs.  Specifically, they wish to stabilize the variability in fetal heart rate interpretations which could considerably impact the frequency of the “fetal distress” diagnosis.

EFM refers to external fetal monitoring which most women know as the belt laboring women wear that measures the baby’s heart rate and is connected to a machine which produces a strip of the baby’s heart rate as well as mom’s contractions.

I found these quotes of particular interest (emphasis is mine).

“Since 1980, the use of EFM has grown dramatically, from being used on 45% of pregnant women in labor to 85% in 2002,” says George A. Macones, MD, who headed the development of the ACOG document. “Although EFM is the most common obstetric procedure today, unfortunately it hasn’t reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions.”

“Our goal with the ACOG guidelines was to define existing terminology and narrow definitions and categories so that everyone is on the same page,” says Dr. Macones. One of the problems with FHR tracings is the variability in how they’re interpreted by different people. The ACOG guidelines highlight a case in which four obstetricians examined 50 FHR tracings; they agreed in only 22% of the cases. Two months later, these four physicians reevaluated the same 50 FHR tracings, and they changed their interpretations on nearly one out of every five tracings.

A meta-analysis study shows that although EFM reduced the risk of neonatal seizures, there is still an unrealistic expectation that a nonreassuring FHR can predict the risk of a baby being born with cerebral palsy. The false-positive rate of EFM for predicting cerebral palsy is greater than 99%. This means that out of 1,000 fetuses with nonreassuring readings, only one or two will actually develop cerebral palsy. The guidelines state that women in labor who have high-risk conditions such as preeclampsia, type 1 diabetes, or suspected fetal growth restriction should be monitored continuously during labor.

Note that VBAC is not listed under “high-risk conditions” that “should be monitored continuously during labor.”  Also, with a 99% false positive rate for cerebral palsy, I wonder about the rate of uterine rupture false positives.

Here is the link, ACOG Refines Fetal Heart Rate Monitoring Guidelines.

If VBAC is reasonable, why does my OB say it is dangerous?

This is a question that I’ve heard a lot.

Here is the three second answer: VBACs got a bad rap in the 1990s before we understood the increased risk of rupture during an induced VBAC labor, especially with Cytotec.  Even if your OB is supportive, s/he may be under pressure from hospital administrators, or other OBs in their practice, who feel differently.  Finally, your OB might have experienced a recent lawsuit, uterine rupture, or other bad outcome that influences the way they counsel you.

In the 90s, babies and moms were unnecessarily injured and died when VBAC labors were induced with Cytotec resulting in a high rate of uterine rupture.  Lawsuits were lost and loads of money was paid out.  Rather than taking a step back and permitting VBACs to begin spontaneously and progress normally, which has a far lower rate of rupture than induced or augmented VBACs, doctors took two steps back and declared VBAC dangerous.  ACOG now says that Cytotec should not be used to induced VBACs.  (For a complete history of VBAC and cesareans, read A History of VBACs and Cesareans in the USA by The Well Rounded Mama as well as the recent article in Time.  For more information on the dangers of inducing labors with Cytotec (misoprostol), read Cytotec Induction and Off-Label Use by Marsden Wagner, MD, MS.)

Often OBs are under pressure from hospital administrators.  For a complete understanding on the inside workings of hospital VBAC bans and how hospitals impact how an OB counsels a woman seeking VBAC, read Interview with Dr. Fischbein – An Inside Look at Hospitals & VBAC Bans.

Finally, as was discussed at the 2010 National Institutes of Health VBAC Conference, a recent uterine rupture or lawsuit could result in an abrupt change in an OB’s VBAC policy.  Chet Edward Wells, M.D., a Professor from the Department of Obstetrics and Gynecology at University of Texas Southwestern Medical Center at Dallas, presented, “Vaginal Birth After Cesarean Section: Views From the Private Practitioner.”  It was fascinating.  You can watch his presentation here and read the abstract here.

As you can see, none of these factors have anything to do with whether you are a good candidate for VBAC or not.  I wish practitioners would be more honest about their situation and refer women out to care providers who do attend VBAC.  It does not benefit anyone to exaggerate or minimize the risks of VBAC.

_______________________________

To view the differing rate of uterine rupture for spontaneous, augmented, and induced labors, read Estimates of Risks of Uterine Rupture and Comprehensive chart on uterine rupture measuring multiple variables.

Vaginal Birth After Cesarean Section: Views From the Private Practitioner

Chet Edward Wells, M.D.

Professor

Department of Obstetrics and Gynecology

University of Texas Southwestern Medical Center at Dallas

stamp approved and not approved with red text isolated on white

Does insurance pay when you leave the hospital against medical advice?

stamp approved and not approved with red text isolated on whiteThe more I read about women birthing in hospitals, the more stories I read of women who are lied to and threatened.  If we can’t trust our provider, how can we trust when they say we need a cesarean?

Don’t get me wrong, there are great hospital-based providers out there, but it can be really hard for your everyday mom to be able to connect with them. Generally, care providers can be broken down into three categories.  There may be a supportive provider in your area, you just need to know where to look.

Here is an email from a home birth midwife, shared with permission.  In this case, parents were told that if they didn’t comply with the doctors recommendations, and left the hospital against medical advice, their insurance would not pay:

Short version: had a postpartum transport last night and since baby was born OOH [out of hospital] and was a nice healthy 9#, parents had a difference of opinion with the hospital staff about how much input, if any, the hospital would have in baby’s care.

Deciding that staying would be one long argument after another, the parents decided to sign out AMA if the hospital wouldn’t budge on what they wanted to do.

The thing that almost made the parents cave was the OB’s comment that if they left AMA [against medical advice] the insurance could (actually would) refuse to pay for care mom had received.

My understanding is that insurance will pay for the care rendered, but if a patient signs out AMA, the insurance can decline/refuse to pay for subsequent care needed.

Comments or suggestions of where to find this answer.

BTW: a very kind nurse stepped into the situation and convinced the nurse supervisor to compromise.

When I looked into this, I found this 2010 article from Emergency Physician’s Monthly which stated, “Fifty seven percent of all health care providers (and probably just as many patients) believe that if you leave the hospital or the emergency department against medical advice, insurance companies will not pay for the visit. Half of doctors surveyed have told or would tell patients that insurance would not pay the bill if they left AMA.”

Yet, a 2010 study examined how 104 AMA insurance claims were processed by 19 insurance companies and found that each and every one of them was paid.  They concluded, “Our study suggests that insurance companies not paying for ED [emergency department] visits of patients leaving against medical advice is a myth. ” (Wigder, 2010)

This article from the American Medical News cites another 2014 study reviewing the claims of 526 people who left AMA. The only claims that were not paid were due to administrative errors. “Not a single claim was turned down for insurance payment because the patient self-discharged.”

Why does this happen? American Medical News suggests, “People who investigated the issue suspect the myth emerged out of a desire to persuade patients to do what physicians believed was best. Eighty-five percent of residents and 67% of attendings said they told patients this information ‘so they will reconsider staying in the hospital.'”

So while it can be quite persuasive to hear that your insurance will not pay if you leave AMA, it’s simply not true.

Neonatal nurse has a homebirth VBAC

This is a great birth story, published with permission, of a woman who had a cesarean for “small pelvis” and then VBACed a larger baby at home!  Since she is a neonatal nurse, it’s interesting to read why she chose HBAC and how she thinks her birth would have gone differently had she labored in a hospital.


I just wanted to let everyone know that I gave birth to a healthy baby
girl Wednesday June 11th. I had a C/S with my son 2 years ago. He was
8lbs 2oz and I was told that my pelvis wasn’t big enough to birth an
8lb baby. Well my VBAC baby was 9lbs 2 oz. Exactly a pound bigger than
they told me. I knew I wasn’t broken. I chose to have a homebirth
because I felt I would always have to fight for what I wanted in the
hospital. My labor went great. Started around 3am contractions coming
10 minutes apart. Then progressed to 3-5 min apart at around 6:30am.
My midwife got there around 7:30am. Later I wanted to go into the
birthing tub to try to get through the contractions. My midwife wanted
to check to see how far I was. 4cm and 100% effaced. She told me to
try to hold off on the tub because it would be better when I am
further in labor. I then took a hot shower. For me the contractions
were more bearable standing up. When one would come on I would bend my
knees and lean over onto either the couch, my bed or my husband. The
worse position for me to labor on was my back and my side. After the
shower I asked if I could go into the tub again. She checked me and I
was 6cm with a bulging bag. I did go into the tub which for me didn’t
make much difference in the contractions. But at that point I stayed
in there for quite a while because it took too much energy for me to
move. For me the worse part was going from 6 cm to complete. I thought
it would have been the pushing part but it wasn’t. In the tub I did
feel like pushing a little bit. We couldn’t tell if my water had
broken since I was in the tub. I decided to get checked in the tub to
see if the water had indeed broken and plus since I was feeling
“pushy.” Still at 6cm but the bag was bulging more. They think that
was why I was feeling like I had to push. They let me push a couple of
pushes to see if that would break my water but it didn’t. Then they
told me not to push and just try to breath through the contractions.
My water still wasn’t breaking and it was the hardest thing trying not
to push when that overwhelming feeling was there. They gave me the
option of breaking my water and felt that once they did that the
baby’s head would apply to the cervix and help with dilation. I
agreed. They broke the water and sure enough baby’s head came right
down and I was 8-9cm. The pushing feeling let up and I labored more
for a while. I then started feeling pushy again and they decided to
check to make sure I was fully dilated before I fully pushed. I just
had an anterior lip. Again they told me not to push so that the
anterior lip would pull back over the baby’s head and not swell. I was
dying to push but breathed through each contraction for an hour or
two. (I lost all sense of time so I don’t know exactly how long it
was) The best position for me was on my hands and knees but they said
that with the anterior lip that the position was actually making it
worse. They wanted me to lie on my back to help take pressure off the
cervix to facilitate it moving around the baby’s head. Lying on my
back was so unbearable but I did it to help with the dilation. The
midwife decided to try to help push the cervix over the head. She told
me to push while she held it out of the way. Finally her head came
down and I could fully push to my heart’s desire. That felt great.
They asked if I wanted to go back to the hands and knees position
since the cervix isn’t an issue now but I said I just could not bear
to move to another position. Then the “ring of fire came” Boy did that
burn. Finally her head came out and, surprise, so did a hand. They
said that her hand was across her face. They pulled the hand out along
with the head and since one shoulder was in and one was out she was
having a little bit of trouble maneuvering. They wanted me to flip to
my hands and knees to open up the pelvis more. I thought they were
crazy. Me trying to flip over with a head hanging out. I knew that I
just had to do it as quickly as I could or it wouldn’t have gotten
done. My husband said he had never seen me move so quickly in my life.
I pushed a little more and she was out! Amazingly I had no tears.
Personally I thought that was pretty amazing to have my first full
term vaginal birth of 9lbs 2oz with no tears what-so-ever! So to all
of those women who have been told that you would have died in
childbirth because you couldn’t push out your own baby YOU CAN! I am
proof that I delivered a baby 1 pound bigger than what they said.
I am an RN in labor an delivery and see all of the unnecessary
interventions that they do. I was pondering about my birth. If I would
have chosen a hospital birth I probably would have ended up with
another c/s or an episiotomy. There were times during my birth where I
thought am I crazy I can’t deal with this pain. The midwives and doula
helped me through the intense contractions. If I was at the hospital
they would have bullied me into an epidural and therefore I wouldn’t
have been able to move around to get her to come down. Also I wouldn’t
have been able to feeling the progression of her head coming down when
I pushed. With my son I pushed and couldn’t really feel any progress
so mentally I was losing hope. With this birth it didn’t feel like I
pushed for an hour because I could feel the accomplishment of her
coming down. I see this happen all of the time at the hospital. If a
mom isn’t pushing quick enough for the Dr or they think the head is
too big then they will automatically do an episiotomy. They probably
would have done that and it just shows that it would have been for
nothing and I would have had a longer recovery time. So therefore I am
grateful that I found homebirth and such wonderful midwives. Any of
you who are contemplating homebirth vs hospital try your best to do
homebirth. Don’t let money be an issue. After all is said and done
money is money. You can always earn the money back but not the
experience of a wonderful birth. I hope this inspires all of you who
are having the normal feelings of “what if I can’t do it.” Good luck
to your future births, You CAN do it!

A RN’s Perspective on the 2 NJ CS Deaths & Her Own Birth Experience

As I’m sure you can imagine there was much discussion on the ICAN list of the two moms who died within days of each other after their cesareans at Underwood, a New Jersey hospital.

I’m sharing the following post, with permission.

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I am a registered nurse, and have no intention of ever working within a hospital setting again. It really is all about the business and not about the patient. The human life we are caring for. In NJ, where I reside, there is a nursing shortage. In addition to a nursing shortage, there are very poor unregulated nurse patient ratios, making quality care hard to provide when the nurse is spread thin. I don’t know what the mother baby ratio was at Underwood, but I do believe that with the appropriate monitoring, these cases if truly resulting in hemorrhage and a clot perhaps may have been prevented. But there are a lot of questions that need to be asked.

At what point in their stay did the episodes occur?

Where was the clot? Was it a pulmonary embolism? Clot went to the lungs. A myocardial infarction? Clot went to the heart. A stroke? Clot went to the brain. Was her PT/PTT time measured before or after the surgery? Bleeding time. What were her platelets? Clotting component. These measure clotting predictability. Was she wearing compression boots on her legs and if so, for how long. This is to prevent clot formation, which is very often where clots form s/p surgeries due to venous stasis, and platelet formation at the incision site. How often was the nursing staff in the room? How often were her vitals measured? Did she complain of any DVT pain? Leg pain, heat, swelling of the leg at the location of the clot? There is clot busting medication available IV for emergency situations. But if no one was in her room for hours upon hours, no one would have seen the signs. I know from my 4 c/s that nurses don’t frequent the room as often as they should
and they don’t respond quickly to your calls on the call bell.

Hemorrhage. Where did it originate? Was her CBC monitored? Was her vitals monitored? If so, how often? What was her PT/PTT pre-operatively & postoperatively? Was something nicked? Was it vaginally? Did they attempt a blood transfusion? Did they attempt to stop the cause of the bleed?
There are so many unanswered questions here.

My horror story,

[After my cesarean] they medicated me and took my baby back to the nursery. They told me they would bring him back at 1am to breastfeed. They did not. I awoke at 6am when they did my vitals, which was done by a tech, at the beginning of each 12 hour shift. Q 12 hour vitals are not enough to detect a potential postoperative problem. They never brought my baby back. I asked for him, and was told, soon. I called again at 7am and they were in the middle of a shift change. I called again at 7:45am and was told the babies were being seen by the docs and he would be brought to me after. 8:30am I called down and was told that he was being seen by the doc. 9 am, the doc came into my room, no baby. No nurse. It had not even been 24 hours since his c/s birth. I was still medicated, still could not feel my legs, I was in compression boots, still had the foley catheter, still had the IV. The doc sat at the foot of my bed and proceeded to tell me that my baby had stopped breathing, needed resuscitation. There were other details but all I could hear was my baby stopped breathing. He WAS fine when he was with me. He left me there, by myself. I called down to the nurse, that I needed her NOW. No one came for the 15 minutes that I was on the phone with my mother and my husband telling them what had happened and to come down. I had to call the nurses station again, this time, demanding that a nurse come and release me from everything or I would do it myself.  For God Sake my baby nearly died. One came, and an hour later I was being wheeled down to see my baby… nothing urgent to them. Not enough staff to meet the needs of the patients. My son is wonderful, thank GOD, he is 16 months old! But if I could not get nursing support, and I was calling for it, who is to say that this was not part of the problems in these Underwood cases?

Tiffani, RN

http://icanofcapeatlantic.blogspot.com/