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

In short, VBAC is a “safe and appropriate choice for most women” with one prior 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 (ACOG, 2010).

What follows is a brief overview of these new guidelines.

They express support for VBAC after one and two prior cesareans:

Attempting a VBAC is a safe and appropriate choice for most women who have had a prior cesarean delivery including for some women who have had two previous cesareans.

They express support for VBAC with twins or unknown scars:

The College guidelines now clearly say that women with two previous low-transverse cesarean incisions, women carrying twins, and women with an unknown type of uterine scar are considered appropriate candidates for a TOLAC.

They detail the risks that can come with multiple cesareans which are often not listed in your standard “informed consent” document:

[VBAC] may also help women avoid the possible future risks of having multiple cesareans such as hysterectomy, bowel and bladder injury, transfusion, infection, and abnormal placenta conditions (placenta previa and placenta accreta).

But what will have the most impact on the most women is the lifting of the “immediately available” recommendation turned requirement as suggested by the NIH VBAC Conference:

The [American] College [of Obstetricians and Gynecologists] maintains that a TOLAC is most safely undertaken where staff can immediately provide an emergency cesarean, but recognizes that such resources may not be universally available.

They acknowledged how the phrase “immediately available” in their last recommendation were used to support VBAC bans:

“Given the onerous medical liability climate for ob-gyns, interpretation of The College’s earlier guidelines led many hospitals to refuse allowing VBACs altogether,” said Dr. Waldman. “Our primary goal is to promote the safest environment for labor and delivery, not to restrict women’s access to VBAC.

And they now support hospitals who do not meet the “immediately available” standard attending VBACs:

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.

Finally, they assert how women should not be force to have a repeat cesarean against their will and that women should be referred out to VBAC supportive practitioners if their current care provider would rather not attend a VBAC:

The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC. On the other hand, if, during prenatal care, a physician is uncomfortable with a patient’s desire to undergo VBAC, it is appropriate to refer her to another physician or center.

Removing the “immediately available” standard while supporting VBAC with twins, after two prior cesareans, and with unknown scars is a huge step in the right direction.  It seems that the option of VBAC is now available to hundreds of thousands of women, many of whom, up to this point, were left with no choice at all.

Read the whole press release dated July 21, 2010: Ob-Gyns Issue Less Restrictive VBAC Guidelines.

Available for purchase dated August 2010: Practice Bulletin #115, “Vaginal Birth after Previous Cesarean Delivery,” is published in the August 2010 issue of Obstetrics & Gynecology.

Dr. Biter has resigned

I spoke to Dr. Biter. He could not discuss the details of his resignation from Scripps Encinitas Hospital but I’m certain it’s more complex than we know. Anytime a person takes on the system, it’s never cut & dry nor is it ever a fair fight. I know Dr. Biter has always put his patients 1st & is putting together a plan to continue to ensure the safe care of his patients during this transitional time.

5/21/10 4:11pm – Very exciting news per BringBiterBack.com!  While I’m saddened I didn’t get to attend any of the protests, I’m pleased with the outcome!

Friday, May 21, 2010

RALLY CANCELLED!!!

After over 1600 signatures to a petition, days of crowds supporting Dr. Biter, cars and trucks painted with slogans such as “We love Dr. Biter” and “Bring Biter Back,” we are pleased to confirm that an email was sent by the administration at the hospital that obstetric privileges were reinstated yesterday for the popular doctor. His gynecologic privileges were never suspended and also remain in place. While we are all excited to celebrate the reinstatement of Dr. Biter’s OB privileges at Scripps Encinitas, he has contacted one of his biggest supporters to request that no public rallies take place today at the hospital. He has also chosen to not make a public statement at this time.

While the overwhelming amount of support for Dr. Biter and his approach to natural child birth has not gone unnoticed, the organizing members of BringBiterBack.com request that any celebrations take place in the privacy of our own homes with our families and babies.

Thanks for your understanding!

• a list of 4 doctors who “are responsible for suspending Dr. Biter”
• how one of these doctors, as well as the head of OB at Scripps, will benefit financially from Dr. Biter’s suspension
• a summary of a meeting between 5 pregnant moms, 2 husbands,  Carol Yeh-Garner, the Scripps Chief of Staff Dr. MacCormick, the  COO, the Chief Executive RN & a HR representative.

So, a little more information has come to light.

There were 2 emergency staff meetings called earlier in the day at Scripps Encinitas. Usually these meetings are held when there is a big case of something going wrong–like a wrongful death. The meetings were held to discuss “the recent events concerning a staff member”. From what I’ve heard from staff that were present at the meetings, nothing was discussed other than the issue is a confidential matter.

It came to my attention late last night from someone that there are 4 doctors that are on a medical board of the hospital that are responsible for suspending Dr. Biter. They are:

Dr. Ronald MacCormick, Chief of Staff
354 Santa Fe Dr. Encinitas, CA 92024
760-633-6807 fax 760-633-6807

Dr. James La Belle, Internal Medicine
354 Santa Fe Dr, Encinitas, CA 92024
760-633-7686

Dr. Thomas Chippendale, Neurology
320 Santa Fe Dr Ste 101 Encinitas, CA 92024
760-942-1390

Dr. Michael Lobatz, Neurology
320 Santa Fe Dr. Ste 108 Encinitas, CA 92024
760-942-1390

Please send letters to these people since they are the ones that have decided to suspend Dr. Biter. With this public outcry, they need to reinstate him immediately. They need to know that it’s not their call, that it’s our call & we are demanding to have Dr. Biter & that they can’t bully him or us. This bullying won’t be tolerated. Thank you for all of the letters you are writing! My email box has been inundated with letters. If you sent me a letter & asked me a question or wrote me something, I want you to know that I haven’t even opened them yet. I’ve been so busy. So if you have an important question or issue, please email me & let me know. Thanks for understanding.

It is also interesting that Dr. MacCormick (& Dr. Fenton–Head of OB) will make money off of Dr. Biter’s suspension IF moms in labor come into Scripps Encinitas & use the hospitalists (on-call OBs) because guess who owns the hospitalist company? Dr. MacCormick! Isn’t that a conflict of interest?

A group of 5 pregnant moms, 2 husbands & I went at 3 pm yesterday (Wed) to Scripps Encinitas to request a meeting with Dr. MacCormick, Chief of Staff. We were surprised that he came back on campus to meet with us along with the COO, the Chief Executive RN & someone from HR. The statement they made is that the issue is confidential & they are not at liberty to share any information. They are sympathetic to the situation & understand that it is a stressful situation for the pregnant couples, but there is nothing that they can share. Dr. MacCormick stated that the hospital has made provisions for their OB hospitalists (on call OBs) to care for the pregnant moms when they go into labor & that he fully trusts in their ability to support their birth plans. One of the moms took the lead & stated that we were there to get answers but understood that it was a legal issue & that we might not get answers. She said that we also just wanted to be heard & have our opinions shared with them. She stated that we all know that Dr. Biter was delivering babies as of Thursday & delivered a baby on Friday that had meconium aspiration that was discovered at the time of birth. She stated that the baby is doing fine & that meconium aspiration is something that is fairly common. So, why was it that he was delivering babies Thursday & Friday but them as of Friday afternoon, was deemed to be too dangerous to deliver any more babies? They couldn’t comment on that because it is a confidential issue. Several of the moms spoke & some cried about how emotionally stressful this situation has been on them & they have developed strong ties to Dr. Biter & can’t & won’t consider birthing with anyone else. A dad shared that they’ve been building a relationship with Dr. Biter the past 31 weeks & they trust him & know that he will honor their wishes for a natural birth for their birth. He said that it’s their 1st birth & they really want it to be a wonderful experience. He said that he knows that Dr. Biter will provide that for them and that they will be loyal to him wherever he goes. One of the moms shared that they recently moved to San Diego. They are in the military & chose to go outside of the military hospital to birth their 2nd child because they had a negative birth experience the 1st time. She researched & learned that Scripps Encinitas was supposed to be the most natural-birth supportive hospital in town. She called the Labor & Delivery dept to get a recommendation for a great OB & the nurse said that she’d have to give 3 referrals but that Dr. Biter got a “gold star”. This mom said that she specifically chose their hospital & this doctor because she wants a better birth. She said that she is committed to having Dr. Biter be at her birth & that she was really unhappy with the decision to suspend him. I shared that I’m a childbirth educator & have had over 350 couples come through my classes. I’ve always referred my clients to Scripps Encinitas because they promote themselves to be the most natural-birth supportive & because they are a mother-baby friendly hospital. I asked them how they could be either of those if they continue getting rid of natural birth supportive care providers like the midwives & Dr. Biter, who is the MOST natural-birth supportive OB in town. They were defensive about the midwives & wanted to clarify that they didn’t make the midwife group leave, but that the midwife group left on their own accord. I stated that they technically may have left, but it was only because the environment was hostile & that we all really knew what happened. I suggested to them that they rethink their decision to suspend Dr. Biter because in doing so, they’ve now tainted their reputation as a natural-birth supportive & mother-baby friendly hospital. In suspending him, they’ve also put themselves in a poor financial situation because almost all of his patients will follow him or choose other hospitals. I shared with them that I was aware of 5 moms that were due & chose to have homebirths with midwives & that NO ONE has chosen to birth in Scripps Encinitas with the on-call doctors since the suspension occurred. The COO & the Chief Exec. RN were defensive again saying that I shouldn’t make blanket statements that include their nurses because their nurses are mother-baby friendly & natural-birth supportive. Dr. MacCormick also stated that there are other OBs on staff who support natural birth & will respect a woman’s birth plan. I then stated that I used to refer clients to several other doctors who say they support natural birth only to find that my couples consistently would report back to me that they were pressured & didn’t have the birth experience they wanted. Yet, every client that went to Dr. Biter for their birth had only positive things to say about their birth experiences. So, they may say they have other doctors, but as they can see, the group of people before them would NOT be coming to their hospital unless Dr. Biter was present. A dad, who is also a doctor, ended the meeting by saying that this small group represents the larger group of Dr. Biter patients & that most if not all of Dr. Biter’s patients would not be coming to the hospital to birth their babies. The dad requested that they reinstate Dr. Biter immediately so the women in the room could birth where they wanted to & with the OB they desired & developed a relationship with. The dad requested that the decision be made as soon as possible & that if they weren’t going to reinstate him, that that decision be made as soon as possible as well. We thanked them all for their time & they did the same. They repeated that they are sympathetic to the situation & that they heard our requests.

Here’s the latest information we have about the rally:

We are expecting over 500 people to come to the rally [Friday, May 14th, 2010]. Please do NOT park on Scripps property. There is a parking lot across the street & residential parking west of the hospital.

If you’d like to order a t-shirt that says Bring Dr. Biter Back!, please contact Deanna at opporders@gmail.com for details.

Here are the new recommendations for signs:
STOP BULLYING BITER!
Bring Dr. Biter Back!
Bring Biter Back!
Dr. Biter IS Mother-Baby Friendly!
www.BRINGBITERBACK.com
Dr. Biter is THE VBAC doc!
Dr. Biter has the lowest C-section rate!
RNs (heart) Dr. Biter
Biter is the only OB that teaches surgery in San Diego!
Best DOCTOR 2 years in a row!
Reinstate Dr. Biter NOW!
My baby needs Dr. Biter!
My birth needs Dr. Biter!
Dr. Biter respects women’s rights!

We want this rally to be positive but we also want to make our point. Please keep your signs focused on what we want–Dr. Biter to be reinstated immediately–and what we love about Dr. Biter.

Feel free to contact the news–TV, radio, online, & print–to encourage them to cover this story & our rally. John Gardner’s sentencing is scheduled to happen at 1:30 pm so they will be covering that, but we’ll be rallying until 3:30 pm, so they can still come cover our rally. If they need a contact person, you can refer them to me: Carol Yeh-Garner 858-837-1259 or to Sheri Menelli: 760-522-2829.

On behalf of all of the people working behind the scenes to make this rally happen & to help get Dr. Biter reinstated, we THANK YOU for your support!

If you are not familiar with Dr. Biter, aka Dr. Wonderful per the Navelgazing Midwife, and the unique obstetrical care he offers, please read the article Rally for Dr. Wonderful on Mother’s Day from the Dou-la-la blog.  It chronicles a birth (home birth transfer) he attended, features amazingly touching photographs, and provides a summary of the first protest dated Sunday, May 10th.  This is how hospital birth should be and it’s a damn shame that the women of San Diego are losing access to this incredible OB.

Want to express your displeasure of the hospital’s actions?  Here is a list of ideas:

• Write a letter to the chief of staff.
• Contact your local representative.
• Write letters to the editor to the local news media & newspapers.
• Write supportive statements on your car windows with window paint.
• Go show your support at a daily vigil in front of Scripps Encinitas hospital.
• Come to the Bring Dr. Biter Back Rally this Friday, May 14th from 1:30-3:30 pm in front of Scripps Encinitas hospital.
• Sign the online petition to help reinstate him immediately.

As Carol says, “Time is of the essence. He must get reinstated within the next 9 days or his case will go in front of the Medical Board, therefore, delaying any chance of him getting reinstated in the near future.”

Please see the email below for more information on each of these action items.

Stay in touch via the Bring Biter Back blog or the I love Dr. Biter Facebook fan page.

____________________________________________________

Hi everyone- Please share this information with your clients, your friends, your family & anyone else that knows Dr. Biter. This is an important issue regarding women’s rights–the right to choose WHO to birth with & the right to choose WHERE to birth! If Scripps Encinitas doesn’t reinstate him immediately, hundreds of women will be left without a care provider that truly understands the normalcy of birth. Thanks–Carol Yeh-Garner

Dr. Robert Biter is a unique physician in the San Diego community. He embraces the concept of a woman’s right to choose a natural birth. He literally embodies the entire gamut of birthing options that an informed health care provider can offer to a woman and her family in a society that increasingly demands baby-friendly and healthy/organic birthing solutions. In supporting his patients’ natural birthing decisions, he also offers the best possible medical and surgical expertise should emergency medical intervention become necessary in the birth process. The patients choose their births, Dr. Biter makes those choices possible as long as the choices are safe, and the patients love him. They call him Dr. Wonderful.

Dr. Biter has held staff privileges at Scripps Memorial Hospital Encinitas in Encinitas, California for the last 8 years. During his time at Scripps, he has held the title of Department Chair of Obstetrics and Gynecology, as well as having headed up the hospital’s ethics committee. He has won Best Doctor in San Diego two years in a row by Ranch and Coast Magazine.

With no warning on Friday May 7, 2010, Scripps Memorial Hospital Encinitas suspended Dr. Biter’s obstetrical privileges effective immediately.

Scripps decision to suspend Dr. Biter’s privileges has left both Dr. Biter and Dr. Biter’s expecting patients reeling and confused. At the most critical time in their pregnancy, Scripps has made it impossible for these women to have the doctor of their choosing deliver their babies; and the likelihood of finding another physician who understands and supports natural birthing is slim to none. The majority of these women would follow Dr. Biter wherever he practices; but for him to establish staff privileges elsewhere is a time intensive endeavor. To make Scripps’ actions even more unclear, there have been no claims of obstetrical malpractice filed against Dr. Biter…EVER.

On Mother’s Day, May 9, 2010, the local community rallied around Dr. Biter and the message that families want the option to choose natural births in a hospital setting. The result was a Mother’s Day rally in support of Dr. Biter held with less than 24-hours notice at Scripps Memorial Hospital Encinitas in Encinitas, California. Approximately 150 people attended.

Scripps Encinitas Hospital has consistently touted themselves as a very holistic, mother-baby friendly hospital. How can they be so mother-baby friendly if they have suspended THE most mother-baby friendly obstetrician in town?

We know that the last couple whose birth he attended had no unforeseen complications that would indicate a need for suspension. The baby had meconium aspiration, which was found only at the time of the c-section. Mother & baby are doing fine. The baby is in the NICU but is breathing & eating on her own. The parents are thrilled with the way that Dr. Biter assisted them during the birth of their daughter & in no way made any complaints against him to bring about the suspension. The father attended the Mother’s Day rally even though he had a newborn in the NICU. His wife recuperated in her hospital room while holding a sign that read, “We support Dr. Biter”.

Dr. Biter needs to be reinstated immediately so that he can provide continuity of care to his patients that are expected to go into labor at any moment. He is such a dedicated person that he has come up with a backup plan of being an unpaid doula to all his patients that are in labor at Sharp Mary Birch Hospital. Anyone who wants to labor at Scripps Encinitas can change doctors or show up & birth with whoever is on call at the moment, but we believe that most, if not all, his patients will want to stay with him to continue to receive the wonderful care he has provided to them.

Here are the latest things you can do to help:

Please send all letters demanding Dr. Biter’s reinstatement to:
Dr. Ronald MacCormick, Chief of Staff
Scripps Encinitas Hospital
354 Santa Fe Dr
Encinitas, CA 92024
His phone number is 760-633-7686. Ask to leave a voicemail for Dr. MacCormick.
Please CC Chris Van Gorder, CEO at: 4275 Campus Point Ct, San Diego, CA 92121.

Please contact your local & state politicians to bring light to this situation:
Assemblyman, Martin Garrick
Assemblyman, Nathan Fletcher
Susan Davis
Francine Busby
Barbara Boxer
Diane Feinstein

Write letters to the editor to the local news media & newspapers highlighting Dr. Biter’s suspension & the travesty of it. Call them to alert them of the upcoming rally this Friday (details below).

Write on your car windows with window paint:
Bring Dr. Biter Back!
The more people that know about this issue, the better! Sheri Menelli will have window crayons at the morning daily vigils in front of Scripps from 9-11 am so stop by & get your windows decorated.

Go show your support at a daily vigil in front of Scripps Encinitas hospital every day until he is reinstated. The vigils will be held from 9-11 am everyday until he is reinstated.

Come to the Bring Dr. Biter Back Rally this Friday, May 14th from 1:30-3:30 pm in front of Scripps Encinitas hospital. We need a lot of people so bring friends, family & neighbors. Kids & babies welcome! Wear green in significance of peace, nature & eco-consciousness, which are all thing Dr. Biter supports. RSVP at the I love Dr. Biter fan page EVENT page. Ricki Lake, author, actress & filmmaker will be there along with Anna Getty, author, actress, great-granddaughter of John Paul Getty III and creator or Pregnancy Awareness Month. There may be other celebrity supporters there as well.

SIGNS for the vigil & rally should read:
BRING DR BITER BACK!
BRING BITER BACK!
HOW IS THIS MOTHER-BABY FRIENDLY?
THIS IS NOT MOTHER-BABY FRIENDLY!
HEY CHIEF OF STAFF! BRING BITER BACK!
SHAME ON SCRIPPS!

Please sign the online petition at: http://www.facebook.com/l/bf255;www.ipetitions.com/petition/bringbiterback/ to help reinstate him immediately.

We have a blog (http://www.facebook.com/l/bf255;www.bringbiterback.blogspot.com) or the I love Dr. Biter Facebook fan page that will keep you updated with the latest information.

Time is of the essence. He must get reinstated within the next 9 days or his case will go in front of the Medical Board, therefore, delaying any chance of him getting reinstated in the near future.

Thank you again for your help & support!

Live, Love, Laugh…Often~
Carol Yeh-Garner, LCSW, HBCE
858-837-1259
http://www.facebook.com/l/bf255;www.AWellLivedLife.Net
read my http://www.facebook.com/l/bf255;blog~AWellLivedLife.blogspot.com

Many of the stories on this website point to the ob/gyns as the bad guys.  While I believe there may be some doctors that use tactics and lies, it is overlooked that the doctors are just as misinformed and scared as the patients!

I would like to add a little clarity based on my experience as a patient who has had 2 c-sections.  I had a section 5 years ago due to “failure to progress”.  (5 minutes after the consent, while the doctor was prepping for surgery, my body signaled the progress I had been “failing” to reach with the most incredible urge to push.  However, I thought he knew best and stupidly agreed to continue with the c section.)  I have regretted it ever since.   However, I believe that the doctor truly was concerned and I trusted it, despite the fact that I personally believe I could have delivered vaginally.

The reason I believe some doctors’ concerns are sincere if not valid is because of the education, both formal and informal, they have received.  My ob/gyn was a specialist in many fields of womens’s medicine and so I trusted that.  Little did I know I was signing on an expert in surgery.   A doctor’s entire training revolves around how to interfere with something very natural… childbirth.  They are taught about evey possible bad case scenario, so they are prepared, so they are trained in intervention.

Then they go into the field and begin to learn the hospital and insurance policies that insist the doctor use these scare tactics becase they have been bitten so badly financially by unsatisfied women who sue them into making this policies in the first place.   The problem is the high costs associated with lawsuits and therefore, the rest of the vbacs suffer.  In my case, I was not ever “allowed” a second c-section because the hospital had lost a single lawsuit against a woman who hemmoraged during her vbac.  It was my “bad guy” doctor that has to pay the high cost of mal-practice to the point that, combined with the overhead of his office, he had to deliver 150 before he began to make any money.  So out of fear he falls back on his training which tells him that women need help to get a baby into the world.

Instead of blame (another product of fear) we should look to ourselves and educate each other about how to accept disappointment and best of all, how to avoid it by educating ourselves.  We can have more confidence for it’s own sake instead of walking into birth/labor with the attitude of going to war with our practitioners.

Miriam,

I agree with a lot of what you said.   I share these stories for a multitude of reasons, none of which include the desire to portray OBs as “bad guys.”

I want women to understand that there are OBs who practice in this manner.  I want to share with women the various tactics that these type of OBs use in order to passively, or actively, encourage a woman to have a repeat cesarean.  I want women to know that if they encounter these tactics from their OB that they have options.  They can find another care provider that supports VBAC.  There are absolutely wonderful OBs out there.  I had the opportunity to hear many speak at the NIH VBAC Conference this past March.

You said, “Instead of blame (another product of fear) we should look to ourselves and educate each other.”  I agree.  Yet there are many women who say, “Why do I need to educate myself?  I didn’t go to medical school.  That is why I hire my OB.  To advise me.”

It’s not until they read a birth story like this do they see how wildly the “standard of care” can vary depending on who you hire as your care provider.  That is why I share stories like this.  To illustrate how bad the care can be to encourage women to become active participants in their care rather than passive patients along for the ride.

You talk about OBs being “misinformed and scared.”  You stated, “Then they go into the field and begin to learn the hospital and insurance policies that insist the doctor use these scare tactics becase they have been bitten so badly financially by unsatisfied women who sue them into making this policies in the first place.”

OBs who have been sued over VBACs have a higher propensity to not attend VBACs in the future, but is it ethical for a doctor to encourage a women to have a repeat cesarean solely because they have been sued?

I think the most ethical thing an OB can do is be honest with the patient about their fears and refer them to a care provider who is supportive of VBAC.  Unfortunately, what many of these OBs do is either lie to the patient about the risks of VBAC vs. repeat cesarean (read Another VBAC Consult Misinforms and Scare Tactics vs. Informed Consent for more) or act like they will give the patient a trial of labor only to pull the plug with some bogus reason in the last weeks of pregnancy or even in labor.

If an OB doesn’t want to attend VBACs, they should be upfront with the patient so they have the opportunity to find a provider who is supportive.

Warmly,

Jen

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 on March 11, 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 MD 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.

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:

• The Three Types of Care Providers Amongst OBs and Midwives
• Questions to Ask a Provider
• Finding a VBAC Supportive OB or Midwife
• Scare tactics vs. informed consent aka why I started this website

______________________________________________________

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.

So here I am, with kids asleep, and I finally get to finish one of the many posts I have started over the last 9 days.  These moments are so few and far between.  It is seriously so luxurious to be able to sit in the quiet and write.  In short, I need your help.

I was beyond thrilled to be at the NIH in the same room as so many vocal and passionate VBAC supportive care providers.  It occurred to me how there are certainly women in their same communities who didn’t even know these fantastic resources existed.  Unfortunately, there wasn’t a list of attendees released for the conference and I continue to receive pleas for referrals from women who cannot find a care provider such as Jessica in Pittsburgh, Maggie in Arizona, and Heidi in Athens, Ohio.

Ever since I started vbacfacts.com over two years ago, many have suggested that I post the names of supportive care providers.  While I do write about care providers who are themselves vocal, I am hesitant to bring public attention to others who discretely support VBAC.  Many practitioners are under considerable pressure from multiple sources such as hospital administrators as well as peers within their practice, hospital, or community.  Then we have midwives who work “under the radar” in states where it is not legal for them to attend births and/or VBACs yet they do so because women in their communities do not have hospital-based options.

While I desperately want to connect women with care providers, I don’t want to bring excess, and possibility negative, attention to a practitioner who, unbeknownst to me, is already under hefty pressure as this might interfere with, or ultimately bar, their ability to attend VBACs at all.

I started creating a database so that practitioners, particularly those who attended the NIH VBAC conference, could volunteer their names and contact information.  I would try to mitigate the attention factor by offering to privately maintain their information on my computer’s hard drive in addition to providing the option of publishing their information publicly on vbacfacts.com. I could then reference the private database as individual women contacted me for referrals.

But before I start such an endeavor, I wondered if there was a better way to go about this.  And so I’m looking for your suggestions.  How I can use this forum as a way to facilitate connecting supportive care providers with moms without bringing potentially harmful attention their way?  Is there even a way to do it?

If you are reading this and wonder, “What’s so hard about finding a VBAC supportive care provider?” permit me to share the story of Brooke Addley from northeastern Pennsylvania.  She asked her current OB his thoughts on VBAC and received so much false information, as typically happens, that it left her in tears.

Women are frequently provided with inflated and inaccurate uterine rupture, infant mortality and maternal mortality rates by their OBs when they breech the topic of VBAC.  It is heartbreaking because women are making major medical decisions, which impact their future health and pregnancies, based on outright lies.

Scare tactics masquerading as informed consent is a major problem.  Somehow, we have to find a way to connect women with supportive care providers in their area.  Please leave a comment or email me with your ideas on how we can do that.

Learn more about finding a supportive care provider:

• The Three Types of Care Providers Amongst OBs and Midwives
• Questions to Ask a Provider
• Finding a VBAC Supportive OB or Midwife
• Scare tactics vs. informed consent aka why I started this website

I received many requests to share it online, not only from conference attendees but by the women themselves who contributed their stories for this piece.  You can download a PDF copy of this document here.

I’m especially excited that I had the opportunity to share the comments provided by Wendy S. from California, Kristen K. of Nebraska, and Rachel R. of Oregon during the public discussion time which you can view via the Day 2 Webcast.  (You can also view the Day 1 Webcast, download a PDF of the Program and Abstracts, as well as pre-order the consensus statement.  The more people who order the consensus statement, the more powerful the message that people are interested in the option of VBAC.)

While the contributors gave permission for their full names to be used on the  handout I distributed at the NIH, not everyone is comfortable with their name on the internet.

American Women Speak About VBAC

In an effort to bring the consumer perspective to the 2010 NIH VBAC Conference,  Jennifer Kamel, Founder of VBAC Facts, asked women across America, “Why is the option of VBAC important to you?”  This is what they said.

Alabama – To avoid not being able to carry your baby because he’s dead from the placental abruption (or uterine rupture) as a result of those damn previous cesareans. – Amanda M.

Arizona – VBAC is important to me because I don’t want to continue to have increased risks with each major surgery. – Amanda McM.

Arkansas – Personally, VBAC is stellar important to me because I wanted to give birth to my babies, not have them cut out and handed to me.  On a soul-deep level, I believe it was necessary to validate my purpose in existing.  – Jer W.

California – It is important to me because I have the right to experience the complex passage of vaginal birth and the positive cascade of effects for mom and baby.  I want the right to experience VBAC without driving 90 minutes or more with traffic. Successful or not, VBAC empowers women for choice and a chance to fill an emotional void that is unmatched.  The whole “readily available” lawyer talk certainly is not protecting our other high risk patients.  – Wendy S., L&D RN

Because when a woman experiences a VBAC, she reclaims her body and gets to see that she is in fact perfectly capable of giving birth without surgery.  She is no longer broken.  Her body and spirit heal. – Layla M.

To me it is like saying someone should be required to have open heart surgery, even though a laparoscope would be safer, just because doctors/ hospitals/ insurance companies, prefer it that way.  It is so much bigger than our desires to experience a vaginal birth or even to be some kind of hippie earth mother. It is about our right to safe and respectful medical care. Courtney Stange-Tregear

I wanted a VBAC to heal my raw emotions and psychological trauma caused by not having a vaginal birth the first time and because I believe it’s safer. Unfortunately, I had to travel 3 hours to get to the closest facility that allowed VBACs. But having the chance to VBAC was great! – Andrea O.

Because I love women and love babies and have spent 20 years investigating what affords the best possible beginning for them both and that is a vaginal birth. – Joni Nichols BS MS CCE CD(DONA) (CBI)

It is wrong that I have to travel to another county and fight for a normal, safe, healthy birth for my baby.  Hospitals and doctors need to get their priorities straight and practice true informed consent. – Kathleen S.

My VBAC proved to me that I was not as broken as I felt after receiving so many labels [FTP, etc] regarding my cesarean. – Alexandra R.

Colorado - VBAC allowed me to trust in my body and let it do what it needed to do.  My midwife and her assistant viewed my “long labor” as simply a variation of normal.  I was finally able to deliver my 10 lb baby, with a nuchal hand, in an amazing waterbirth.  My body is amazing and strong and did not let me down. Jill K., Ph.D. (Clinical Psychologist and Professor)

Connecticut – Without VBAC, women have no choice and are forced into dangerous births. – Danielle M.

Florida – VBAC matters because it is lifelong; it is forever; it is not short term.  The effects of a VBAC never wear off. – Shannon M.

My VBAC offered me a better recovery without worrying about an incision site. – Meredith S., HBA2C mom

Hawaii – The fact that the possibility of a malpractice suit dictates what most obstetricians offer and results in them pushing the birth option that is more likely to end in a mother’s death is totally incomprehensible to me. Evidence-based care is what our standard should be.  Every single obstetrician should be pushing the safest option for mother and baby, not the safest option for avoiding a lawsuit. – Naomi S.

Idaho – My VBAC was validation of my womanhood. It has made me a better mother and spouse. – Bonnie M.

Indiana - I wanted to have a large family and I think VBAC is the best option instead of repeat c-sections!!  I have had 6 VBACs so far and hope to be able to have as many more! – Stacy G.

Kentucky – Because having my baby cut out of my abdomen was very traumatic for me.  The bonding was more difficult [than my three previous vaginal births] and PPD followed. – Denise H.

Massachusetts – When my son was born by (unnecessary) cesarean, I felt like someone had deflated my belly and handed me a baby. He was mine, but a part of me felt like they could have handed me any baby. But when I look at my daughter’s head and stroke it while I am nursing her, I can say I gave birth to that head. I gave birth to that head! This is my baby. And no one can take that away from me. – Catie Ladd

Michigan – There are all sorts of “soft” reasons why VBAC is great but when it really comes down to the bottom line, what keeps me working for ICAN, what brings tears to my eyes, is the fact that women and babies are dying who shouldn’t, because VBAC is no longer a real option for most women in the U.S. – Gretchen Humphries, MS DVM

Mississippi. After my first baby’s labor ended with a cesarean, I felt that I really hadn’t been given a chance.  I felt bullied and pushed into a cesarean I didn’t want because it was more convenient for the doctor than letting me continue at a ’slower than normal’ dilation rate. – Nancy W.

Nebraska – If VBAC was not an option, my daughter would have been an only child.  I could never willingly conceive knowing my child would be cut out of me via a completely unnecessary surgery. – Kristen K.

New Jersey - VBAC is certainly safe for both mom and baby as long as the original incision in the uterus was a low segment transverse incision. Evidence based medicine reports approximately 75% of women can successfully VBAC. As long as the mom is aware of the risks (minimal) and the benefits (MANY) they should have the right to VBAC. – JoAnn McQueen Yates, CNM

New York - Because I didn’t want to go through surgery if it wasn’t necessary.   Doctors take little stock in the emotional and psychological factors of giving birth – it’s not just about pushing out a baby!! – Carrie Moyer Howe

Ohio - Delivering vaginally for me was a “rite of passage.” I was finally able to cast off the numerous doubts and my sense of failure I experienced. I really was “adequate.” – Ellen B., Nurse Manager & VBAC mom X2

Oregon – After my c-section with my daughter, laughing was extremely painful for weeks.  I would think, how awful that during a time that should be filled with joy, I’m unable to laugh.  - Rachel R., HBAC mom

I think it’s important for the operating room space and staff to be available for a true emergency cesarean, rather than have me taking up their space and time for convenience. – Rebecca C.

Pennsylvania – If I had to plan a pregnancy to end in surgery, I would not have another child, period.  – Judy P., DVM, PhD (molecular biology)

VBAC is important to me because it has the capacity of healing my broken Self. – Monica R., PhD.

South Carolina – VBAC is a natural conclusion to a natural process.  Not to mention, how many babies with true emergencies, would be saved by not having operating rooms tied up with elective cesareans? – Raechel Fredrickson

West Virginia - Aside from the fact that offering VBACs is practicing Evidence Based Medicine and should be offered without question, I would like for other women to experience the joy and self-assurance that comes from working with her body as well as the indescribable feeling of pulling her fresh, warm baby up to her chest as I experienced with my HBA3C. – Teresa S.

You give statistics but don’t list any of the sources. If you want to lend any kind of credibility to this article you really should consider actually posting where you got your information from. Not to mention some people consider it plagiarism

All I see in this article is “I say home birth is awesome. These women agree with me because they had bad experiences in the hospital. Home birth is the best.” You say this is for the number crunchers but I find that rather laughable. I see only a few numbers that actually matter and, like I said before, you don’t say where these numbers came from. For all I know they are made up. If I was a true number cruncher interested in only facts and unbiased information then I most definitely would find this article completely useless. Numbers are supposed to be unbiased information, though they can be twisted, and this article is anything but. I would be far more impressed by an article that can show numbers AND an unbiased point of view. If home birth is as safe as you say then you needn’t go on a raging rant in your article about how it’s so amazing because the numbers and statistics would say it for you.

Nice try though, E for effort.

Angie,

Thank you so much for your comment and for bringing unreferenced statistics to my attention.

This is an article that I’ve been meaning to update and your comment has once again brought to my attention how I can make it better.

You said, “You say this is for the number crunchers but I find that rather laughable. I see only a few numbers that actually matter and, like I said before, you don’t say where these numbers came from. For all I know they are made up.”

Please read the very first sentence in the article where I state, “there are major limitations if you are going to rely solely on case controlled studies to decide between home and hospital birth.  There are so many variables and nuances that haven’t been ‘number crunched’ to that extent but make a HUGE difference in the how your birth progresses and the ultimate outcome.”

I state upfront that this is not a review of the literature, but rather a review of some factors that can have a significant impact on how a labor progresses and the ultimate success such as (please note the resources as I don’t think you saw them the first time):

• the importance of privacy, or lack thereof (which linked to an article from the Journal of Perinatal Education) illustrated by…
• how labor can change upon transfer to the hospital, which leads us to…
• the risks of augmentation (which linked to a very well referenced chapter entitled “Slow Labor” from Henci Goer’s book “The Thinking Woman’s Guide to a Better Birth”)

Additionally, there are factors that women are often unaware of that might impact their perception of hospital vs. home birth:

• some complications can be safely handled at home (such as my post-partum hemorrhage)
• hospital birth carries risks and does not guarantee a good outcome (as demonstrated by the links provided)
• American’s high maternal mortality rate relative to other industrialized nations (per figures cited by the CDC).

If you are interested in numbers, let’s review a few.  In the US, 1% of babies are born at home and only 8% of births are attended by midwives. The US has the second highest newborn mortality rate in the developed world. We rank 29th in the world in maternal mortality rates (meaning 28 countries have fewer moms dying) and 42nd in infant mortality rates (meaning 41 countries have fewer babies dying.) In the Netherlands, 30% of babies are born at home and they have one of the lowest infant and maternal mortality rates in the world.  Their infant mortality rate is 60% lower than America’s (4.1 deaths per 1,000 live births vs. 6.9 per 1,000.) (WebMD 2008, CDC 2008)  In fact, the countries that use midwives for low-risk pregnancies and OBs for high-risk pregnancies, have the best outcomes. (CDC 2008) Clearly there is some misconnect in how the US manages birth if we have all these births taking place “safely” in the hospital, yet we have these high rates of death. It was our country’s mortality rates that made me initially question the whole system. How can we spend so much money on obstetrics, and have all this technology available to us, yet we have these atrocious outcomes? Maybe all of those interventions, maybe how we handle birth in general, introduces more risks than rewards? A great book to read on this is Dr. Marsden Wagner’s Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First.

You can get more hard numbers by referring to the VBAC Class bibliography or reading articles like Scare tactics vs. informed consent aka why I started this website or Rebutting Dr. Amy’s Information.  While you might not be interested because it’s not research based, Interview with Dr. Fischbein – An Inside Look at Hospitals & VBAC Bans discusses factors such as hospital politics and the influence of hospital administers which are important pieces of the home vs. hospital decision making process.

I quoted two statistics (3% chance of emergency transfer vs. 10-15% chance of unnecessary repeat cesarean) in the original article without citing the references.

The 3% transfer rate is from the Johnson 2005 study entitled, “Outcomes of planned home births with certified professional midwives: large prospective study in North America.”

The “unnecessary cesarean surgery” rate comes from two pieces of information.  First, the USA’s cesarean rate was 31.8% in 2007 according to the CDC’s 2009 publication “Births: Preliminary Data for 2007.”  Secondly, the World Health Organization (WHO) has repeatedly stated that a 10-15% cesarean rate is optimal.   Below 10% and you have mothers and babies dying because they don’t have access to medically necessary cesarean section.  Over 15% and you see higher maternal and infant mortality and morbidity rates from cesarean related complications.  As the 2009 edition of WHO’s “Monitoring Emergency Obstetric Care: A Handbook” states, “It should be noted that the proposed upper limit of 15% is not a target to be achieved, but rather a threshold not to be exceeded.”

When you subtract the total cesarean rate from the top end of WHO’s recommendation (30% – 15%), you get a risk of 15% of unnecessary cesarean.  Do the same with the low end of WHO’s recommendation (30% – 10%) and you get 20%.  This give us an unnecessary cesarean risk of 15% – 20%, higher than the conservative 10%-15% I stated. But, that is the total rate of unnecessary cesarean sections for all woman.  For women with a prior cesarean, the risk is even higher.

Again, let’s look at “Births: Preliminary Data for 2007.”  There, the CDC quotes a 90.8% repeat cesarean rate in the USA.  The average VBA1C success rate is 74% (Landon 2006) yet only 9.2% of women had a VBAC in 2007 (CDC 2009), so we can extrapolate that to mean that 12.4% of women attempted a VBAC.  Yet the national 2006 Listening to Mothers II survey found that 45% of women were interested in the option of a VBAC.  So while 45% of women want a VBAC, only 12.4% are permitted a trial of labor.  Listening to Mothers II explains the discrepancy: 57% of women interested in VBAC were denied the option primarily due to the “unwillingness” of their hospital or caregiver.  That figure is similar to ICAN’s 2009 Hospital Survey which found that 50% of American hospitals have either a formal or de facto VBAC ban in place.  (ICAN 2009)  So women seeking a VBAC have at least a 57% of having an unnecessary repeat cesarean solely because they can’t find someone to attend their birth.  Add to that women who have bait & switch care providers, and the risk rises.

But this is looking at the rate for the entire United States.  Depending on your local hospital’s rate, your odds might be higher or lower. Some areas, especially rural areas where there might be only one or two hospitals serving a large area, there might be no hospitals within a hundred miles that attend VBAC.  Obviously, a woman’s chances of a successful hospital VBAC there are slim to none.

Other areas, especially major metropolitan areas, have more hospitals and generally more options.  However, if we look at a large area like Southern California (including Los Angeles, Orange, Riverside, and San Bernardino counties), you might be surprised that the VBAC rate is only 5% (California Office of Statewide Health Planning and Development 2008).  This is why it’s so important to truly vet your local hospital and OB/midwife.

But the two statistics I originally quoted (3% chance of emergency transfer vs. 10-15% chance of unnecessary repeat cesarean) don’t give an accurate picture of the risks of homebirth vs. hospital birth and I have expanded the article to include that information.

When considering the risks of home vs. hospital, I think the following are three important questions to consider.

1. Do hospital mandated procedures, policies, and timelines interfere with the progression of labor resulting in an otherwise avoidable “failure to progress” repeat cesarean?

The answer to this question could be a whole book.  I think the Lothian 2004 article Do Not Disturb: The Importance of Privacy in Labor nods possibly yes by examining the impact of the lack of privacy available in the hospital setting.  Books like “Gentle Birth, Gentle Mothering,” “Born in the USA” and movies like “The Business of Being Born” touch on this question as well.

2. Are women more likely to need the advanced emergency equipment available at the hospital because in addition to naturally occurring unavoidable complications, they are at an increased risk for otherwise preventable compilations resulting from cascading interventions?

In other words, are OBs and hospital based nurses more likely to perform frequent vaginal exams, because they have the medications and facilities to perform an “emergency” cesarean if an infection does develop?  Are OBs more likely to perform episiotomies, even though women who have had episiotomies are more likely to tear into their rectum (4th degree tear) (Jandér 2001, Klein 1994, Signorello 2000), because they have the skill set to suture that severe of a tear?

And are women aware that frequent vaginal exams, especially once their water has broken, are linked to higher infection rates or that they are more likely to tear into their rectum if they have an episiotomy?  Or are they just thankful that they were in the hospital so when the infection developed or the tear occurred, they had access to advanced medical techniques?

3. How does fighting your way through labor with an OB who is not supportive of vaginal birth impact the progression of labor, if at all?

There are OBs who will patiently wait for labor to unfold provided that mother and baby are OK.  Most recently, a doctor at Good Samaritan in Downtown LA, attended a woman in labor who was at 8cm for over 8 hours.  Many OBs (the majority?) would have diagnosed a “failure to progress” and recommended/required a cesarean.  Counter that with the birth stories featured in VBACing Against the Odds and Hospital VBAC turned CS due to constant scare tactics.  How your labor plays out depends greatly on your care provider’s personal birth philosophy and your hospital’s standards and policy.  It’s not so much where you are as what is done to you.

Let’s now look at the primary risk of home birth which, in my opinion, is experiencing a 3% chance of a complication (Johnson 2005) that is outside your midwife’s scope of practice or training and requires emergency transfer to the hospital.  The primary question here is:

Does your midwife have the knowledge and skill set that will enable her to quickly diagnose complications, such as uterine rupture, placental abruption, umbilical cord prolapse, placenta previa, severe post partum hemorrhage (1), and coordinate rapid hospital transfer?

I talk about this more in the article, I’m pregnant and want a VBAC, what do I do?:

The most important thing when interviewing midwives is experience.  You need to know how many births she has attended and of those, how many was she the primary midwife (the responsible person at the birth as opposed to assisting a senior midwife.)  I am a full supporter of non-nurse midwives, but please do your homework.  If you have an inexperienced midwife with limited informal or formal education, you are taking on additional risk that is really unnecessary.

…

Additionally, you want a midwife who has enough experience to know when to go to the hospital as well as the professionalism to interface, and even take crap from, hospital employees.  You and your baby’s well being should come well before her possible discomfort.  In states where it is illegal for a midwife to attend a OOH (out-of-hospital) VBAC, your midwife is not likely to present herself as your midwife if you transfer and this is understandable.

You said, “All I see in this article is ‘I say home birth is awesome. These women agree with me because they had bad experiences in the hospital. Home birth is the best.’”  I did not select the birth stories of the women who had “bad experiences in the hospital” because they love home birth.  I highlighted their stories because I wanted to counter the conventional wisdom which states, if you are at home and a problem happens, you are out of luck but that if you are in the hospital, everything will be ok as well as demonstrate that you don’t even need an actual medical complication in order for your birth to become difficult in the hospital.

You said, “If home birth is as safe as you say then you needn’t go on a raging rant in your article about how it’s so amazing because the numbers and statistics would say it for you.”  Please find where I use the phrase “homebirth is safe/amazing/good/better.”  It’s not there.  The only reference I made in the original article about homebirth safety is to quote the 3% transfer rate per the Johnson 2005 study.  I don’t say whether home birth is safe or dangerous.  I leave that up to individual women to decide for themselves by weighting the risks and benefits of home vs. hospital birth.  There are risks to home birth and there are risks to hospital birth.  Each woman selects which set of risks she is willing to accept.  Is a 3% risk of emergency transfer a fair trade when your local hospital has a 96% repeat cesarean rate?  That is a quandary that woman seeking VBAC face daily.

I have to wonder if you even read the entire article including the part where I discuss my post-partum hemorrhage (PPH):

I’m glad I was home, but my story might have ended very different if my midwife didn’t have Pitocin and Methergin and was able to act quickly. This is a testament to hiring a good, experienced midwife and ensuring that they have drugs to manage PPH.

…

I trusted the skills of my midwife to diagnosis my PPH and I trusted those drugs to make my bleeding stop quickly when birth veered off course.  Complications do happen at home and when interviewing a homebirth midwife, I suggest asking her how she handles complications as well as hospital transfers.

…

The truth is, there are no guarantees regardless of where you give birth.

For the record, I thought my home birth was an awesome, incredible experience and I can’t imagine ever giving birth in a hospital again unless medically indicated.  But that doesn’t mean I think you should have a home birth.  Birth at home if that’s what you want to do.  Birth at the hospital if that is where you want to be.  As I say at the closing of the article, “I wish you the best wherever you chose to birth your children” and that is the genuine truth.  I have friends who have birthed in the home as well as hospital.  I have friends who have opted for multiple repeat cesareans.

I am not someone who thinks home birth is always good and hospital birth is always bad.  My objective is not to convince anyone to make any specific decision.  I give information, including references to medical research, to supplement women’s research.  I provide my personal, lay perspective on birth.  As I wrote over two years ago in the article Why Homebirth/HBAC?, “I think the most important thing is for every woman to birth where she, after much research and thought, feels safe and comfortable. Where she feels her wishes will be respected and not just viewed as requests. Where she feels she, and her baby, will receive the best care and experience the best outcome. And I know for many women, this is the hospital. And for a very small minority of us, it’s at home.”  I still believe that.

Warmly,

Jen from vbacfacts.com

I see things daily that I want to write about, but never actually have the time between laundry, dishes, meal prep and daydreaming of going to the National Institutes of Health’s upcoming free conference entitled Consensus Development Conference on Vaginal Birth After Cesarean: New Insights.  I’m hoping to use my Southwest credit from the cancelled Controversies in Childbirth conference to make a little trip out to Bethesda.  We shall see.

I’ve been on Facebook a lot, where you can become my friend or a fan of the site, because committing to a small little 420 character blurb fits in quite well as I unload the dishwasher and retrieve my toddler off yet another piece of furniture. 

However, the best way to stay in touch with me and receive updates and coupons for upcoming classes, is to join my mailing list.  I am investigating my options for doing an on-line webinar as well, so stay tuned!

So I’m using this quiet moment, at 3am when my children are asleep and I can write this uninterrupted (oh, the luxury!!), to share something that is really special.

In the last few days, a woman had a VBAC with triplets with the legendary Dr. Tate of Atlanta, Georgia.

According to Doula Momma:

The details are just coming out about this VBAC but apparently the woman had her triplets in a hospital attended by Dr. Tate. I am assuming she went natural, as in unmedicated, as that’s generally the way with a VBAC with Dr. Tate.  From what I am reading so far, the first two babies were head down and the third was footling breech. Here are the babies stats according to the ICAN of Atlanta chapter posting.
3 girls, all vaginal, all Apgar 8/9.

A= 4# 6oz, 18.25in @ 10:24pm, vertex.
B= 6# 4oz, 18.25in @ 10:37pm, vertex.
c= 3# 11oz, 16.5in @ 10:39pm, double footling breech extraction.

All three babies are successfully breastfeeding as well.

In a time where VBAC is banned in 50% of US hospitals, either through formal or defacto bans, (ICAN 2009 Hospital Survey) and women of multiples believe that they have no other option but a surgical delivery for their children, this is a huge victory.  There are practitioners that support VBAC.  Maybe even one that lives close to you.  Learn more on finding a provider and your options for planning a VBAC here: I’m pregnant and want a VBAC, what do I do?

I want to plan for a VBAC I am not pregnant as of yet but will be ttc in 2 months. I am from La Crosse WI area and they have two hospitals Gunderson Lutheran and Franciscan Skemp..when I called them to get there statistics about VBACs they told me they didn’t have any. So how should I choose which hospital to go to for the better chance of succeeding with my VBAC. I also do not have any doulas in the area is it necessary to have a doula for a successful VBAC? Any thoughts or suggestions would be great. Thank you.

Hi Jeri!

It’s ironic that the person you spoke with at the hospital said that they didn’t have any VBAC statistics, because when I googled “Gundersen Lutheran VBAC,” I found a page entitled "Births by Cesarean and Vaginal Births After Cesarean” on Gundersen Lutheran’s very own website where they state:

A vaginal delivery is the preferred, naturally-designed way to have a baby but when needed, delivery by Cesarean section is a second option. At Gundersen Lutheran, efforts are made to choose a vaginal birth, even after a previous C-section unless there are reasons that would put mother or baby at risk.

“Generally, successful VBAC is associated with shorter maternal hospitalizations, less blood loss and fewer transfusions, fewer infections, and fewer thromboembolic events than cesarean delivery.” [ACOG Practice Bulletin #54 2004)

AIMS
1. To have a cesarean section rate below the national rate
2. To have a VBAC rate higher than the national rate

They have succeeded in their goals as Gundersen Lutheran boasted a 27.3% VBAC rate in 2006.  That is exceptional considering that the national average is 9.2% (CDC 2006) and the Wisconsin state average is 12% (Wisconsin: Infant Births and Deaths 2006).

Ted Peck, M.D. is named “activity leader” on that page so I would contact him and ask for the top three VBAC doctors at Gunderson Lutheran.  I would also check out the resources here for additional referrals and to see if any of the names overlap.  Keep in mind that just because the hospital has a great VBAC rate doesn’t mean that all the OBs are supportive of VBAC.  You will still want to ask the same questions and interview a couple different doctors, just like you would get more than one quote if you wanted work done on your house.  You are the consumer, you have the power to chose who you will hire!  It’s important for you to understand the risks and benefits of VBAC vs. repeat cesarean to you, your baby, as well as your future children and health, but be on the look out for scare tactics masquerading as informed consent.

I also googled “Franciscan Skemp VBAC” and was directed to ICAN’s VBAC Hospital Policy Information where Franciscan Skemp is listed as a de facto VBAC ban hospital.  This means that while there is no formal ban in place, the hospital does not attend VBACs.  They could give you a whole list of reasons like, “Our OBs don’t want to do them” or “Our anesthesiologists don’t want to sit in the hospital during a VBAC labor,” but Dr. Stuart Fischbein gives us another perspective:

[Hospitals] 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.

(To read more of this interview with Dr. Fischbein, please go to: An Inside Look at Hospitals & VBAC Bans.)

If I was unable to easily find this information by googling, I would have gone to Wisconsin’s Department of Health Services and just start searching for VBAC, birth, cesarean, and hospital statistics to see what I could find.  Sometimes this data is so deep within a website, it can be tricky to locate.  You could also call the Department of Health Services and ask them if they maintain hospital birth statistics.  The state of California maintains this data, but I don’t know if all states do and if they make that information available to the public.

In terms of a doula, yes, I think it’s very important for any woman laboring in a hospital, especially women seeking a VBAC, to have a doula.  (Here is more information on what a doula is and the many benefits of having one: DONA’s Birth Doula FAQs.)  Some practices are not supportive of doulas, even going so far as to post a sign in the waiting room detailing their anti-doula policy.  Switch providers immediately if you read a similar sign or if you discover that your provider is not doula friendly.  A great way to find out is to ask your OB or midwife if they have any doulas they can recommend.  Their response will quickly tell you if this care provider and you have the same vision for your birth.

I went to findadoula.com, and found there was one doula listed for La Cross, WI:

Renee Plunkett

Telephone: 608-786-4466

Location: West Salem Wisconsin United States

I also cover the following geographic areas:
La Crosse, WI

Hopefully you two will be a good fit and if not, the list of resources I provide for finding a supportive OB or midwife can also be used for finding a doula.  I would add DONA and toLabor (formally ALACE) which are Doula credentialing organizations as additional resources.  DONA lists 64 birth doulas and toLabor lists 10 birth doulas in Wisconsin.

You can find more VBAC statistics by going to the The Birth Survey’s State Resources page which provides links to each state’s birth statistics.

For Wisconsin, we have Wisconsin: Infant Births and Deaths, 2006 where we are given the following statistics on page 30:

Delivery Method	Number	Percentage
Vaginal (no previous C-section)	52,713	72.9%
Primary C-Section	10,342	14.3%
Repeat C-Section	7,418	10.3%
VBAC	1,017	1.4%
Forceps	812	1.1%
Other	0	0.0%
Total Births	72,302	100%

We can determine the VBAC rate by adding the number of Repeat C-Sections (7,418) and VBACs (1,017) together to get a total number of births after cesarean in 2006 (8,435).

By dividing the total number of VBACs (1,017) by the number of births after cesarean (8,435), and multiplying that number by 100, we get the VBAC rate of 12.06%.  This means that 87.9% of women in Wisconsin have repeat cesareans.

Here’s hoping you are in that 12%!

Warmly,

Jen from vbacfacts.com

This is the same weekend as the Trust Birth Conference, so if you are in town, you will have ample time after the conference is over at noon on Sunday to scoot on over to Century City (10309 Santa Monica Blvd, Suite 300, Los Angeles, CA 90024) and then back again if you want to attend the Stragglers Dinner at 6:30pm.

Additional classes have been scheduled in Claremont in July and Vista in October.

To register for the LA March class, please go here.  Space is limited.

What will the class discuss?

“The Truth About VBAC” delivers a comprehensive review of the medical research to parents, doulas, midwives, nurses and other birth advocates and medical professionals.  Topics include:

• Repeat Cesarean vs. VBAC Realities
• Risks of Hospital vs. Out-of-Hospital Birth
• Finding a VBAC Supportive OB or Midwife
• The Marketing of “Risk”
• Hospital VBAC Strategies
• Factors of Uterine Rupture
• Maternal & Infant Outcomes
• Elements of VBAC Success
• Benefits of Spontaneous Vaginal Birth
• Hospital VBAC Bans

What do past attendees say about the class?

A mom with two prior cesareans:

This class is all about the facts. It is low pressure. It gives you information from scientific journals that will help you make the best decision for you and your baby.   At the end, you get to decide which set of risks you are willing to accept.  It opened my husband’s eyes. Even though I’ve been telling him, he needed to hear the research and the numbers.  Thank you!!!

A Labor & Delivery nurse:

Thanks for an outstanding class! It was very nice meeting you. Your hard work and dedicated research is incredibly impressive. Knowledge is Power, wish it would rub off on the whole OB community. I think the trend to eventually turn that direction for women’s choice of birth options will happen as more people put that kind of pressure on the issue. Bravo to you!

A mom with one prior cesarean:

My husband and I certainly felt even more confident after the class.  I would definitely recommend it to anyone considering a VBAC.

Do I need to be pregnant to attend?

The best time to educate yourself is before you get pregnant when you have time to research, decide what kind of birth you want, and then assemble your birth team without a due date looming.  That said, highly motivated women have decided mid-pregnancy to change gears, reconsider their scheduled cesarean, and plan VBACs.

Why is this class important?

It’s likely either you or someone you know has had a cesarean.  Unfortunately, there is a lot of fear and misinformation about birth after cesarean.  Is VBAC dangerous?  What are the risks of repeat cesareans? What is the safest thing for babies and mothers?  What should you do if you want a large family?  What hospitals are most supportive of VBAC?  Is out-of-hospital (home or birth center) birth an option?

With half of American hospitals actively enforcing VBAC bans and increasing numbers of obstetricians preferring repeat cesareans, many women wonder if their only choice is another surgical delivery.  A 2005 survey revealed that while 57% of American women desire a VBAC, less than 10% succeed.

Banner ads and flyers are available.

I am very disheartened by the tone of this website. I am a board certified Ob/gyn and a very strong advocate for VBACs, IF a patient chooses one within the hospital guidelines. I DO believe and say to my patients my goal is “a healthy mom and a healthy baby” because I truly believe this statement. You would not believe the number of patients who believe that I want to do XYZ to go home to my family, go shopping or improve my golf game. A vaginal delivery is easier for me in the long run because I have less paper work, less rounding and have avoided performing a major surgery on a patient. I have no desire to perform a patient’s 6th c-section!

But each patient who chooses a VBAC has to realize there ARE risks associated with the procedure. I would be committing malpractice if I did not inform each patient of the risks and benefits of both options. The risk of uterine rupture is [less] than 1 percent, but if it happens to my patient she will be upset that I did not inform her of the risks. The “seeds of doubt” you discuss are all things that I have told patients considering a VBAC. I prefer to stretch the informed consent process over the entire course of the prenatal visits versus just one 5 or 10 minute conversation. If I have discussed all the options ahead of a patient’s actual labor, if I come in and say that I need to perform a repeat c-section for XYZ reason, I am not having that discussion for the first time in the LDR, but rather we have discussed the possibility months ago. I use my prenatal visits to build a repoir [sic] with my patients and to educate her/her family about the scenarios we may face in the delivery room.

In an ideal world, every patient would be presented with the option to have a VBAC if she desires. Unfortunately due to the malpractice climate some doctors and hospitals no longer feel comfortable giving patients this choice. The rhetoric in this article does nothing healthy to advance the cause  of ensuring this happens. It only serves to create mistrust between patients and doctors who are true advocates for patients.

Dear VBAC Supportive OB/GYN,

I’m very happy that you left this comment and hope that you stick around and read some more.  We need more OBs who are supportive of VBAC and vaginal birth.  (I’m curious about your hospital’s guidelines.  Would you share?)

The unfortunate reality is that there is a huge segment of OBs who perform surgery under the guise of maternal/fetal health when in reality it is for their personal convenience.  I have had the opportunity to hear that directly from OBs.  Often the “healthy mom/healthy baby” reason is used in the midst of a repeat cesarean recommendation and I believe that is true in the birth story featured in Hospital VBAC turned CS due to constant scare tactics.

If you look over on the category list and click on ‘uterine rupture’ you will see that it is a common topic on this site.  I cite specific rates as well as sources so people can independently verify what I write.  I absolutely agree that women need to understand the risks of VBAC, but they need the accurate numbers, not some inflated risk provided by an unsupportive OB and not some understated risk provided by well-meaning, but misinformed, birth advocates.  (Check out my article Lightning strikes, shark bites & uterine rupture for more on this.)

Here’s how I make the distinction between informed consent and scare tactics.

Informed consent is understanding the risks and benefits of VBAC vs. repeat cesarean.

Scare tactics are just talking about the risks of VBAC without mentioning the risks of a repeat cesarean.

Informed consent includes accurate statistics.  Women write me all the time telling me that their OB quoted a uterine rupture rate of 5% or 10% or even 25%!  A woman just recently contacted me and said that women seeking VBACs are “selfish, unbelievable IDIOTs.”  Naturally she would say this as her OB told her that she and her baby had a 10% chance of dying if she attempted a trial of labor after cesarean.

If the doctor tells you there is a 10% chance of you and your baby dieing [sic] and you do this any way…you are a selfish, unbelievable IDIOT…I have two perfect babies and I wouldn’t have my 1st if it wasn’t for a c-section…why on earth would I risk the life of my 2nd child to say I had a ‘v-back’…do you psychos want a metal [sic]…go away and get off your freakin’ soap boxes…you are all scary and creapy [sic]!

This is why I started the website.  Women are lied to all the time.  They contact me either via angry emails like the one above or really sad depressed emails because they were fed these falsehoods, consented to surgery, and then learned the truth.

So, this is how I responded:

I completely understand why you were happy to have a repeat cesarean given that you were told the risk of mortality was 10%. I’m sorry to tell you that you have been misled. The risk of maternal mortality with repeat cesarean and VBAC is very low, but the risk is higher with a repeat cesarean: 0.04% vs. 0.02% per a National Institute of Health Study of 18,000 women. (Landon 2004: http://content.nejm.org/cgi/content/abstract/351/25/2581) This is 500 times smaller than the risk you were quoted of 10% maternal mortality. That same study found the rate of infant death to be 0.01% and they did a review of 880 uterine ruptures in a 20 year period resulting in 40 infant deaths in 91,039 VBACs which is a rate of 0.04%. They found the combined risk of infant death or brain damage to be 0.05% or 1 in every 2000 VBAC labors which is a 200 times smaller than the risk you quoted of 10%. If you or your OB have a large VBAC study showing a 10% mortality rate, please email me.

Needless to say, she did not respond as there is not one large VBAC study showing maternal or infant mortality rates anywhere near 10%.  This woman was lied to.  Why do you suppose her OB would tell her that?

Informed consent also includes asking how many more children the woman wishes to have.  We know that the risk of uterine rupture, uterine dehiscence and other peripartum complications decrease after the first VBAC, (Mercer 2008) whereas the risk 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.  [In addition] 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.” (Silver 2006)

How many VBAC consent forms include the risks of cesarean?  Not just the risks to mom and baby in the current pregnancy but the downstream consequences for future pregnancies?  I’ve never seen it.  Does your VBAC consent form include this information?

It’s one thing to understand the risks of VBAC, but they must be countered with the risks of repeat cesarean, otherwise the patient is left with the false notion that repeat cesareans are risk free.  This does not benefit the patient and I believe it’s only because women haven’t started suing over complications resulting from repeat cesareans that this erroneous philosophy on informed consent continues to thrive.

Informed consent is putting the risk of uterine rupture into perspective by comparing the risk to other obstetric complications as Larry Leeman MD MPH and Eve Espey MD MPH do when expressing their concern over the rising cesarean rates in Native American populations due to hospital VBAC bans.  They say:

Should you offer vaginal birth after cesarean delivery at your facility?

Should your referral facility be offering VBAC?

Let’s put some of the above issues into perspective.

What are just a few of the risks that you should currently handle very well:

[Note from me: I used the chart they provided here and combined it with uterine rupture & infant mortality/morbidity stats for use in the VBAC Class I teach.]

Taken on their own individual merit, most of the above common urgencies and emergencies occur more frequently than 0.5 percent. Taken as an aggregate, the risks above far outweigh the risks of VBAC. Now seeing the above risks, if you feel you need to re-evaluate offering obstetric intrapartum care because the above risks, then please contact me as soon as possible.

Scare tactics are simply saying, “VBAC is dangerous” or “Is it worth your baby’s life?”

Informed consent is having a thoughtful thorough conversation where you ascertain if this is the first time the woman has heard about the risks of uterine rupture, or if she is an informed patient who is well aware of her risks, benefits, and options.

I do believe that coming back to the risks of VBAC again and again during a pregnancy conveys to the patient that you really think this is a considerable risk, and not one worth undertaking.

Lisa Allee, CNM, wrote this in response to a hospital that instituted a VBAC ban.  The hospital said that their ban wouldn’t impact many since only 2 patients a year perused VBAC after the VBAC counsel.  She recommended:

Re-evaluate how VBAC counseling is done. To provide true informed consent the numbers need to be presented clearly. The data consistently shows a uterine rupture rate of 0.5-3%–it is important to explain that this means 97-99.5 women out of 100 will not have a uterine rupture and out of the few that do, not all will have problems. It is, of course, important to discuss the risk of uterine rupture to mother and baby, but to put it in this perspective of being rare and review the high-quality, careful care we provide to women who are VBACing to help prevent problems. It is also very important to review the differences in postpartum morbidity and risk between a vaginal birth and cesarean delivery, (be sure to include the oft ignored higher rates of breastfeeding and orgasm difficulties post cesarean delivery.) If, in contrast, providers only make a recommendation of repeat cesarean delivery and an institution has a policy that only allows for repeat cesarean delivery, then they have effectively negated a woman’s right to make an informed decision in a situation where there is a choice.

And she suggests that women be given an accurate picture of what a cesarean is like:

Review the postpartum morbidity and risk differences for women post vaginal birth vs. post cesarean delivery. This will help to dispel the delusion that a woman who has had a cesarean delivery is walking out of the hospital “healthy” and bring a more accurate sense of respect for what is really happening for that woman. She has just had major abdominal surgery and is in recovery from that surgery. She is in pain and is at risk for a number of post-surgical complications. Her future pregnancies have also now taken on a longer list of potential risks. Along with all this she is also a new mother with a newborn to care for and feed every 1-2 hours with an abdominal incision that she is fully aware of each time she moves. This human perspective of the implications of a cesarean delivery might help providers to be concerned with their personal and institutional cesarean delivery rates.

I did not get the feel from the birth story relayed in Hospital VBAC turned CS due to constant scare tactics that the OB was really supportive of VBAC, did you?  Would you classify this OB as a “true advocate for patients?”

• OB only talks about the risks of VBAC.
• OB required a VBAC consent form that only lists the risks of VBAC.
• OB wants to schedule a cesarean at 38 weeks.
• OB “did not seem very please” when the patient expressed her desire to VBAC.
• OB began NST at 37 weeks.  Patient lists no reason for this.
• OB does not put the process and significance of dilation into context.  Patient seems to believe that no dilation at 37 weeks and no change till 40 weeks is a bad sign.  Patient does not understand that dilation is not a hard sign of labor.
• OB tries to scare patient by telling her that her baby was big and it “could be a very hard delivery” for her.  It is this scare tactic, and the subsequent recommendation for cesarean based on suspected macrosomia  that convinces patient to schedule a cesarean.  Baby ends up weighing 7lbs 2oz.  ACOG does not recommend cesarean for suspected macrosomia unless the baby is 11lbs (ACOG’s Practice Bulletin No. 22 on Guidelines for Fetal Macrosomia published in the November 2000 issue of Obstetrics and Gynecology).
• OB makes a “threatening call” to patient upon her spontaneous labor and lies by saying that if patient doesn’t have the “C-sec at the decided time, [OB] was not going to be available for the entire week and that some random doctor from the hospital” would perform her surgery.
• OB gets caught in this lie when the nurse tells patient that OB “has asked to be informed about your progress [and] will continue to be there for you.”
• OB then has a colleague tell patient that “she was sure it was going to be a very tough delivery” because of “baby’s head was big” and would weight “at least 8 lbs.”
• OB who said she wouldn’t be available after 11:45am, suddenly becomes available and is present to perform the surgery.

You stated in your comment that my article “only serves to create mistrust between patients and doctors who are true advocates for patients.”

Here is my sole goal with that article and this website: To implore women to put as much effort into interviewing and hiring an OB as they would for someone to install a pool.  Educate yourself.  Get referrals.  Ask questions.  Don’t just stay with your current GYN because they do a great pap smear and you enjoy the small talk.  Hire someone who has a birth philosophy similar to yours.  Hire someone who is supportive of vaginal birth!  And look for the red flags!  There were so many in this woman’s story.  I know we disagree on that.  Maybe that is because you are a VBAC supportive OB who doesn’t see stories just like this one every day.

While there are OBs who are truly supportive of VBAC, I personally know three, most are not.  Most behave exactly like this OB.  And I don’t believe for a second that this OB ever intended to give this patient a genuine opportunity to VBAC. I really wish the OB would have just said that upfront to the patient so she could have had the opportunity to hire a truly supportive practitioner.  At the very least, this OB can post a sign in their waiting room, like this one above from a Provo, Utah practice, so women know their birth philosophy as soon as they walk in the door.  As unappealing as it is, this practice is providing their patients with informed consent on the type of birth they provide.  What is shocking to me, is that there are enough patients who are so ill-informed that they would continue care with a practice like this.

And this site will be there for the women who had cesareans under the care of OBs, like this Provo practice, to provide them with accurate, easily verifiable information for them to make an informed decision on what kind of birth they want the next time.

Warmly,

Jen

Claremont VBAC Class

The "Truth About VBAC" seminar in Claremont, California is 8 days away on Saturday, October 24th from 1p – 4p.  Don’t miss out on your opportunity to experience an extensive review of the best VBAC and repeat cesarean research as well as learn specific, practical tools to maximize the likelihood of hospital or out-of-hospital VBAC success!  To register or sponsor a ticket, please visit: http://vbacfacts1024.eventbrite.com/

Do I need to be pregnant to attend?

The information is targeted towards women with prior cesareans who wish to have more children and the childbirth professionals who support them.  The best time to educate yourself is before you get pregnant when you have the luxury of time to research, decide what kind of birth you want, and then assemble your birth team without a due date looming.  That said, many women, have decided mid-pregnancy to change gears, reconsider their scheduled cesarean, find a new care provider, and plan successful VBACs.

Fullerton Class Recap

The Fullerton class last month was full of inquiring parents, midwives, doulas, Bradley childbirth educators, and labor & delivery (L&D) nurses some of whom drove over two hours to attend.  Not only did the moms and dads learn about VBAC, but they participated in a lively and candid discussion with the L&D nurses and doulas who were able to share exactly what it is like to VBAC in a hospital environment.  It would be very hard, if not impossible, to have these same exchanges on the L&D floor.  We also had homebirth midwives and doulas who provided the out-of-hospital perspective.

Here’s some feedback from one of the L&D nurses, who works in a hospital with an official VBAC ban and is working towards change:

Hi Jen, Thanks for an outstanding class! It was very nice meeting you. Your hard work and dedicated research is incredibly impressive. Knowledge is Power, wish it would rub off on the whole OB community. I think the trend to eventually turn that direction for women’s choice of birth options will happen as more people put that kind of pressure on the issue. Bravo to you!

"The Truth About VBAC" Book

Included with each ticket is one "Truth About VBAC" book which includes all the slides from the presentation, the bibliography, as well as lined paper throughout for easy note taking.  As the class is research heavy, this will enable you to sit back and absorb the information rather than frantically copying statistics and study citations, as I have often done in seminars.

Additional books will be available purchase that day for $15.  Quantities are limited.  To guarantee your copy, pre-purchase here: http://vbacfacts1024.eventbrite.com/

VBAC Class Advocacy

If you can’t come to the class but want to spread the word, consider putting a banner ad on your website or blog, posting flyers in your local community, or sharing VBAC FAQ cards with your friends or clients.

Shape the 2010 Class Schedule

You can influence where the next VBAC Class will be held!  I expect to hold 3-4 classes in Southern California throughout 2010.  I’m looking at the area bordered by Santa Barbara, Lancaster, Palm Desert, and San Diego.  If you want "The Truth About VBAC" to come to your city, please email info at vbacfacts dot com with your name, city, and zip code.  Those cities with the most requests will determine the next VBAC Class!

If you have facilities that can accommodate 20-40 people and want to host a class, please contact me at info at vbacfacts dot com.  I will be emailing those who have contacted me in the past in the coming weeks to discuss scheduling a class.

Win Two VBAC Class Tickets at the LA Holistic Moms Open House!

VBAC Facts has donated 250 VBAC FAQ cards as well as two tickets to a 2010 "Truth About VBAC" class to the Holistic Moms Network LA Open House Raffle.  Please join us Wednesday November 4th, 6:30pm at South Pasadena Library Community Room, 1115 El Centro St, South Pasadena, CA.  Here is a flyer with all the details.

Chino Birth Center Open House before VBAC Class

If you would like to tour a birth center and speak to a out-of-hospital midwife before heading over to the VBAC Class, the Oaks House Family Birth Center at 13770 Oaks Avenue, Chino CA 91709 is having an Open House on Saturday, October 24th from 11am – 2pm.  For more information call (909) 464-0974.

mybestbirth San Diego Party & Screening

I’m going to  this event which is scheduled for Thursday, November 12, 2009 at 5:30 PM and can’t wait!  To register please visit: http://mybestbirthsd.eventbrite.com/  All proceeds benefit the Business of Being Born Educational Outreach Project, ICAN and the San Diego Birth Network. Here are the details:

Join us for an exclusive VIP Reception at Babies in Bloom at 5:30 pm. Meet Ricki and Abby, enjoy delicious appetizers and beverages, and see a sneak peek of Ricki and Abby’s new film! We will also have a silent auction of fabulous items from our sponsors.

After the party, "The Business of Being Born" will be shown at the Krikorian Theaters in Vista Village at 7 pm. Several local birth professionals (including midwives Barbara Herrera and Michelle Freund, and Dr. Robert Biter) will join Ricki and Abby for a discussion panel  following the screening.

Private Screening of "Laboring Under an Illusion"

I’m so bummed this is the same night at the mybestbirth event!  Hopefully CABO will host another screening in the future!

Attend a private showing at Laguna Hills Community Center on Thursday, November 12, 2009 5-8pm of "Laboring Under an Illusion," a documentary that depicts how the media portrays labor and birth.  It is quite comical and contrasts delivery and birth.  Hope you will consider this and join us and distribute widely. Women that are pregnant or planning to have a baby may be interested as well!  All proceeds support the efforts of project CABO (Community Alliance for Birth Options). 

Here is a flyer with all the details.