Category Archives: Hospital birth

Calling women who plan home VBACs “stupid” misses the point

I’m in an online group for labor & delivery nurses where the discussion of vaginal birth after cesarean (VBAC) at home came up. While some understood the massive VBAC barriers many women face, others simply said, “Find a hospital that supports VBAC.”

I left a late-night comment stating that “finding another hospital that supports VBAC” is just not a reality in many areas of the country. It’s literally not possible. Not even in the highly populated state of California. (Barger, 2013)

I also suggested rather than calling women stupid or debating the validity of the decision to have a home VBAC​, we should consider why women make this decision.

First, it is not one they take lightly.  Every parent wants a safe, healthy birth for themselves and their baby. It takes more research, work, and energy to plan a home VBAC—and it usually means thousands of out-of-pocket dollars up front. It is most certainly not the easy way out.

Women choose out-of-hospital birth due to disrespectful and abusive care, including obstetric violence and forced/coerced cesareans, delivered by hospitals. Parents also choose out-of-hospital VBAC due to VBAC bans and restrictive VBAC policies (i.e., repeat CS scheduled at 39 weeks, labor can only last 12 hours, baby must weigh less than _____, no induction/ augmentation, etc.).

These are serious issues:

Disrespectful care.

Abusive care.

Obstetric violence.

Forced/coerced cesareans.

VBAC bans.

Restrictive VBAC policies.

And this isn’t a comprehensive list of why women choose home VBAC, but it’s the ones that many nurses, providers, and administrators have control over.

In my comment on the nurses’ group, I posted the link to my California Medical Board testimony addressing these barriers and the resulting importance of access to out-of-hospital VBAC.​

We shouldn’t be asking why women are so stupid and reckless.  We should be asking:

“What can we do to make women feel safe coming to our hospital to give birth?”

And:

“How can we increase access to VBAC in all hospital settings?”

I also suggested that coming from a place of judgment on this option may very well color the tone of their communication. Even if they’re not using the words “stupid” or “reckless,” parents will pick up on what’s not being said. That’s not good for the provider-patient relationship. People want to be heard, understood, and respected. All of us.

It’s important to hear parents when they talk about their past hospital experiences, without being defensive.

Hear them and see it as an opportunity to make a change. Consider, how can you make a difference in your practice and facility?

If this were any other business, we would probably say that this is a services and marketing problem.

If you have a restaurant, and you start to lose customers to a competitor, you figure out why your customers are leaving and appeal to that.

You don’t slam the other restaurant.

You don’t call your customers stupid because someone else is offering a product that they like better.

Even if you would never personally eat there, that other restaurant is offering something that people want. And they are leaving your restaurant to get it.

So, find out what that thing is and change it.

Yes, I said all that in this nurses’ group.  The next morning, I checked to see how my comments were taken, because I know from experience that not everyone wants to hear or acknowledge the realities I outlined.

I smiled to see that the conversation had remained respectful, even from some folks who disagreed with me.  There was no name calling. No personal attacks.  My comments even had a couple likes!

It is possible to disagree without being disagreeable. And I think it’s so important to consider that many women around the country do not have access to respectful care in a facility that supports VBAC.

What are some other reasons that women choose out-of-hospital birth? Leave your comment below.

Learn more:

Askins, L., & Pascucci, C. (n.d.). Retrieved from Exposing the Silence Project: http://www.exposingthesilenceproject.com/

Barger, M. K., Dunn, T. J., Bearman, S., DeLain, M., & Gates, E. (2013). A survey of access to trial of labor in California hospitals in 2012. BMC Pregnancy Childbirth. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3636061/pdf/1471-2393-13-83.pdf

Kamel, J. (2014, Dec 17). What I told the California Medical Board about home VBAC. Retrieved from VBAC Facts: http://vbacfacts.com/2014/12/17/what-i-told-medical-board-home-vbac-part-1/

Kamel, J. (2016, Jan 6). “No one can force you to have a cesarean” is false. Retrieved from VBAC Facts: http://vbacfacts.com/2016/01/06/no-force-cesarean-false/

Pascucci, C. (2014, Feb 17). Home Birth vs. Hospital Birth: YOU’RE MISSING THE POINT, PEOPLE. Retrieved from Improving Birth: http://improvingbirth.org/2014/02/versus/

 

“Hospitals offering VBAC are required to have 24/7 anesthesia” is false

In 2010, I was sitting next to an OB/GYN during a lunch break at the National Institutes of Health VBAC Conference. She was telling me about how she had worked at a rural hospital, without 24/7 anesthesia, that offered vaginal birth after cesarean (VBAC).

I asked her what they did in the event of an emergency. “I perform an emergency cesarean under local anesthetic,” she plainly stated. She explained how you inject the anesthetic along the intended incision line, cut and then inject the next layer and cut, all the way down until you get to the baby.

It certainly wasn’t ideal, but it was how her small facility was able to support VBAC while responding to those uncommon, but inevitable, complications that require immediate surgical delivery.

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They had everything a hospital needs to offer VBAC: a supportive policy, supportive providers, and motivation to make VBAC available at their hospital.

From a public health standpoint, it’s to our benefit to offer VBAC because repeat cesareans increase the rate of accreta in future pregnancies as well as hysterectomy and excessive bleeding.

And rural hospitals are NOT capable of managing an accreta because it requires far more than (local) anesthesia and a surgeon. (Read more on how morbidity, mortality, and ideal response differs between uterine rupture & accreta.)

When I hear of smaller, rural hospitals telling women that they can’t offer VBAC because “ACOG requires” 24/7 anesthesia, I think of that OB/GYN and ACOG’s (2010) guidelines which state

Women and their physicians may still make a plan for a TOLAC [trial of labor after cesarean] 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.

So, yes, it is possible and reasonable to offer VBAC without 24/7 anesthesia.

It is ideal? No.

But do you know what else is not ideal?

It’s not ideal to have VBAC bans mandating repeat cesareans that expose women to the increasing risks of surgical birth across the board as a matter of policy—risks that can be far more serious and life-threatening than the risks of VBAC.

It’s not ideal to have any vaginal delivery at a hospital that doesn’t offer 24/7 anesthesia, because any woman giving birth may require emergency surgery.

It’s not ideal to have a cesarean (scheduled or emergency) at a hospital that doesn’t have a blood bank.

It’s not ideal nor realistic to have every pregnant woman drive hours in labor to larger hospitals that offer blood banks, 24/7 anesthesia, and various obstetric sub-specialties for planned VBAC.

It’s not ideal to have state troopers attending roadside births for some of those women.

And it’s deadly for rural hospitals to be managing a surprise accreta.

So, we have to come up with better options.

We can’t continue to pretend that banning VBAC is in the best interest of families.  It does not serve our communities in the long run because it simply exposes the ones we love to a more serious complication in future pregnancies.

Learning how to perform a cesarean under local anesthetic makes hospitals—regardless of geography—safer places to give birth. It enables them to perform cesareans more quickly when they don’t have an anesthesiologist in the hospital but the baby needs to be born NOW.

This could make a huge difference in the outcomes for any laboring mom—VBAC or non-VBAC—as well as her baby.

Learn more about VBAC barriers and watch me debunk the four reasons why hospitals ban VBAC in my workshop, “The Truth About VBAC.”

Does your rural hospital offer VBAC or not?

Does your urban or suburban hospital offer VBAC or not?

Leave a comment below!

References

American College of Obstetricians and Gynecologists. (2010). Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Obstetrics and Gynecology, 116 (2), 450-463,http://m.acog.org/Resources_And_Publications/Practice_Bulletins/Committee_on_Practice_Bulletins_Obstetrics/Vaginal_Birth_After_Previous_Cesarean_Delivery

Kamel, J. (2015, April 2). Too Bad We Can’t Just “Ban” Accreta – The Downstream Consequences of VBAC Bans. Retrieved from Science & Sensibility: http://www.scienceandsensibility.org/placenta-accreta-vbac-ban/

Kamel, J. (2010, July 22). VBAC ban rationale is irrational. Retrieved from VBAC Facts: http://vbacfacts.com/2010/07/22/vbac-ban-rationale-is-irrational/

Komorowski, J. (2010, Oct 11). A Woman’s Guide to VBAC: Putting Uterine Rupture into Perspective. Retrieved from Giving Birth with Confidence: http://www.givingbirthwithconfidence.org/p/bl/ar/blogaid=181

VBAC: A husband’s experience and lessons learned

“I have just seen so many women who have husbands who aren’t supportive because they don’t understand. My husband would love to help more men understand.”

A couple recently shared their VBA2C (vaginal birth after two cesareans) journey with me.  It touched my heart.  My the time I was done reading it, I had tears in my eyes.

So many women do not feel that VBAC is an option for them because their partner isn’t on board.  Now I know there are women who will birth how they please regardless of their partner’s feelings or thoughts, but there are many women who wish to bring their baby into the world while preserving their relationship.  And, what typically happens in these scenarios, is that the woman puts the desires of her partner above her own and she schedules a repeat cesarean.  Often, the challenge of educating and convincing their partner is just to great in the face of the conventional wisdom that states VBACs are just plain dangerous.

Just the other day, I was talking to a couple in their 40s who didn’t have children.  Yet despite the fact that they were not in the “world of childbearing,” they thought “once a cesarean, always a cesarean.”  This falsehood is so ingrained in our society that even those without children know it by heart and believe it to be true.

The absence or presence of social support is a huge factor in whether a woman plans a VBAC or a repeat cesarean.  This is why it is so important for partners and people of non-childbearing age, such as the birthing woman’s parents, grandparents, and extended family, to know that the American College of OBGYNs and the National Institutes of Health say that VBAC is a safe, reasonable, and appropriate choice for most women with one prior cesarean and for some women with two prior cesareans.  When friends and family members are undereducated about VBAC, it negatively impacts the birthing mom.  Many women are simply not willing to create family drama in order to plan a VBAC.  And the seeds of resentment are planted.

And then there are men that want to support their wives, but don’t know how.  They feel trapped between a growing mistrust of their doctor and the desire for a good outcome for their wife and baby. Today I spoke with a father who said that he “felt powerless” as his wife was bullied into a cesarean. He really believed that he should be able to completely trust his wife’s OB, but as her labor progressed, he did so less and less.  And yet, he didn’t know what to do.

Men need to hear the experiences of other men as partners are such a critical part of the birthing woman’s support team.  For many women, when their partners are on board, they have the emotional sustenance required to plan a VBAC in a country where over 90% of women have a repeat cesarean and women planning VBACs are often bombarded with stories of “VBACs gone wrong.”

I hope you enjoy the words of this engineer, this military man, this caring father, as he graciously articulates his VBAC journey.

I would love to share more VBAC stories from the partner’s perspective.  You can submit your birth stories via email.

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One of the most important life choices is the freedom to choose what one wants for their own health and their body.  For my wife, it was the choice to have a VBAC after two c-sections and the need for her husband’s support to make it happen.  This is a short story about a husband’s lesson learned and incredible experience of sharing a VBAC birth with his wife.

Our first child together was a cesarean because the labor would not progress and ultra sound pictures indicated a large head.  The doctor feared complications due to the large head and the concern over my wife’s first vaginal birth 9 years earlier that resulted in a 4th degree tear.  Our going in game plan was always as natural as possible.

Before we decided to start a family, my wife relayed her desire to have a natural birth when the time came. She described the challenges in her first birth that resulted in a painful 4th degree.  She relayed that in retrospect, the 4th degree tear could have been prevented had the atmosphere of the delivery room been more supportive, more relaxed and the doctor vetted more carefully prior to delivery.

All doctors are not created equal.  A medical degree does not guarantee that two doctors will have equal outcomes. And with my wife’s first child years before I was in the picture, there was good evidence to support her claim that both support structure and doctor helped lead to a painful labor.

“I could not understand the true emotional implications”

When our son was born cesarean, there was a disappointment that only she could truly understand. I was simply happy to have a healthy son.   I remember her making a comment about cheating me out of the experience to have a natural birth, as if her body had failed what it was made to do.  I reminded her that natural or cesarean, it was all the same to me as I just wanted wife and baby to be healthy.  How this was accomplished was not important to me.  But, to my wife the cesarean felt like a violation of her choice and cheated her out of the way nature created the female physiology to behave after 9 months of baby development.

I admittedly could not understand the true emotional implications that having a cesarean had on my wife until she went through her second cesarean.  When we decided to have baby number two together, my wife’s third, our doctor immediately said that since our son was born cesarean that our next child would have to be delivered cesarean too. We argued the point and our doctor, whom we loved and took care of all the children and my wife, finally gave us the option to find another doctor because the hospital “protocol” required that under the circumstances (quoted as saying the 4th degree and then a cesarean) dictated a second cesarean regardless of how the pregnancy was to progress.  This catch-22 complicated several factors for us.

“Our doctor, whom we loved, gave us zero options”

First, our doctor, whom we loved, gave us zero options.  She was a great person, wonderful doctor, but she was strapped to the protocol of the local hospital or their medical group that tells patients what they will do as opposed to giving the patient real options and choices on their health care.  I mentioned to my wife that we could switch doctors for this pregnancy but found that it may complicate our life because we were getting good care just miles from our house with the current doctor.  In the end, we stuck with the doctor we liked.  The lesson learned was that I should have told the good doctor to either grow a pair and stand up to the hospital’s myopic protocol and allow us the opportunity to do it our way or we should have just cut ties and got a new doctor who supported our VBAC wishes.  In the end, my wife’s freedom to decide should have been more important than our comfort zone with the local doctor.

I reluctantly supported our doctor and their protocol for a second cesarean.  I could tell my wife was disappointed, but she did not fight me.  This is one of those critical marriage lessons that go both ways.  Since there was little objection, just subtle and maybe even lingering apprehension to not make the decision to switch, we stayed with the plan.  Looking back, my wife’s apprehension to switch doctors was due to lack of VBAC education and lack of support from any of her caregivers, including me.  She just couldn’t understand why she was being forced into major surgery.

Later, after our daughter was born, I realized how much the inability to have the option of a natural birth meant to my wife.  The night before the scheduled cesarean, it appeared my wife was going into natural labor.  In retrospect, considering the labor signs and the small size of the baby, there is little doubt that she could have delivered vaginally.  My wife mentioned this to me the night before the c-section when she was having contractions and said, “I can do this naturally.” My response was, “No, we already have this scheduled for a cesarean in the morning and the doctor said that they would not do it.”  This response was naive and void of any empathy or realization of what that lack of support meant to my wife.  We went into surgery and it wasn’t until she was pregnant with our third that I realized how much the second cesarean had left her with some lasting emotional stress and even low grade secret resentment toward me for not supporting her or understanding her feelings on the topic better.  Whether she’ll admit it publicly, she harbored feelings against me for not supporting her, for the medical community’s lack of birthing choices, and to the doctor who we loved but had a hard time saying no to.

“I realized I let my wife down”

When I finally realized how critically important it was to have the freedom and choice to labor naturally, without absolutes dictated by the medical community or their “legal directives,” did I realize that I let my wife down. When the clue light came on I was set on supporting her on a VBAC, but it didn’t start that way.  My awakening did not come immediately when we found out we were having a third baby.

The pregnancy of our last child coincided with the pop up surprise news that I had to leave on a one year deployment to Afghanistan. In January 2012, I found out I was leaving the first week in April for a one year deployment and days later my wife announced she was pregnant.  What great timing.  Now my wife had to be a pregnant single mom to 3 children for an entire year.  Fortunately, we found out that due to the length of the deployment I was allowed 15 days of leave any time after 90 days in theater and therefore we started planning on my arrival for leave to coincide with the birth of our new baby.

“A selfish desire to try”

My wife quickly relayed her wishes about how this pregnancy would go.  She said to me bluntly that we’re doing this naturally. I quickly shot back with absolutely not.  My engineering brain quickly argued with her that we had three data points that indicated this was not a good idea: a 4th degree tear from forceps and 2 cesareans.  I told her that I did not want to take the chance of having my wife or baby put at risk because of a selfish desire to try and prove something to me or the world that she could do this naturally.  I had read medical reports of women’s uterus rupturing and dying from bleeding after attempted VBACs.  I feared what could happen.  But, I never knew the more thorough and recent facts of what my wife wanted to do.  She knew that I was a man who required facts to make critical decisions so she turned away from this conversation and re-engaged me at a later time with literature that showed a VBAC after 2 cesareans is not as dangerous or risky as I originally thought.  She showed me numerous medical associations that supported VBACs of all types.  I did a little more research and realized that from a technical perspective; it was possible assuming the pregnancy progressed normally without anomalies.

“It was at this moment that guilt set in”

When my wife dropped this data in my lap and looked at me with a long, deep stare that pierced right through me, my awakening had begun.  I realized that she wanted to have the choice to deliver this baby naturally without anyone in the medical profession telling her no unless there was a clear smoking gun for why it wasn’t possible, like high probability of death to baby or mom.  I knew she needed my support to make this work.  I decided at that moment that I would support her wish to have our baby without surgery.  I knew if anyone could do it, she could.  And I knew that there was no reason why we shouldn’t try to do it naturally.

It was at this moment that guilt set in for not doing something about my wife’s desire to try and have our daughter (second c-section) naturally.  I could have pulled my alpha male tricks and told the hospital to pack sand and that we were going to labor naturally and they’d have to follow our wishes or put us in the parking lot.  But, I didn’t do that and I was determined to redeem myself for not understanding how she truly felt.

“The only doctor we could find was a 2.5 hour drive without traffic”

The plan was complicated.  The only doctor we could find that took our military insurance and would entertain our idea of a VBAC with my wife’s past birthing history was in Los Angeles, a 2.5 hour drive without traffic from our desert home.  The doctor seemed too good to be true.  Our doctor, Dr. W, was personable, professional, and most importantly very supportive.  There was no talking down or psychological political play to try and convince us that our decision was not wise.  I told him that if there was no real reason why the baby couldn’t come into this world naturally, then we wanted his support for a VBAC.   He said he’d support our wishes as long as mom and baby were healthy, and the American College of Obstetricians and Gynecologists (ACOG) supported VBAC.

This seemed too good to be true because our impression was that California was much more litigious than Washington State from where we had our last two children and the previous c-sections.  We assumed we would have fewer choices in California because California is a highly regulated state.  In our case, it took a very experienced doctor with the courage and trust to allow us to proceed with our desire to have a natural baby.  He was under pressure from both the hospital and his own reputation if things went badly, but he took a chance and gave us the benefit of the doubt to respect our right to choose.

“I wasn’t worried about the rocket attacks from insurgent forces, I was worried about my wife.”

While in Afghanistan, I wasn’t worried about the every 8 to 10 day rocket attacks from insurgent forces, I was worried about pregnancy issues and my active wife.  She was now a pregnant single mom, raising a teenager and two children, running 3 houses (we own two in WA State) and maintaining an aircraft.  With our son, my wife was put on bed rest at 29 weeks due to pre-term labor and in the end because the labor did not progress she had the first cesarean.  The surgery was an experience she did not ever want to repeat but ended up repeating with our daughter.  While I received the daily reports via emails, skype sessions and pictures, I prayed for her and the kids’ safety and health.  I was slated to fly home on or around the 5th of October and be present for the birth, due date October 11th.

There is no doubt that the 15% increase in grey and white hair while deployed was due to the reports of life at home.  While pregnant, my wife traveled to Florida, Georgia, and Colorado, traveled and hiked the forest on the Pacific coast with all the kids.  And at 8 months pregnant I would get pictures of her painting various rooms in the house and even using a chain saw to do yard work.  I pleaded with her to hire the labor and help as I was scared something was going to happen.  She was simply not a sit on the couch woman.  She was on the go all the time.

With our second daughter, my wife fell out of the car 10 days before the scheduled C-section and shattered her left 5th metatarsal. Ten days after breaking her foot, she had the c-section, then 2 weeks later she was in a car and we were moving from Washington State to California and into temporary housing, headed to our next California duty station.  She had a cast on her foot for 4 months. This experience was painful both emotionally and physically.  Now, 8000 miles away, I was afraid something similar might happen but even worse since I would not be there to help.

“Preparing her mind and body for a successful VBAC”

Simultaneously while my wife traveled with the kids, painted, and did yard work with chain saws, she took numerous steps to ensure that the VBAC would succeed.  Of her many objectives, one was to ensure that the baby would not be occiput posterior as her first and only vaginal birth yielded a decade earlier and a contributor to the 4th degree tear. She also contacted and connected with various people who gave her more information on how to best prepare for a VBAC.  She had chiropractic appointments to help loosen up her hips and to prepare her body for natural labor.  She read more medical data, communicated and worked with people like our doula, who volunteered her services free to military members.  The doula could be instrumental in helping many women and seems to be an underutilized service.  Our doula volunteered with Operation Special Delivery for families of deployed military members, free of charge.  Free expert doula care is something that does not exist and therefore we were fortunate to be in the right part of the country at the right time when a humble, caring and experienced woman was offering her doula services free to military spouses.  This too was a unique windfall and something that feels more like a blessing than pure luck.

Through my wife’s various connections, proactive appointments, nightly stretching rituals, she was preparing her mind and body for a successful VBAC.  People such as our doula volunteered hours talking about the game plan for VBAC day.  There was a real possibility that my leave period could have been canceled or late, because anything in the military is possible. Therefore, our doula was necessary to coach and represent my wife’s interest in the event that I couldn’t get home.  With both me and our doula in the room with my wife we were able to support her and time share in helping her along.  Fortunately, we both shared the same objectives and wanted the birthing room to be sterile of negativity and only wanted supportive hospital staff to interface with my wife.  This was a critical aspect of the successful VBAC.  The doula’s warrior like spirit and endurance meant that I had help and an advocate by my side the entire time.  By the time the baby arrived, all three of us, the doula, my wife and I had been up for almost 36 hours since we never got to sleep the night contractions started. My wife text messaged our doula when the contractions got bad and she stayed up on standby until my wife told her that we were headed into the hospital.  Our doula arrived shortly after we arrived at the hospital and stayed through the entire experience.

“What was important was her health and the baby’s, not my convenience of being home”

Thankfully, my wife’s pregnancy was just about as perfect as one could hope for.  She had terrible heart burn, the normal stuffy nose and difficulty sleeping at night, due to the physiological challenge of having a baby grow against the bladder, making nightly trips to the bathroom routine.  All this was normal and when I finally arrived in Los Angeles on October 7, we were ready to have a baby.  There were no indications that the pregnancy could not continue into normal labor.  Now, the next step was simply getting my wife into labor.  She tried acupuncture, lots of walks and when I arrived, we tried the husband-wife techniques that usually help stimulate labor.  But, after a few days home, there were no signs of labor and my wife was getting frustrated.  She so desperately wanted me to experience this with her and my window home was short.  I told her what was important was her health and the baby’s, not my convenience of being home.  The strict military protocol didn’t have flexibility in the return schedule: unless it was a major medical emergency, I was slated to leave on the 16th day after I arrived home.  So if the baby came late, then I would have very little time with the baby.  If the baby had to be delivered via yet another c-section, my wife would be in dire need of help because she’d be hard down with NO family scheduled to be around after I left. This iteration of the various scenarios had me the most concerned. I was sick to my stomach thinking about this situation; leaving my wife days after a c-section with a house full of kids was unthinkable.  I knew I’d have to come up with some creative way to get her immediate help at home.

Another scenario that had me concerned was the baby being 7-9 days late, as was the case with a friend during the same period.  The reality of me coming home and then leaving with no baby was a possibility and then having to deliver just hours or days after I left to return to Afghanistan was a horrible thought too. In this scenario, the probability of complications increased because the possibility of the baby growing too big and then again requiring a c-section increased significantly.  When my wife began to panic a little about having no signs of labor, I tried my best to reassure her that everything would work out.  In my statistically oriented mind, I knew the odds were against us.

“Contractions were coming about 4-5 minutes apart and they were getting stronger”

Lying in bed on the 8th of October, my wife was upset at the possibility of our grand plan not working out and I assured her that this baby was coming and it would come on the due date.  Early in the afternoon on October 10, my wife started to have small contractions.  By around 10 pm they were getting more significant.  Just after midnight on October 11, the baby’s due date, the contractions were coming about 4-5 minutes apart and they were getting stronger.  Then with the first real sign of labor, the bloody show, we decided to leave for the hospital, which was about a half hour drive from our hotel.

My father had flown into town a few days before I arrived from Afghanistan.  He was the cat herder; he took care of our 4 and 2 yr old.  My father at 68 years old has the amazing stamina to handle two energetic kids. We left at around 0130 in the morning on October 11 and left my father to pack up the entire little cottage we were renting at a local air force base in LA.  When we got to the hospital, my wife’s contractions became very strong and painful. I remember my wife saying labor will be hard for me because I’ve never seen her in real pain and I’m not good with seeing her in pain.  I didn’t know what she meant until she started to go into active labor.  Our doula met us at the hospital.  Between the doula and me, we helped coach my wife through 17 hours of painfully slow labor.

My wife’s labor pains came strong and painful.  She was right; I’d never seen her in that much pain before.  She had painful contractions for hours and hours.  Her first cervical check revealed she was only 1-2 centimeters.  She became frustrated again – after all that work and pain we assumed she would have been considerably further along. Since my wife had two c-sections previously, the staff was trigger happy to react to any anomalies seen in my wife or the baby.  Their threshold for pregnancy challenges was low.  If the monitors weren’t on at all times, they’d come into the room quickly and impatiently.  Our doula and I had to tell the staff to stop over-reacting.  They settled down a bit, but they reminded me that there wasn’t much wiggle room for the monitor rules.  The previous night, a woman’s uterus ruptured just after birth and she almost died in a room next to ours.  So the staff was even more on edge than usual.

Therefore, we had additional pressure to ensure my wife was relaxed but yet progressing.  After 13 hours of labor, she was exhausted and the pain was beginning to take its toll.  Her dilating slowed at around 6 centimeters.  The anesthesiologist recommended an epidural in case my wife needed a c-section.  They could put one in without administering medicine.  We did not want an epidural to prevent my wife from being able to position on all fours or sitting on the port-a-potty they brought in for her to labor on.  But, the pain was so bad, that it was preventing her from relaxing and she was simply running out of energy.

At 8 cm the epidural was in, we made the decision to administer a very low amount of pain relief, just enough to take the edge off.  This technique worked and the small amount of pain relief helped my wife regain some confidence as it reduced her pain level. They put in enough pain meds for 1 hour of relief.  The doctor said the water bag needed to be broken to further progress.  Several hours after the water broke the doctor came in and checked her.  She was 10 centimeters now, the magic number to begin the delivery.

After 15 hours of labor, the baby had to be delivered now.  The doctor recognized how tired my wife was and he ensured no more epidural medicine was administered because he needed her strength to push the baby out if we were to do this naturally.  He pulled me aside and told me the baby’s threshold heart rate was down 30%, something I had observed and was concerned about. Dr. W told me that it was time to get the baby out and it was coming out one of two ways.  He said when he comes back, we’re having the baby.  He couldn’t let the heart rate deteriorate any further and said the baby is plus 1 and not happy about being stuck in that position.

“The natural urge to push wasn’t happening”

I went immediately to my wife, who was exhausted and told her when Dr. W comes back in, it’s time to push.  I calmly gave my wife a pep talk, but she was too tired to respond and her lack of response had me worried.  But, she listened.  Both our doula and I could tell that my wife was having a hard time pushing. The pain was difficult to push through and for some reason the natural urge to push wasn’t happening like my wife envisioned it would happen.  Her body made it to 10cm, slowly, but wasn’t sure what to do now.  The natural urge to push wasn’t occurring.  But, it was time to push anyway.

I didn’t want to seem panicked, but I told my wife several times when the good doctor comes back, he’s either taking you to the OR or you’re going to have to push this baby out.  A delivery nurse came in first and she wanted to observe my wife push and immediately gave her some corrective technique.  Then Dr. W came in and did the same assessment and recognized some technique issues and then he turned into an assertive drill instructor, telling my wife to push.  Both the labor nurse and the doctor’s quick technique advice were key.

“Is that the baby’s head?”

After one of my wife’s strong pushes and while I was holding her right leg back I noticed something unusual looking next to the doctors finger that was positioned about a half inch inside my wife’s vagina. I couldn’t make out the object initially but once my tired brain thought of all the possibilities I realized that it looked like a mat of wet hair.  I asked the doctor, “Is that the baby’s head?” He said yes it is. I was filled with energy and excitement that I hoped would jump to my wife when I told her the news of what I had just witnessed.  I couldn’t believe I was staring at the top of our child’s head.  We made it I thought!  I told my wife I could see the baby’s head.   She pushed harder and after about 3-4 good pushes, our baby came right out.  It was the most amazing thing I’ve ever witnessed.

Once the baby was out, they placed her on my wife’s bare chest. After several minutes we realized that we never checked to see what the sex was.  My wife lifted her up, moved the umbilical cord and I think we were both surprised to see a little girl part.  We did not want to know the sex of the baby until he or she was born.  We assumed we were having a boy because of how strong the baby was during the pregnancy and how much the baby looked like our son from the 3-d ultra sounds.

“She felt so good that we requested to leave the hospital at the absolute minimum stay period.”

Lucy Rose was born at 7:47pm on October 11, 2012.  She was 7 pounds 1 ounce.  My wife had no tearing and her uterus showed no signs of trauma from the VBAC.  She felt so good that we requested to leave the hospital at the absolute minimum stay period.  The baby was born at 7:47 pm and we told the hospital we’d stay exactly the required 24 hour monitoring period. By 8pm, 24 hours later, we were loading up the car and heading back to our desert home, 2.5 hours from the hospital.  We arrived at our home around 11:30pm.

This was the first time I had been home since April 7th and it was so nice to be back.  No hospital nurses checking vitals every 2 hours and the comfort of our own nest.  The next 10 days at home with the baby, my wife and kids were absolutely wonderful.  Due to the natural birth, my wife was immediately mobile.  Unlike the previous two births, it was great seeing my wife smile, happy and glowing and able to move without pain.  She loathed the c-section and dreaded the possibility of having to go through that again, especially without the help of her husband.  Thankfully, we were able to have a successful VBAC preventing my wife from having to relive another c-section.

“She came in and began lecturing us on the dangers of a VBAC.”

When we arrived at the hospital, the birthing process started out badly.  The first nurse we dealt with was what I would consider bluntly, an idiot.  She came in and began lecturing us on the dangers of a VBAC.  I quickly told her to stop and leave. This same nurse came in again and tried to make more negative commentaries and this time our doula rolled in and told her to essentially shut up and do her job.  I pulled this nurse out and told her that we weren’t going to have any negativity in the room.  I told her that we weren’t 16 year old idiots; we were well informed and educated people who most likely knew more about the risks than she did.  I had thoughts of leaving the hospital due to the initial behavior of the nurses.  In all honesty the staff on duty when we arrived was absolutely horrible. They were unfriendly and unprofessional.

But at shift change, something wonderful occurred.  The next shift yielded very competent, supportive and professional nurses who understood that our path through this experience was going to be nothing but positive and supportive.  Two of our nurses were also doulas.  We had great health care providers through the rest of the stay at the hospital.  No more myopic lectures about the risks but instead an all out effort to support my wife through this delivery.  There is no way we could have made it through this experience without the help and support of true and knowledgeable nurses who understood compassion and realized that the patient is first and foremost.

“My initial thought was that this hospital was going to be a disaster but I was happy to be wrong.”

My initial thought was that this hospital was going to be a disaster but I was happy to be wrong. We fortunately experienced a well organized and supportive hospital where our experience was wonderful and our dream of a natural birth and of a successful VBAC was realized.  The ability to have a natural birth allowed my wife to function immediately after the birth, something that would be crucial when I left again for another 5 months.  My 9 days at home after Lucy was born, allowed my wife to rest and regain her strength.  Then when I left, she would be able to successfully handle the newly expanded family.  If she had had a c-section, our lives would have been even more complicated and challenging.  Alleviating this variable was crucial and it was extremely important in allowing my wife the choice and freedom to labor as she desired.

“Having hospital protocol tell you what you can do with your body is a crime.”

Having hospital protocol tell you what you can do with your body is a crime.  It was a crime with our second baby and one that I unfortunately did nothing to stop.  I was guilty of not recognizing the deep and complicatedly emotional desire and need to have that choice.  I was guilty for not carefully listening to my wife.

But, I was fortunate to have had a second opportunity to ensure she was able to have that choice.  When I saw and finally understood my wife’s deep desire and passion to have a VBAC, something that I can’t really explain, but instead felt – I knew she could in fact do it and that I needed to help pave the way to ensuring it was possible. That meant I needed to knock down the obstacles that got in our way, like doctors saying no or nurses trying to convince us that our decision was dangerous and risky.  I listened to my wife, and we thank God that we found a doctor who trusted us.

Ultimately, faith, education and research, proper planning, incredible support that we received from people like Dr. W and our doula, and the great nurses who helped make this a success were critical to the successful VBAC.   We heard it before “you’ve had one, so now you need to have them all c-section.” This we now know is myth and one myth that removes the woman’s choice to attempt a VBAC.  Our hope is that other women and couples will have the same support and success as we experienced.

Why cesareans are a big deal to you, your wife, and your daughter

surgery-surgical-instrumentsI hear a lot, “What’s the big deal about cesareans? What difference does it really make if you have a cesarean?” Of course, if a cesarean is medically necessary, then the benefits outweigh the risks. But in the absence of a medical reason, the risks of cesareans must be carefully considered.

“Once a cesarean, always a cesarean”

If a woman has a cesarean, she is very likely to only have cesareans for future births. This is because while 45% of American women are interested in the option of VBAC (1), 92% have a repeat cesarean (2). Let me say that another way. Only 8% of women with a prior cesarean successfully VBAC.

One might interpret this statistic to mean that planned VBACs often end in a repeat cesarean. However, VBACs are successful about 75% of the time (3-7). The VBAC rate is so low because of the women interested in VBAC, 57% are unable to find a supportive care provider or hospital (1). And I would argue further that even among the women who have a supportive care provider, those women are so bombarded by fear based misinformation masquerading as caring advice from friends and family, they have no chance.  It is shocking to learn how ill-informed both women planning VBACs and repeat cesareans are about their birth options even upon admission to the hospital.  There is a fundamental gap in our collective wisdom about post-cesarean birth options.

Cesareans make subsequent pregnancies riskier

What’s the big deal, right? Who cares if you have a cesarean without a medical reason?

Forget about the immediate risks to mom and baby that cesareans impose. Just set that all aside for a moment.  Much of the risk associated with cesareans is delayed.  Most people are not aware of the long term issues that can come with cesareans and how these complications impact the safety of future pregnancies, deliveries, and children.

It is a well-established fact that the more cesareans a woman has, the more risky subsequent pregnancies and labors are regardless if the mom plans a VBAC or a repeat cesarean.  This was discussed at great lengths during the 2010 National Institutes of Health VBAC conference and was one of the reasons why ACOG released their less restrictive VBAC guidelines later that same year.

Many moms chose repeat cesareans because they believe cesareans are the prudent, safest choice. The fact that cesareans, of which over 1,000,000 occur in the USA each year, increases the complication rates of future pregnancies is often not disclosed to women during their VBAC consult.

A four year study looking at up to six cesareans in 30,000 women reported a startling number of complications that increased at a statistically significant rate as the prior number of cesareans increased:

The risks of placenta accreta [which has a maternal mortality of 7% and hysterectomy risk of 71%], cystotomy [surgical incision of the urinary bladder], bowel injury, ureteral injury [damage to the ureters – the tubes that connect the kidneys to the bladder in which urine flows – is one of the most serious complications of gynecologic surgery], and ileus [disruption of the normal propulsive gastrointestinal motor activity which can lead to bowel (intestinal) obstructions], the need for postoperative ventilation [this means mom can’t breathe on her own after the surgery], intensive care unit admission [mom is having major complications], hysterectomy, and blood transfusion requiring 4 or more units [mom hemorrhaged], and the duration of operative time [primarily due to adhesions] and hospital stay significantly increased with increasing number of cesarean deliveries (8).

Because the growing likelihood of serious complications that comes with each subsequent cesarean surgery, including uterine rupture, this study concluded,

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 (8).

This is because the risks of placenta accreta and previa in particular increase at a very high rate after multiple cesareans (9).

The largest prospective report of uterine rupture in women without a previous cesarean in a Western country,” concurred:

Ultimately, the best prevention [of uterine rupture] is primary prevention, i.e. reducing the primary caesarean delivery rate. The obstetrician who decides to perform a caesarean has a joint responsibility for the late consequences of that decision, including uterine rupture (10).

“Well, I just plan on having two kids…”

Unfortunately, many women don’t think about these future risks until they are pregnant again. And we all know the great difference between intended and actual family size.

According to the CDC, 49% of American pregnancies are unintentional (11). Thus, these theoretical risks quickly and suddenly become a reality for hundreds of thousands of American women every year. How women birth their current baby has real and well-documented implications and risks for their future pregnancies, children, and health.

VBAC bans and emergency response

In light of these increasing risks, VBAC bans do not make moms safer (12). Hospitals are either prepared for obstetrical complications, like uterine rupture in moms who plan VBACs and placenta accreta, previa, and cesarean hysterectomies among moms who plan repeat cesareans, or they are not. It is hard to understand how hospitals can claim that they are simultaneously capable of an adequate response to cesarean-related complications and yet they are unable or ill-equipped to respond to complications related to vaginal birth after cesarean.  Especially in light of the fact that we know motivated hospitals currently offer VBAC even in the absence of 24/7 anesthesia (13).

A recent Wall Street Journal article discusses how hospitals are trying to create a standard response to obstetrical emergencies:

The CDC is funding programs in a number of states to establish guidelines and protocols for improving safety and preventing injury.  And obstetrics teams are holding drills to train doctors and nurses to rapidly respond to maternal complications. They are using simulated emergencies that include fake blood, robots that mimic physiologic states, and actresses standing in as patients (14).

Because hospitals vary so greatly in their ability to coordinate a expeditious response to urgent situations,

Vivian von Gruenigen, system medical director for women’s health services at Summa Health System in Akron, Ohio, advises that pregnant women discuss personal risks with their doctor and ask hospitals what kind of training delivery teams have to respond in an emergency. ‘People think pregnancy is benign in nature but that isn’t always the case, and women need to be their own advocates,’ Dr. von Gruenigen says.

Impact of VBAC on future births

Counter the increasing risks that come with cesareans to the downstream implications for VBAC. After the first successful VBAC, the future risk of uterine rupture, uterine dehiscence, and other labor related complications significantly decrease (15). Thus, family size must be considered as VBAC is often the safer choice for women planning large families.

Bottom line? I defer to two medical professionals and researchers:

“There is a major misperception that TOLAC [trial of labor after cesarean] is extremely risky” – Mona Lydon-Rochelle PhD, MPH, MS, CNM (16-17).

In terms of VBAC, “your risk is really, really quite low” – George Macones MD, MSCE (16-17).

Women deserve the facts

Women are entitled to accurate, honest data explained in a clear, easy to understand format (18). They don’t deserve to have the risks exaggerated by an OB who wishes to coerce them into a repeat cesarean nor do they deserve to have risks sugar-coated or minimized by a midwife or birth advocate who may not understand the facts or whose zealous desire for everyone to VBAC clouds their judgement (19-20).

If you would like to get the opinions of actual VBAC supportive medical professionals who support a woman’s right to informed consent, there are several obstetricians and midwives who you can talk to on the VBAC Facts Community.

Take home message

Cesareans are not benign and the more you have, the more risky your future pregnancies become regardless of your preferred mode of delivery.

Almost half of the pregnancies in America are unintentional.

If hospitals can attend to cesarean-related complications, they can attend to VBAC-related complications.

_________________________________________________

1. 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. Retrieved from Childbirth Connection: http://www.childbirthconnection.org/article.asp?ck=10068

2. Osterman, M. J., Martin, J. A., Mathews, T. J., & Hamilton, B. E. (2011, July 27). Expanded Data From the New Birth Certificate, 2008. Retrieved from CDC: National Vital Statistics Reports: http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_07.pdf

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. Kamel, J. (2012, Mar 30). Placenta problems in VBAMC/ after multiple repeat cesareans. Retrieved from VBAC Facts: http://vbacfacts.com/2012/03/30/placenta-problems-in-vbamc-after-multiple-repeat-cesareans/

10. Zwart, J. J., Richters, J. M., Ory, F., de Vries, J., Bloemenkamp, K., & van Roosmalen, J. (2009, July). Uterine rupture in the Netherlands: a nationwide population-based cohort study. BJOG: An International Journal of Obstetrics and Gynaecology, 116(8), pp. 1069-1080. Retrieved January 15, 2012, from http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2009.02136.x/full

11. National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. (2012, Apr 4). Unintended Pregnancy Prevention. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/index.htm

12. Kamel, J. (2012, Mar 27). Just kicking the can of risk down the road. Retrieved from VBAC Facts: http://vbacfacts.com/2012/03/27/just-kicking-the-can-of-risk-down-the-road/

13. Kamel, J. (2010, July 22). VBAC ban rationale is irrational. Retrieved from VBAC Facts: http://vbacfacts.com/2010/07/22/vbac-ban-rationale-is-irrational/

14.  Landro, L. (2012, Dec 10). Steep Rise Of Complications In Childbirth Spurs Action. Retrieved from Wall Street Journal: http://online.wsj.com/article/SB10001424127887324339204578171531475181260.html?mod=rss_Health

15. Mercer BM, Gilbert S, Landon MB. et al. Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Obstet Gynecol. 2008 Feb;111(2):285-291. Retrieved from: http://journals.lww.com/greenjournal/Fulltext/2008/02000/Labor_Outcomes_With_Increasing_Number_of_Prior.6.aspx

16. NIH Consensus Development Conference. (2010). Vaginal Birth After Cesarean: New Insights. Bethesda, Maryland. Retrieved from http://consensus.nih.gov/2010/vbac.htm

17. Kamel, J. (2012, Apr 11). The best compilation of VBAC research to date. Retrieved from VBAC Facts: http://vbacfacts.com/2012/04/11/best-compilation-of-vbac-research-to-date/

18. Kamel, J. (2012, Dec 7). Some people think I’m anti-this/ pro-that: My advocacy style. Retrieved from VBAC Facts: http://vbacfacts.com/2012/12/07/some-people-think-im-anti-thispro-that-my-advocacy-style/

19. Kamel, J. (n.d.). Birth myths. Retrieved from VBAC Facts: http://vbacfacts.com/category/vbac/birth-myths

20. Kamel, J. (n.d.). Scare tactics. Retrieved from VBAC Facts: http://vbacfacts.com/category/vbac/scare-tactics/

VBAC bans, exercising your rights, and when to contact an attorney

legal-gavel-booksA mom recently left this comment and I thought many other women likely have the same question. Keep in mind that this article does discuss America law which may not be applicable to other countries.

________________________________________

Jen,

First thank you for your site!

I’m under the care of an OB who practices at a hospital that does not “allow VBACs” but has stated the only way to deliver at said hospital is to show up in labor & pushing.

Quoting from your site quoting the ACOG bulletin:

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.

If a patient (Me 3 prior sections), presents one’s self in labor at said hospital and declines a section, the hospital then has to heed the wishes of the patient? Am I understanding this correctly? Does the hospital have the right to stop contractions and section the patient? This is what I’m hearing in my birthing community and I really cannot believe a hospital would/could do that.

_____________________________

Hi Thia!

Many women believe that all one must do to prevent an unwanted cesarean is declare, “I do not consent!” While technically true, you are entitled to control what happens to your body, the reality is, it often doesn’t play out that way. A hospital does not have a legal right to perform a cesarean on you without your consent. However, it still happens either by coercion or lies and even more rarely, by court order.

I think part of the problem is, many women are not familiar with ACOG’s guidelines. As a result, they don’t understand what ACOG recommends and discourages. (For example, many women believe that VBACs should never be induced. That is false.) Women frequently take their OB’s word as the truth. However, ACOG’s recommendations are often obscured by unsupportive care providers to mimic what the care provider wants the mom to think ACOG says. In other words, unsupportive care providers want moms to think that their options are limited per ACOG and that is just not the case.

The fact that you are doing your research gives you a massive advantage over women who just take their OB’s word for it. I highly recommend you review the article I wrote about a mom who was threatened with a forced cesarean after her OB withdrew support of her planned VBA2C at 37 weeks. It includes legal and media contacts. Through the help of the ACLU, ACLU Women’s Rights Project, National Birth Policy Coalition, and National Advocates for Pregnant Women, the mom was granted a trial of labor. I use the (demonized) term TOL because the mom ultimately did have a medically necessary cesarean during labor due to a placental abruption. However, the mom was still happy that she had the opportunity to labor.

That is as much as I can say as a non-attorney. I consulted with the brilliant Lisa Pratt who is an attorney specializing in the legal issues that uniquely affect women during pregnancy and childbirth. She said,

This answer is true for all women, not just this one. If she needs legal advice specific for her situation then she should consult an attorney. You have the right to refuse any treatment you do not want. I am sure that what she is hearing is the same horror stories that we hear of a mom being harassed by the doctor and staff to consent to a c/s or threatening to seek a court order or call CPS. I know this is a scary thought to have to deal with any of these scenarios, but fear of something happening should not keep you from exerting your legal rights, unless you really are okay with what you are consenting to. You cannot assume that the staff is not going to honor your refusal. They are people just like us, some are jerks and some are ethical and will follow your refusal, but you won’t know what you are dealing with until you are in the moment. ACOG guidelines are just that, guidelines, they are not law; while it is nice when they put out a guideline that supports your factual situation, falling outside of their recommendation does not mean you must consent to something you do not want.

You can learn more about Lisa, and schedule a phone consultation if you have further questions, via her website.

Lisa presented at the 2012 VBAC Summit in Miami. Her session, “A Legal Guide to VBAC,” is available for download.

Warmly,

Jen

Woman has 4th cesarean and requires 33 gallons of blood

Update: This powerhouse of a woman has since started the non-profit organization “Hope for Accreta Foundation.”


What a miracle this woman survived!  This was her fifth baby and fourth cesarean.

She had a complication known as placenta percreta which is when “the placenta attaches itself and grows through the uterus, sometimes extending to nearby organs, such as the bladder” (March of Dimes 2012).  The risk of having placenta accreta, increta, or percreta during a fourth cesarean or a VBA3C (vaginal birth after three cesareans) is 2.13% (1 in 47) (Silver 2006).

Image credit: Wikipedia

Image credit: Wikipedia

Most women planning a VBA1C (vaginal birth after one cesarean) are aware of the risks of uterine rupture.  However, women planning their first vaginal birth or VBA1C need the WHOLE picture so they can really work to prevent an unnecessary cesarean.  They need to understand the risks and benefits of VBAC versus repeat cesarean for mom and baby now as well as how current choices impact mom’s future health, fertility, delivery options, and complications that present in subsequent births.

A huge part of this – I believe – is hiring a vaginal birth/VBAC supportive care provider because once a woman has that first cesarean, her options narrow, and they do so even more drastically after that second cesarean.  As her options narrow, her risks increase and unlike uterine rupture which you can circumvent through a repeat cesarean, the risk of accreta, percreta, and increta are not as easily mitigated.

By avoiding one complication, we are increasing our risk for another serious complication in future pregnancies.  For women who plan for large families, this should be on your radar and every practitioner should be discussing intended family size with their patients so that it can be taken into consideration.

Read more about placenta abnormalities, the risks of multiple cesarean sections, the marketing of risk, and how reversing VBAC bans would make birth safer for everyone.

And please donate blood. These women need it.

Woman survives crisis delivery with 33 gallons of donated blood

Posted on April 11, 2012 at 9:46 PM

SAN ANTONIO — University Hospital is sharing an incredible story of survival. A San Antonio woman was saved during a crisis baby delivery. But it took more than 33 gallons of blood.

Two-month-old Addison Walker came into the world in an unusual way. Her mother, Gina, had a rare pregnancy condition called placenta percreta. The placenta invaded through the uterine wall into the bladder, causing massive bleeding during a delivery operation.

Doctors at University Hospital recalled the February eight-hour operation.

“Unfortunately, Ms. Walker had blood loss that superseded anything that we could have prepared for,” said Dr. Jason Parker, U.T. Health Science Center OB/GYN.

Walker lost more than ten times the amount of blood surgeons anticipated. She needed more than 33 gallons. That’s 540 units to keep her alive.

“After I watched cooler after cooler after cooler with my wife’s name on it full of blood going up and down the hallways, yeah, I did get worried,” recalled Gina’s husband Dustin. Read more.

A couple comments left on Facebook:

University is a Level 1 trauma center.  It is the trauma center in San Antonio.  Only other hospital that takes the worst of the worst is SAMMC [San Antonio Military Medical Center] which is the military hospital.  University takes all the gunshots, stabbings, multiple injury accidents, etc…. And these come in multiple times a day.  If any hospital has 100+ units on hand it would be that hospital.  Even if it didn’t, it is literally a couple hundred yards from a half dozen other hospitals that could dip into their supply.

It’s approx $1060 per unit of blood from the blood bank, not including the one time cost of all the testing, which is about $400-500. (These costs depend on the facility, but are a ball park.) Think about what the cost of the blood alone was…

I laboured just fine with my attempted VBA3C but the labour pains at the end were intense and I needed some meds of sorts so I went off to the hospital only to be bullied into the surgery room. All stats were excellent with me and my baby (and noted by the doctors in surgery that my little girl was down the birth canal and had I only been given something to help with pain, I would have pushed her out just fine). Because of that unnecessarian I had to endure a 6 hour reconstructive surgery to fix the mistakes of all the other batched c-sections and to repair the fistula left by the 4th C. But in the meantime I got the pleasure of toting around a catheter for the 5 months in between surgeries. That’s on top of the other procedures, tests and pain I had to go through. All of this could have been avoided had the doctors not allowed me that very first c-section and all the others that were not required. I kick myself in the butt for not educating myself right from the beginning, but how was I to know the doctors wouldn’t be educated either!

I desire to go on to have more children, but am terrified for things like this article speaks of.

Options when threatened with a “forced” cesarean

3/26/12- The ACLU has posted an article on their blog regarding this case where they released the letter they faxed to the OB group on behalf of the “forced CS” mom. This letter is an excellent resource for any person who works with pregnant women as it reviews the case law and illustrates that “a pregnant woman, like all other persons, has the right to refuse any and all medical interventions that she does not want, even if her doctor disagrees.  In a case called In Re A.C., brought by the ACLU 25 years ago on behalf of a woman forced by court order to undergo a life-threatening C-section, the judge explained: ‘[I]n virtually all cases the question of what is to be done is decided by the patient – the pregnant woman – on behalf of herself and her fetus.'”

A Little Background

On March 2, 2012, a doula contacted me because a GBS positive client was seeking a VBA2C. Her OB group was supportive until they withdrew support of her VBA2C plans at 37 weeks due to factors that had nothing to do with her. I suspect that the OB group – who was known to be VBAC & VBA2C supportive – had a lawsuit/ uterine rupture/ bad outcome that made them so abruptly change their VBAC policy. Nothing developed during the mom’s pregnancy that suddenly made her a poor candidate for VBA2C.

With the mom’s permission, her doula contacted me to help them determine their options. (Below you will find the initial email I received from the doula.) I’m not an attorney or a medical professional, so I could not advise them. I turned to Facebook to collect options and opinions. Through those posts, I was directed to people who could help them – OBs, midwives, reporters, legal organizations, and attorneys. Now it was up to the mom whether she wanted to contact those people/orgs to get their opinions and advice.

Her name and her doula’s name were not made public so that the mom could make this decision without the public eye directly on her and all that comes with that.

What follows below is a brief timeline of the events and then there are emails that follow sharing more detail.

The National Advocates for Pregnant Women becomes involved

Update 3/3/12 12:08 PST- I contacted the National Advocates for Pregnant Women last night and the Executive Director Lynn Paltrow replied early this morning with lawyer referrals and a review of the case law. I have included her email below with her permission. This is good information for anyone who works with pregnant women.

1:01 PST- Mie Lewis of the ACLU Women’s Rights Project recently expressed interest in taking on cases like these. Mie Lewis is in New York city and would be an excellent resource for any other women who experience similar situations.

For women in South Carolina, you can contact your state chapter of the ACLU:

Susan K. Dunn
Legal Director
ACLU, South Carolina
P.O. Box 20998
Charleston, SC 29413-0998
843-720-1425

Elizabeth Cohen, Senior Medical Correspondent for CNN and CNN’s Sabriya Rice are two reporters who have written about birth and might be worth contacting if you find yourself in a similar situation. Check out “Mom defies doctor, has baby her way” dated December 16, 2010 to get a feel for their writing.

3/5/12 6:40 PST – I learned last night that the mom was able to get her cesarean rescheduled two days later for March 7th.

ACLU, NAPW, & NBPC fax a letter to the OB group, mom has preoperative appointment

3/6/12 4:15 PST – The mom’s doula contacted me with an update. Today the mom and the doula attended the mom’s preoperative appointment for her scheduled cesarean on March 7, 2012. Early this morning, a letter composed by members of the ACLU, ACLU Women’s Rights Project, National Birth Policy Coalition, and National Advocates for Pregnant Women was faxed to the OB group. (You can read the letter here.) The mom and doula also brought a copy of the letter to the appointment. From the doula’s statement: “[The OB] said that this was clearly a misunderstanding and miscommunication and that it didn’t deserve legal attention. That right there tells me that the point and purpose of the letter had worked!!”

When the OB referenced ACOG’s VBAC recommendations and the fact that they do not support VBA2C, the mom asked for the date of the recommendations the OB was using. Turns out he was not aware, and was shocked to learn, that ACOG released a new VBAC Practice Bulletin in 2010 stating, VBAC is a “safe and appropriate choice for most women” with one prior cesarean and for “some women” with two prior cesareans.

This is why it is crucial for women to be informed and resourceful! What if this mom was like most moms who choose whatever mode of delivery their OB recommends without understanding the risk and benefits of their options? She would have had a cesarean at 40 weeks per an outdated ACOG VBAC Practice Bulletin.

Instead, the cesarean date has been moved back to 41 weeks (March 17th) and if mom doesn’t go into labor before that, she is OK with having a cesarean on that date. You can read the full letter from the doula detailing the pre-operative appointment below.

Mom goes into labor

3/7/12 – I’m informed that the mom’s water broke and am in communication with the doula throughout the day. Several hours after spontaneous rupture of membranes, contractions start and labor progressed, but then fizzled out. “Dr S. decided that because she had come this far only to hit a wall that wasn’t moving after trying all natural approaches, he would start a very, very, very low dose of Pitocin [starting at 2 milliunits/hour with a maximum of 4 milliunits/hour] through her IV.” Things start picking up again, but then some fetal distress was detected and Pit was backed off and finally turned off completely. Fetal heart tones stabilized but at a lower baseline than before.

Suddenly fetal heart tones drop and then disappear. A STAT cesarean is called, mom was put under general anesthesia, and within TEN MINUTES, the baby is born. Mom was fine as well.

A placental abruption was diagnosed during surgery. An abruption is when the placenta detaches from the uterine wall before the baby is born. This deprives the baby of oxygen and mom is at risk for hemorrhage. Full abruption is very dire for baby. While there is about a 6% chance of infant death or oxygen deprivation after an uterine rupture (Landon, 2004), there is a 12% risk of infant death after a placental abruption (Ananth, 1999). That is a grim statistic.

I am extremely thankful that this mom birthed where she felt safest which was in the hospital despite the many who suggested she plan a last minute home birth.  While I am supportive of home birth and I myself had a home birth, that doesn’t mean that I think all complications can be easily managed at home.  There are complications that are better served in the hospital environment.  Had she planned a home birth, she could have been totally fine, transferred in time, or she could have had a bad outcome.  The fact is, we don’t know.   I do think women who have placental abruptions have better odds in the hospital.

As the doula said of the mom,

She is very thankful she didn’t take the suggestions of some – to call in an underground midwife, to have a home birth, to go to another state and deliver, to labor at home until she was feeling pushy. Any of those suggestions could have had deadly consequences for Emily and her baby. She is thankful that she was given the opportunity to attempt a vaginal delivery, and she is thankful that her body tried to labor. Ultimately though, she is so very thankful that there was an amazing medical team who jumped right into action and essentially saved the lives of both her and her sweet baby girl. She let me know that if she could go back in time, there is nothing she would have changed.

In the mom’s own words:

I don’t think I would have done anything different. I might have said hey lets keep it [the pitocin] at two [milliunits] but hey it [the abruption] would have happened either way. It was God’s way of saying, hey this baby needs out and isn’t coming out the normal way. I let you try it now it is time for you to go ahead and meet her.

Mom is up and around the day after surgery and not needing pain medication! Hopefully this means she will have one of those easy cesarean recoveries of which I am forever jealous! Baby is breastfeeding well. I wish this mom and baby a quick recovery and a happy, happy babymoon!

You can read the doula’s full account of the birth here.

Follow Up

I’ve received a few comments questioning the use of Pitocin in a VBAC and even some comments suggesting that if the mom was at home, the abruption wouldn’t have happened because she wouldn’t have had the Pitocin.

In terms of Pitocin in VBAC moms: 99% of VBAC induced/augmented labors do NOT rupture (Landon, 2004). I haven’t seen rupture rates in VBA2C induced/augmented labors. With induction or augmentation, the increased risk of rupture comes from the drug and the dose. I do not know if the dose given to the mom is in the “danger zone.” I’d appreciate any studies that have measured Pitocin augmented uterine rupture rates and abruption rates by dose in VBAC labors.

But please know, that most ruptures occur in spontaneous labors. Zwart (2009) is a Netherlands based study that included 358,874 total deliveries, making it “the largest prospective report of uterine rupture in women without a previous cesarean in a Western country.” It also differentiated between uterine rupture and dehiscence. Zwart (2009) “found of the 208 scarred and unscarred uterine ruptures, 130 (62.5%) occurred during spontaneous labor reflecting 72% of scarred ruptures and 56% of unscarred ruptures. 28 (13.5%) ruptures occurred during cervical prostaglandin induction. 22 (10.6%) ruptures occurred during oxytocin (Pitocin) induction.” 40% of scarred ruptures occurred during prostaglandin induction. Read more here.

In terms of Pit causing the abruption, none of us know whether that is true to not.  Certainly most women who have Pitocin do not abrupt.  Further, people said that if she was at home, she wouldn’t have been augmented, and she wouldn’t have abrupted.  None of us know that.  Some people believe the myth that nothing can go wrong in a spontaneous “unmessed with” birth.  That is a dangerous and false belief.  All complications are not the result of “interventions gone wrong.”  Sometimes you can do everything “right” and still have a complication/ bad outcome.  Here is one mom’s story of her placental abruption at home (trigger warning).  She survived, her baby girl Aquila did not.  I share this story solely to illustrate the severity of placental abruption and how having a competent care provider and immediate access to operating rooms, surgeons, and blood products can literally make the difference between life and death.  Abruption can be a very serious complication.  Most women who have home births will not have a placental abruption or any other complication that requires immediate access to surgery, but those who do will greatly benefit from a qualified care provide who can facilitate immediate transfer to a hospital.

A quick google search found this study which found a slight increase of abruption risk per mode of delivery: 1.06% during the third cesarean vs 0.91% during the third vaginal delivery. I’d be interested in reading other studies people have handy. It did not control for induction or augmentation, so if you have a study that does control by drug and dose, please share.

The OB suggested the Pit and the mom consented.  I do think that is the point.  I do think women should be given the option of augmentation/induction rather than just “required” to have another cesarean as many OBs do. As Dr. Stuart Fischbein, a breech & VBAC supportive Southern California OB, recently shared on my Facebook page,

According to ACOG, prior low transverse c/section is not a contraindication to induction (other than the use of misoprostol [Cytotec]) so a foley balloon or pitocin may be used safely in these women. The problem arises when a practitioner does not believe in doing inductions on women with prior c/section. Despite the evidence and the ACOG clinical guideline the reality is that many doctors will just not want to deal with it.

I actually was impressed that the OB gave the mom the option of a gentle augmentation. It’s certainly better than just saying, “Your time in up.” I don’t know if I would have made a different choice being in this mom’s position: VBA2C, GBS+, contractions sputtering out… It’s really hard for me to say what I would have done. Yet it has seemed very easy for people  sitting at their computer the morning after to make judgements as they do not have to deal with the real risks or consequences. Sometimes you can do everything “right” and still have a bad outcome. Fortunately, the abruption was detected, surgery was performed, and everyone survived.

———————————

3/2/12 – [This is what I wrote upon receiving the doula’s initial email.] I just received this email tonight and need ideas quick. This term mom seeking VBA2C is in the the Columbia area of South Carolina. Her OB was supportive until 37 weeks. Her cesarean is scheduled for March 7, 2012. She was told that if she shows up in labor, she will be “forced” to have a cesarean. Does anyone know of a care provider in her area that would be willing to accept a new client this late in pregnancy? What other options does she have? Additionally, I’m looking for information on the legality of a hospital/OB “forcing” a c/s? What happens if she shows up at the current hospital and refuses to sign the c/s consent form? What exactly CAN they do??

Jen,

I need some quick help with a client of mine and was wondering if you’d lend an ear and offer up any words of wisdom as I know you are an amazing resource to VBAC.

I have a client who is due today. She had a primary c/s 4 years ago exactly on her EDD for a breech baby. She had a RCS 15 months ago because she was carrying twins.

She is seeing the same practice who did her first two c/s, so they are well versed in her medical history. She had double layer sutures both times, good space between deliveries, deliveries were due to breech & twins and not FTP, CPD, ect… She was deemed a good candidate for VBA2C and has been planning once since.

At her 37wk check-up, the OB told her that the staff had changed their minds and could no longer offer her a VBAC. She questioned the reasoning and he said it was just too risky. She was completely blindsided by this and broke down crying – the OB left the room.

Back to her 38wk appointment and she found out the OB had scheduled her RCS for 2 days after her EDD. She confronted the OB (this time a different one than she saw the week prior) and the OB said she didn’t see any reason why she couldn’t be offered a TOLAC. Relieved, my client went on about her business. Pregnancy has been great. Minimal weight gain, no GD, BP always great. She is GBS +. She received a phone call two days later and the OB said each OB on staff had met and it was decided that a VBA2C was too risky and she wouldn’t be allowed to have a TOLAC. My client was furious, and rightly so. She tried to get in touch with the OB but played phone tag back and forth.

Her 39wk appointment came – this time with a different OB yet again. He was a total jerk. Laughed when she told him she wanted a chance to labor. She showed him the current ACOG guidelines which support VBA2C with the right circumstances (which she has) and he disregarded it and showed her a paper on the risk of VBAC. She argued yet again and said she wouldn’t consent to a c/s unless she or the baby were in danger. He told her that if she showed up to L&D in labor they would “force” her to have a c/s. Yes, he actually told her they’d “force” her. She left a crying, hurt, furious mess.

The next day she called to request her records and the OB told her again – if she delivered with their practice, it would be VIA c/s – end of story. If she didn’t want to comply, they’d (legally) find another practice to take her (HIGHLY unlikely considering she’s due today)…

She hasn’t been back since but has a section scheduled for the 5th that she intends to cancel. I am virtually her only support. Her MIL has 2 c/s, her mother had 3 c/s and thinks she’ll die if she attempts a vaginal birth. Her husband says he has to know when the baby is coming so he can plan to get off of work – so he is fine with the section and not supportive or helpful much.

We have had massively long talks over the past few days and what it boils down to is that she has two choices essentially.

#1 – Show up in labor at her current hospital and have to fight like hell to be able to labor. Almost certainly have the OB on call make the process very difficult. She voiced a concern that the OB may be so pissed off that she’s refusing a c.s that they’ll find some reason to section – “fetal distress”, baby too big, baby not fitting, failure to progress, ect… She also worries exactly what they truly mean by they’ll “force” her to have a c/s. She worries they’ll do something extreme like call DSS/CPS. She’s heard a horror story of a court-ordered c/s. I told her that all that worry, stress, and anxiety during labor will do absolutely nothing good for her well being and progress.

#2. Show up at a different hospital and deliver with the hospital OB. Problem here is she has no record of prenatal care, no surgical records to show suture status, time between sections, ect… She requested her records from the current OBs office, but no one is getting back to her (and I doubt they will…). I know they’ll look down on that and potentially try to coerce into a section due to that. She feels she’d face the least opposition going this route, but has concerns.

I’m exhausted and so is this mama. She is still firm in her choice that a VBAC is the best and safest option for her and her child and I fully support that. I’m not even sure what the right option is at this point or where to turn or what to do. I’m trying to let the mama guide but she’s looking to me as if I can somehow make this entire situation go away… I wish I had the answers, but I don’t.

I was just wondering if you had any information on the legality of a hospital/OB “forcing” a c/s? What happens if she shows up at the current hospital and refuses to sign the c/s consent form? What exactly CAN they do?? Have you had any experience in with cases like this?? What option do you feel would be best (#1 or #2) and how should I direct the mama to handle the staff? What is my role here? I’m just at a loss and felt I needed to seek counsel…

Thank you for listening, I know it was so long..

3/3/12 – I receive an email from Lynn Paltrow, Executive Director for the National Advocates of Pregnant Women:

Dear Jen:

By this email,I am cc’ing two lawyers in South Carolina, Susan Dunn and C. Rauch “Rock” Wise, and SC activist Sally Hebert as well as other people out of state who may have useful suggestions, including Farah on our staff who is especially knowledgeable about cases involving threats of forced cesarean surgery. I know a great deal about the law in South Carolina but am not admitted to practice there, so any legal questions should be directed to lawyers admitted to the bar in South Carolina.

I can, however, share with you some general background. As a matter of constitutional law, medical ethics, and human rights, doctors may not force their patients — including pregnant ones — to undergo procedures they do not consent to.

As a policy matter, both the American Medical Association and the Ethics Committee of the American College of Obstetricians and Gynecologists have taken express positions opposing court ordered interventions against pregnant women and against effort by hospitals and doctors to seek such orders. The American College of Obstetricians and Gynecologists has issued a formal opinion stating that “actions of coercion to obtain consent or force a course of action limit maternal freedom of choice, threaten the doctor/patient relationships, and violate the principles underlying the informed consent process.” See American College of Obstetricians and Gynecologists Committee Opinion No. 55, Patient Choice: Ma­ternal-Fetal Conflict (1987) (And more recent opinions 2005); Report of American Medical Association Board of Trustees, Legal Interventions During Pregnancy, 264 JAMA 2663, 267 (1990) (“Judicial intervention is inappropriate when a woman has made an informed refusal of a medical treatment designed to benefit her fetus.”)

Appellate cases decided on full records and addressing the issue of court ordered interventions on pregnant women have held that the medical and constitutional principles of informed consent, bodily integrity, and patient privacy and autonomy require that pregnant women have the right under the common law and the constitution to accept or refuse medical treatment, like all other patients. See In re A.C., 573 A.2d 1235, 1253 (D.C. 1990) (en banc) (vacating a court-ordered cesarean section that was listed as a contributing factor to the mother’s death on her death certificate); In re Fetus Brown, 689 N.E.2d 397, 400 (Ill. App. Ct. 1997) (overturning a court-ordered blood transfusion of a pregnant woman); In re Baby Boy Doe, 632 N.E.2d 326 (Ill. App. Ct. 1994) (holding that courts may not balance whatever rights a fetus may have against the rights of a competent woman, whose choice to refuse medical treatment as invasive as a cesarean section must be honored even if the choice may be harmful to the fetus). Cf. Stallman v. Youngquist, 531 N.E.2d 355, 359-61 (Ill. 1988) (refusing to recognize the tort of maternal prenatal negligence, holding that granting fetuses legal rights in this manner “would involve an unprecedented intrusion into the privacy and autonomy of the [state’s female] citizens”).

Nevertheless, South Carolina stands out in the nation for having judicially created law that treats viable fetuses as if they are separate persons. As a result, certain women have been found guilty of child abuse for risking harm to their unborn children. None of these cases in South Carolina, so far, involve women who have refused cesarean surgery. These decisions, do apparently embolden doctors to believe they can impose their view of what is best on their patients.

Theoretically, it might be possible to go to court to get a Temporary Restraining Order –ordering the hospital not to do as they have threatened. If Susan or Rauch or another South Carolina attorney and the client wish to and are able to go this route, our office may have some draft/model papers that would help with such an effort and we would be happy to consult with/advise/share information with that lawyer.

Regardless, however, of what rights this woman has on paper, she has to deal with the stress of this situation and ensuring that she has access to the health care she does need and want. I cannot advise on what medical course she should take.

I can say though that, however she proceeds NAPW would be very interested in also exploring how we could help if she wishes to challenge these actions after the birth or bring them to public attention. Similarly, if child welfare is called,(something else that would not be supported by constitutional law etc– but is a scary, if remote, possibility) NAPW would be interested in helping her local counsel.

I will be on a plane this morning, but my cell phone is below in the signature block. When it gets a bit later, I will try and reach some of the South Carolina folks by phone to give them the heads up about your email.

Please, in any event, let us know what happens. We will be worrying about this Mom.

Sincerely,

Lynn M. Paltrow
Executive Director
National Advocates for Pregnant Women
15 West 36th Street, Suite 901
New York, New York 10018
212-255-9252
212-255-9253 (fax)
917-921-7421 (cell)
lmp@advocatesforpregnantwomen.org
www.advocatesforpregnantwomen.org
Be a “Fan” of NAPW on Facebook
Follow me on Twitter.Mel

3/6/12 4:15 PST – Update from mom’s doula:

Thank you everyone – especially Jen – for uplifting this mother in your thoughts and prayers and helping us join together as a community to help this wonderful mother out!

Last night, four wonderful women got together and composed a letter to the mama’s OB/GYN practice. These women were members of ACLU, ACLU Women’s Rights Project, National Birth Policy Coalition, and National Advocates for Pregnant women. Thank you so much Jen for contacting these women on the behalf of my client and myself. The letter was absolutely wonderful and explained in detail the things the practice were doing were wrong among many other things – it was very detailed!!! The letter was faxed to the practice first things this morning and a copy was sent to myself and my client.

When we arrived at the consultation, the practice had already received and read the letter and it was in my client’s chart. We were ushered directly to the OB’s office instead of an exam room. We sat down and began to discuss the issues at hand. I was providing moral support while my client took the lead. The OB explained that he believed this was all simply miscommunication. He said that while they have very strong feelings on things such as this, they could not and would not force her to do anything and that no one would come and drag her out of bed tomorrow for her scheduled cesarean. He said that this was clearly a misunderstanding and miscommunication and that it didn’t deserve legal attention. That right there tells me that the point and purpose of the letter had worked!! I knew when I read the letter that it was either going to upset the practice tremendously and they would seek a court order for a cesarean, call DSS/CPS for her endangering her child’s life since SC is a personhood state, or something similar. Alternatively, the letter may shake them into reality and make them realize they are dealing with a mother who is fully informed of her rights and ready to take action and they would back down. Thankfully, the second option ended up happening!! You could tell it was obvious he was shocked that someone went to such lengths to get their attention and fight for what they wanted.

He had the ACOG guidelines book on his desk bookmarked to the VBAC policy and showed us that VBAC after two or more cesareans is contraindicated and the ACOG doesn’t support it. He explained the risk of rupture was 1-2.6% after 2 cesarean section. He explained the risk and that if my client were his wife, he would advise she have a RCS. He was very calm and we remained very calm as well. He said that now the ball was in her court. When he was done explaining his position, my client began to explain hers. Her first question was the publication date for the VBAC ACOG guidelines he had looked up because she believed they were out of date. He looked surprised to be challenged and we took out my binder that had the most recent, revamped ACOG recommendation that is to allow a TOLAC in mothers with two prior low transverse uterine incisions. He was shocked and had no idea that the guidelines had changed…. No wonder our system is so in need of VBAC support – the doctors don’t even know their own governing body’s recommendation!! She explained that she understood the risk involved, but she also understood the risk of a 3rd cesarean section and all she wanted was their blessing to have a trial of labor. She explained that she wouldn’t hesitate to agree to a cesarean section should there arise a true need. They talked further and agreed that she would be allowed to be left alone until 41 weeks – March 17th (they have her EDD as March 11th) to go into labor and be allowed a TOLAC. No induction methods would be used. If no labor and no changing cervix by March 17th, a cesarean will be scheduled and the mom is ok with this.

Everything looks great at her appointment – she’s had no cervical change and the baby is very high still – baby is floating according to the doctor. She’s going to work to bring her baby down and prepare her body for labor. She feels as if a weight has been lifted from her shoulders and she can finally relax. We both agree that being stress-free will do a world of good and we pray she goes into labor on her own before the 17th. Send her good thoughts and prayers that her body kicks into gear and decides it is time to have a baby!!

I am elated that this took such a wonderful turn!! It was such a dark time for quite awhile! Thank you everyone for the continued support and I will keep everyone updated with the mother’s permission!! Hopefully she has a wonderful story to tell very soon!

Study finds that women choose the mode of delivery preferred by their doctor

Update: Metz (2013) came to the same conclusion of Bernstein (2012).  Metz concluded, “Less than one third of the good candidates for TOLAC [trial of labor after cesarean] chose TOLAC. Managing provider influences this decision.”  Read more here.

______________________________

The findings of “Trial of labor after previous cesarean section versus repeat cesarean section: are patients making an informed decision?” presented at the February 9, 2012 annual meeting of the Society for Maternal-Fetal Medicine’s, The Pregnancy Meeting ™, in Dallas, Texas is not surprising.  Doctors have so much influence over patients and apparently, patients are making medical decisions without a basic understanding the benefits and risks of their options.

“Even though most women can achieve a vaginal delivery with trial of labor, less than 10 percent of them attempt to do so,” said Sarah Bernstein, MD, with St. Luke’s-Roosevelt Hospital Center, Obstetrics and Gynecology, in New York, and one of the study’s authors. “In fact, when patients perceived that their doctor preferred a repeat cesarean, very few chose to undergo trial of labor, whereas the majority chose trial of labor if that was their doctor’s preference.”

The study was a survey provided to women upon admission for their elective repeat cesarean section (ERCS) or trial of labor after cesarean section (TOLAC).  I am really shocked at the level of knowledge most of the women had. 73% of the women admitted for a ERCS did not know the chances of a successful VBAC and 64% did not know the risk of uterine rupture.  54% of women choosing a TOLAC did not know the chances of a successful VBAC and 45% did not know the risk of rupture!  WOW!!

Women in both groups demonstrated lack of knowledge on the risks and benefits of TOLAC and ERCS, particularly women in the ERCS group. Specifically, patients were not familiar with the chances of a successful TOLAC, the effect of indication for previous CS on success, the risk of uterine rupture, and the increase in risk with each successive CS.  Only 13% of TOLAC patients and 4% of ERCS patients knew the chances for a successful TOLAC, while the majority in both groups stated that they “did not know”.  The majority (64%)of ERCS patients did not know the risk of uterine rupture during TOLAC and 52% did not know which delivery mode had a faster recovery time.

This is why, even if you are on the fence about VBAC vs. repeat cesarean, selecting a care provider who is genuinely supportive of VBAC gives you the power of choice.  Read more on what makes a supportive care provider here.

Read the press release and a news article.  The abstract is available on page 3 of this PDF.

Quickly and easily provide the resources for VBAC information with the FAQ card.

Sources

Bernstein, S., Matalon-Grazi, S., & Rosenn, B. (2012). Trial of labor after previous cesarean section versus repeat cesarean section: are patients making an informed decision? Supplement to JANUARY 2012 American Journal of Obstetrics & Gynecology, S21. Retrieved from http://www.smfmnewsroom.org/wp-content/uploads/2012/01/Abstracts-27-35.pdf

What can you do when your hospital bans VBAC?

Amber recently left this comment on the Quick Facts page:

i am pregnant for the second time my first child was delivered by c-section my goal is to have my second child natural but the obgyns in my area will not allow someone who has had a c-section to have a natural birth they said it is hospital policy what would you recommend?

Amber,

First educate yourself and then you can take action. You have many options.

I suggest you review the following documents and provide a copy to your health care provider: the most recent ACOG VBAC guidelines, the National Institute of Heath’s 2010 VBAC Statement, and the article VBAC ban rationale is irrational.

Next, read through the steps of planning a VBAC and familiarize yourself with the misinformation that some OBs have used to persuade women to schedule repeat cesareans, so if you hear these same lies, you can identify them: Another VBAC Consult Misinforms, Scare tactics vs. informed consent, VBACing against the odds, and A father says, Why invite the risk of VBAC?.

Additionally, it’s important to know that there are many birth myths rampant on the internet that misrepresent the primary risk of VBAC by minimizing the risk of uterine rupture such as “the risk of uterine rupture in a VBAC mom is similar to (or double) that of an unscarred mom’s risk,” or “the risk of uterine rupture in an induced, unscarred mom is the same as a VBAC mom,” or “a VBAC mom is more likely to be bitten by a shark or struck by lightning than have an uterine rupture.” Again, all these statements are false. And if you see a blog report really low uterine rupture or mortality rates, it’s likely the result of incorrect math.

On to your question. . . Unfortunately, I don’t have any personal experience of pursuing a VBAC in a VBAC ban hospital because I planned a home VBAC in order to avoid all that (almost certain) drama in the hospital. So, I went to my Facebook peeps and got their suggestions and they did not disappoint!

Here are their ideas in their own words…

1. Let hospital administrators and the board of directors know.

Mamas that are passing on a hospital because of their VBAC policy, need to then write the hospital administrators and the boards of directors to tell them that they birthed at XXX Hospital instead of theirs because of their VBAC policy. Hospitals need to hear that they are losing births (aka $$$) because of their policies.

2. Find an ICAN chapter near you.

She needs to get in touch with her closest local ICAN chapter TODAY. They will know details on the exact situation in her area. She should not put stock in what one person tells her- there is a lot of misinformation and myth out there. She can find both a local chapter and information about fighting a VBAC ban at www.ican-online.org

3. Sign a waiver and exercise your legal right to refuse surgery.

I had a VBAC at a hospital where no doctor staff supported it but low and behold all the nurses were amazing! I went in at 5 cm and 3 hours later baby was in my arms. Strong support is a must – I had a midwife, my husband, mom and sister. Stay focused. Don’t sign anything- except the refusal of c/section form- get in there and push your baby out!

and . . .

I would encourage her to ask to see this policy & ask if she would be allowed to sign a waiver. Ask friends if anyone they know has VBAC’d there or at another area facility. I had an experience in my last VBAC where I was told of a “policy” that didn’t really exist except in that person’s mind.

and . . .

Under the right to informed decision making she has the right to say “no thank you”. Absent a court order for a cesarean they cant force her. I’m not a huge fan of the “show up pushing” crowd, but it may appeal to her. Or she could labor in a nearby hotel with a midwife or montrice to monitor the baby and then go in to the hospital at the last minute. Again, not a fan but we’re looking at options here.

and . . .

Regarding stories of VBAC-ban hospitals. I don’t have experience myself, as my VBAC was done with a CNM at a supportive facility – but I’ve attended a VBAC at a local hospital with a VBAC ban. Mama had a RCS [repeat cesarean section] scheduled (though she didn’t intend on going in) but went into spontaneous labor 6 days prior. She labored at home several hours until contractions were about 3 minutes apart. When we arrived and they realized she had a previous c/s, they began calling in a team to prep the OR.

The mama was beyond calm – and in the middle of labor – requested to speak with the staff. The nurses (there were maybe 4 in there?), the attending OB, and the anesthesiologist (who had already been paged for the spinal for surgery) were in her room (ready to wheel her to the OR). Between contractions, she quickly and quietly explained that she was aware it wasn’t typical policy to attend a VBAC, but she was there and it was their legal duty to treat her and she was exercising her legal right to refuse unnecessary surgery.

The nurses looked shocked, the anesthesiologist said something about he was clearly not needed, and the OB (who I swear was VBAC accepting but just was staffed at a VBAC-ban hospital) told her that she was correct, they had to treat her and couldn’t force her to do anything unless her baby was in danger but she’d need to sign quite a bit of paperwork documenting the situation. He had the most odd grin/smirk on his face while he said that as if to somehow thank her for having the nerve to stand up for herself. He left the room and we didn’t see him again until she was crowning.

I in no way, shape, or form feel that that scenario is typical of a VBAC-ban situation, but it was certainly enjoyable and entertaining to have experienced that with my client.

and . . .

I just refused the c-section at a VBAC ban hospital. With my first, I pushed for 4 hours, and he didn’t get past the 0 station (he was presenting transverse) — We lived too far away from the hospital for a homebirth at our own home, but I hired the homebirth midwife for concurrent care. She was going to monitor us at a hotel near the hospital for labor, but thankfully everything went so fast we just met her at the hospital. She served as doula there. I found out from an OB nurse that one of the OBs did support a woman’s right to refuse (though not enthusiastically). I knew I needed care I could trust, so that the only c-section I got was medically necessary. You can read where my midwife tells our story here.

You have every right to refuse an unnecessary c-section, I’d just HIGHLY recommend laboring out of the hospital, and having a doula or knowledgeable advocate with you!

and . . .

This is my advice for VBACing at a banned hospital –

– Sign your informed refusal ahead of time, and be aware that when presented with the risks of VBAC, it will majorly underplay RCS risks; it might be a good idea not to bring your husband to this appointment if he’s feeling nervous about VBAC. [Or have your husband read this article beforehand.]

– Don’t let them give you a late term ultrasound for anything other than a medical problem (in other words — refuse the late ultrasound for size)

– Plan to labor out of the hospital; use a monitrice if you are nervous about that, or a good doula

– Have a smart advocate with you at the hospital so you don’t have to fight any battles yourself and can just focus on laboring

– Get good prenatal care — I did acupuncture and chiropractic, and both of those people had offered to help me in labor if I needed; having that support and belief was very empowering, because my OB absolutely didn’t think we “could” VBAC

– Own your decision; don’t be wishy-washy… be stubborn… this is YOUR BODY. I had a personal mantra that I repeated to myself over and over, “I will only have a medically necessary c-section.”

– Learn ways to get through labor naturally; I really liked the strategies in “Birthing from Within” — even more than hypno or Bradley techniques

– Show up in advanced labor (I was complete when we got to the hospital)

– Know your personal hang-ups — I pushed for 4 hours with my son and am SO GLAD that I labored down in a small bathroom until my urge to push was really strong and spontaneous; I am so glad I wasn’t on the bed pushing for a long time, because this would have brought back too many bad memories and made me feel panicky, tired, and out of control. When I got on the bed to push, I was practically crowning. THAT was very empowering for a “failure to descend” mama

To bottom line – do what you have to to get the care you need, even with limited options; own your body and decision, and give yourself every advantage and tool that you can to help ensure success.

and a VBAC supportive OB who worked in a VBAC ban hospital says:

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

4. Ask a different person at the hospital.

Remember that not everyone is knowledgeable about VBAC or a specific hospital’s VBAC policy, even if they work at that hospital.

I have heard an OB tell a mother that her only option was repeat cesarean because the hospital didn’t allow VBAC. The director of Maternal Child Health said it absolutely wasn’t true and gave her the names of VBAC friendly providers.

5. Find another hospital via the VBAC Policies by US Hospitals database compiled by ICAN.

Remember you are buying a service. Why pay for something you don’t want. Shop elsewhere.

6. Find another provider and ask these questions.

7. Birth in another city, county, or state.

Know what you’re comfortable with, hire a doula as well as a midwife or doctor especially if you have a hospital birth, and do your research so you know your rights and options. I’m currently about to “relocate” to Seattle at 37 weeks, from Juneau, AK where there is a hospital VBAC ban at our one hospital in town so I can try to have a VBAC in a more supportive environment. I didn’t think I wanted to fight the VBAC ban while in labor, I’d rather do my political activism in a clearer state of mind! It has been a stressful journey but I know I’m doing what’s right for me so I’m feeling really good about things now. I know this isn’t an option for many and a few women since the beginning of 2011 have refused repeat c/s at our hospital. Good luck!

and . . .

Go somewhere else. . . I traveled 40 mins for my vbac in 2010 because the 6 hospitals around here wouldn’t let them either.

and . . .

I even know a family who crossed state lines to have her baby the way she desired because her states laws wouldn’t allow her.

Joy Szabo said

I found a sane doctor 5 hours away. I got slightly famous for it, too.

and I’ve heard of women traveling to Mexico to VBAC at Plenitude with Dr. José Luis.

8. Consider a homebirth.

Fighting the hospital system while trying to push out a baby is not a simple task. Yes, a support team can be a big help. Personally, I felt more comfortable staying home than going to the hospital with my boxing gloves. It’s a personal choice and she’ll have to see what she’s most comfortable with. At the end of the day, I played out both options in my mind and went with the one that I felt most at peace with.

and. . .

Hello, my personal story in a nutshell… iatrogenically necessitated c/s with my first. For #2, it was a last minute change of plans… I’m a physician and I discovered through the grapevine that OB was planning to resection me without medical indication so #2 turned into planned HBAC. Homebirth VBAC successful with my second. The second was so beautiful, so peaceful, so uncomplicated!

9. Connect with resources for more ideas.

Stratton, B. (2006). 50 Ways to Protest a VBAC Denial. Retrieved from Midwifery Today: http://www.midwiferytoday.com/articles/50ways_vbac.asp

A good closing thought:

The term “will not allow” always bothers me. Perhaps they “won’t attend a VBAC” but they definitely can not stop you. Stand up for your rights. Show them the ACOG recommendation which is to allow a trial of labor! Seek out support. Call every OB you can think of. Look into a midwife. Hire a doula. You can do this.

Do you have more ideas?

Did you deliver at a VBAC ban hospital?

What was your strategy?

Are you a health care provider at a VBAC ban hospital and have some insight?

Do intrauterine pressure catheters make VBAC safer?

A mom planning a VBA1C (vaginal birth after one cesarean) at a Southern California Kaiser recently emailed me. She discovered while interviewing her care provider and asking how they treat VBAC labors differently than non-VBAC labors (an excellent question), that they require intrauterine pressure catheters (IUPC) in all VBAC labors. She wanted to know what I thought of their policy.

As I read more and more about IUPCs, I was increasingly curious why they would be required.  The evidence for their ability to predict uterine rupture is lacking and as a result major OB/GYN associations do not endorse their use in VBAC labors.  Below you will find the recommendations of the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists (RCOG aka Canada’s ACOG), abstracts of the studies they reference, as well as questions to ask your care provider if they require IUPCs.  As I find more info, I’ll update this page.

What is an IUPC?

WebMD describes it as “a small catheter that is placed along side the baby [that] measures the strength and duration of contractions.”

In order for the IUPC to be inserted next to the baby in the uterus, the fetal membranes must be ruptured and the cervix dilated to at least 1-2cm (UptoDate, 2011).  I suspect that this greatly, if not entirely, limits mom’s ability to move during labor depending on the policies of the hospital and care provider. This also increases the risk of infection and puts mom on the clock in terms of how long her care provider/hospital permits her to labor once her water has been broken.

Do professional obstetrical associations recommend IUPCs in VBACs?

While trying to find if IUPCs were helpful in labor, particularly in diagnosing uterine ruptures, the National Guideline Clearinghouse (2011) gave me a good starting point:

With regard to intrauterine pressure catheters, RCOG notes that their routine use in the early detection of uterine scar rupture is not recommended. ACOG similarly states that no data suggest that intrauterine pressure catheters are superior to external forms of monitoring, and there is evidence that their use does not assist in the diagnosis of uterine rupture.

What does ACOG say about IUPCs?

As I was interested in the exact language used in ACOG’s (2010) VBAC guidelines, I looked it up and found this:

No data suggest that intrauterine pressure catheters or fetal scalp electrodes are superior to external forms of monitoring, and there is evidence that the use of intrauterine pressure catheters does not assist in the diagnosis of uterine rupture.

What IUPC VBAC studies does ACOG reference?

ACOG cites only two studies in that paragraph. The first was published 18 years before ACOG’s recommendations where released and the second, 21 years before. If these are the best studies ACOG can find, then I’m left thinking that there are not many high quality studies on IUPC through 2010.

The first study cited was Devoe (1992) which concluded (emphasis mine),

Though intrauterine monitoring was brief, this model allows a unique view of ‘controlled’ uterine rupture. Spontaneous uterine rupture may evolve more gradually; however, neither catheter type [fluid-filled or solid] would be likely to aid its early recognition.

The second study was Rodriguez (1989) which found (emphasis mine):

The usefulness of the intrauterine pressure catheter in the diagnosis of uterine rupture was assessed by review of 76 cases of uterine rupture, 39 of which were monitored with an intrauterine pressure catheter. The classic description of a loss of intrauterine pressure or cessation of labor was not observed in any of the patients. However, an increase in baseline intrauterine pressure was observed in four patients with an intrauterine pressure catheter. The increase in pressure was associated with severe variable decelerations such that by itself the intrauterine pressure catheter added little to the diagnosis of uterine rupture.

What does RCOG say about IUPCs?

Then I looked up RCOG’s (2007) VBAC guidelines and it stated (emphasis mine):

The routine use of intrauterine pressure catheters in the early detection of uterine scar rupture is not recommended. Observational studies, with varying methodology and case mix, have shown that intrauterine pressure catheters may not always be reliable and are unlikely to add significant additional ability to predict uterine rupture over clinical and CTG surveillance. Intrauterine catheter insertion may also be associated with risk. Some clinicians may prefer to use intrauterine pressure catheters in special circumstances (such as in women who are obese, to limit the risk of uterine hyperstimulation); this should be a consultant-led decision.

What IUPC VBAC studies does RCOG reference?

RCOG cites four studies in that paragraph. Again, it’s surprising that these studies were published 15 – 25 years before the 2007 RCOG guidelines.

First, Arulkumaran (1992) which I found so interesting, I included the entire abstract (emphasis mine):

To evaluate the symptoms and signs of scar rupture with special reference to intrauterine pressure measurement a retrospective analysis of labour records of those women who had trial of labour with a previous Caesarean scar in the National University Hospital over a period of 6 years (1985-1990) was carried out. Known symptoms and signs associated with scar rupture, cardiotocographic tracings and fetal and maternal outcome in these patients were studied. Of the 1,018 women with previous Caesarean scar (4.2% of our pregnant population at term) 722 (70.9%) had trial of labour; 70% delivered vaginally. There were 4 (0.55%) incomplete and 5 (0.69%) complete scar ruptures. All 9 women had an oxytocin infusion; 3 were diagnosed postdelivery (all 3 had complete ruptures); 3 of the 6 who had rupture prior to delivery had sudden reduction in uterine activity, 1 had scar pain and prolonged bradycardia and 2 had no symptoms or signs. Continuous cardiotocography with intrauterine pressure measurements may help to identify scar rupture early and may be of value especially in those who have an oxytocin infusion.

Second, Beckley(1991) whose abstract doesn’t give us much information:

A series of 12 trials of scar associated with scar rupture is reviewed. Uterine activity patterns were assessable in 10 of them. Clinical features and characteristics of the intrauterine pressure waveform and uterine activity are discussed in relation to the integrity of the scar.

The third study RCOG cited was Rodriguez (1989) which ACOG also cited and I previously shared.

Fourth, Madanes (1982) whose abstract also is lacking any conclusions or major findings:

A case of uterine perforation by an intrauterine pressure catheter is described. Five similar cases from the literature are reviewed. A revision of the pressure catheter insertion technique is discussed.

Do IUPCs pose any risks to the baby?

I was very disappointed in the overall lack of published research on IUPCs in VBACs. I was further disappointed that there was very little discussion on the specific risks of IUPCs to mom or baby and at what rate these complications occur. I found Wilmink (2008) which discusses the IUPC related complications in two labors resulting in one infant death:

CASES: We describe the placement of an IUPC during induction of labor with oxytocin in two cases, one presenting with a singleton pregnancy and the other a twin pregnancy. After introduction of the IUPC, both cases were complicated by blood loss and signs of fetal distress on cardiotocography. An emergency cesarean section was performed in both cases. In the first case, extramembranous placement of the IUPC was observed, whereas in the second case, the IUPC had lacerated an arteriovenous anastomosis in the membranes, resulting in perinatal [infant] death. CONCLUSION: Placement of an intrauterine pressure catheter instead of external tocodynamometry has a small risk for serious fetal complications.

It would be helpful to have a large scale study on IUPCs conducted so we know how frequently complications like this occur.  It’s very difficult to weigh the pros and cons of IUPCs if we don’t fully understand the risks that they pose.  Is it worth mandating the use of IUPCs in VBAC labors if it means that the misplacement of the IUPC could sever the blood, and thus oxygen, supply to baby?

If your care provider requires IUPCs, what questions should you ask?

I posted on my Facebook page requesting the opinion of various midwives and OB/GYNs I know on the use of IUPCs in VBAC labors. Barbara Herrera provided this excellent list of questions:

  1. How will you know if there is a UR [uterine rupture]? What signs are you looking for?
  2. What is the process you go through to know it is a UR and not the IUPC misplacement or falling out?
  3. Who puts the IUPC in? The RN? Or you (the doc)? Who has more experience putting it in?
  4. How do we assure its proper placement?
  5. Will I be able to move about the bed and beside the bed once the IUPC is placed?
  6. If the IUPC registers something is amiss, as long as the FHR [fetal heart rate] is still okay, can I trust those around me not to freak out until we know if it is dislodged or misplaced? (Most women are much more able to move around with the IUPC than the external monitors.)
  7. Will using the IUPC mean I am going to have pitocin augmentation at some point?

The take away message

In light of the fact that

  • ACOG and RCOG do not recommend the use of IUPCs in VBACs as
  • IUPCs have not been proven effective in predicting uterine rupture and as
  • IUPCs can pose risks to babies (including blood loss and signs of fetal distress resulting in emergency cesareans and infant death) at a rate that we do not yet know while
  • requiring the (premature) breaking of fetal membranes (“breaking your water”),
  • increasing the risk of infection, and
  • possibly restricting mom to bed for her labor,

I can’t imagine why any hospital or OB would require their use.*

Elizabeth Allemann, MD left this comment on my Facebook page which I think summed up the issue well:

If a woman has decided to labor and birth with a uterine scar, she’s made her decision. If she wants to be successful, she’ll need what every woman needs to give birth: privacy, love, good nutrition, time, patience, touch, and care by a team that trusts her to give birth. And she’ll need that even more because she’s been scarred–in her heart and soul, not just on her uterus. And we need things to come down and out. An IUPC isn’t going to give her any of that. It’s a sad state of affairs when we can’t provide any of that in the hospital (generally) for any women and we end up forcing women to birth at home, just to get a chance to birth at all. Not that there’s anything wrong with home birth, but if a woman wants to give birth in the hospital, we should be able to provide that for her without a Niagara Falls of interventions waiting to pounce on her.

_____________________________________

* I had a conversation with a friend who teaches Bradley childbirth classes recently. She said that OBs/hospitals use IUPCs because then they can show that they “did everything” to protect the mom from uterine rupture and in the event that a UR did occur and they were taken to court, they could bring that information with them. But I responded with the fact that IUPCs have not been proven effective in predicting UR and ACOG/RCOG don’t recommend their use, so I don’t believe that would be a strong enough argument hold up in court.  I’m not an attorney, so I could be completely wrong, but that is what makes sense to my non-legal mind.

_____________________________________

American College of Obstetricians and Gynecologists (ACOG). Vaginal birth after previous cesarean delivery. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2010 Aug. 14 p. (ACOG practice bulletin; no. 115).

Arulkumaran S, Chua S, Ratnam SS. Symptoms and signs with scar rupture: value of uterine activity measurements. Aust N Z J Obstet Gynaecol 1992;32:208–12.

Beckley S, Gee H, Newton JR. Scar rupture in labour after previous lower uterine segment caesarean section: the role of uterine activity measurement. Br J Obstet Gynaecol 1991;98: 265–9.

Devoe LD, Croom CS, Youssef AA, Murray C. The prediction of “controlled” uterine rupture by the use of intrauterine pressure catheters. Obstet Gynecol 1992; 80:626-9. (Level II-2)

Lucidi RS, Chez RA, Creasy RK. The clinical use of intrauterine pressure catheters. J Matern Fetal Med. 2001 Dec;10(6):420-2. Review. PubMed PMID: 11798454.

Madanes AE, David D, Cetrulo C. Major complications associated with intrauterine pressure monitoring. Obstet Gynecol 1982;59: 389–91.

National Guideline Clearinghouse (NGC). Guideline synthesis: Vaginal birth after cesarean (VBAC). In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): 2011 Jan. [cited YYYY Mon DD]. Available: http://www.guideline.gov.

Royal College of Obstetricians and Gynaecologists (RCOG). Birth after previous caesarean birth. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2007 Feb. 17 p. (Green-top guideline; no. 45).

Rodriguez MH, Masaki DI, Phelan JP, Diaz FG. Uterine rupture: are intrauterine pressure catheters useful in the diagnosis? Am J Obstet Gynecol 1989; 161:666-9. (Level III)

Wilmink FA, Wilms FF, Heydanus R, Mol BW, Papatsonis DN. Fetal complications after placement of an intrauterine pressure catheter: a report of two cases and review of the literature. J Matern Fetal Neonatal Med. 2008 Dec;21(12):880-3.

Contra Costa Regional Medical Center Supports VBAC & Wins Award

Below I’ve included an article from MartinezPatch and I highlighted some sections.  This hospital boasts a 90% VBAC success rate.  That is huge!

As I shared in A father asks “Why invite the risk of VBAC?:

I had the opportunity to attend the March 2010 National Institutes of Health VBAC Conference where the ability of rural hospitals to safely attend VBACs was extensively discussed. 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.) Read more about the policies that this hospital implemented: VBAC Ban Rationale is Irrational.

It just goes to show that if a hospital is willing to make the effort, they can offer VBAC safely and with “no long-term complications among patients who attempt a VBAC birth or to their babies.”  Kudos Contra Costa!

Contra Costa Regional Medical Center Wins Award for Perinatal Program

County hospital receives top honors for its program to reduce repeat cesarean sections.

December 20, 2011

Contra Costa Regional Medical Center (CCRMC) in Martinez has been honored for its perinatal program that helps more women who have had a cesarean delivery avoid the surgery with their next pregnancy.

CCRMC received the award earlier this month from the California Association of Public Hospitals and Health Systems and its quality improvement affiliate, the California Health Care Safety Net Institute. The award is given to a public hospital program that best represents an innovative approach to improving health care.

Historically, most medical providers advised women who have had a C-section not to attempt a non-surgical delivery because of the slight risk of a tear in the uterine wall during labor that can be dangerous to the mother and baby. However, in recent years established medical science has recognized that a vaginal birth after a cesarean (VBAC) is possible and preferable whenever it can be achieved safely, according to Judith Bliss, MD, chair of CCRMC’s Obstetrics and Gynecology Department.

“A non-surgical delivery carries less risk to mom and baby and allows them to bond more quickly.  The key is being able to offer this option to women who’ve had a cesarean while ensuring the safest outcome possible,” Dr. Bliss said. “It’s a great joy to be able to offer many women this choice when they thought the option didn’t exist.”

The 166-bed county hospital is part of Contra Costa Health Services and about 15 percent of all babies born in Contra Costa County are delivered there. CCRMC’s perinatal unit was able to provide previous C-section patients with the VBAC option by developing a specific set of interventions, known as a “bundle,” to ensure staff could respond quickly to any complications that might occur during labor or delivery. The interventions include the ability to perform an emergency C-section, which should be started immediately in the unlikely event that a uterine rupture should occur.

Since initiating the program in October 2009, CCRMC has had significant success in reducing the percentage of repeat C-sections among eligible patients. This year, the average vaginal delivery rate for VBAC patients at CCRMC has averaged close to 90 percent through September; the national success rate for VBAC births ranges from 60 – 80 percent.   CCRMC’s success rate has been attained with no long-term complications among patients who attempt a VBAC birth or to their babies, noted Dr. Bliss, who heads the team for the VBAC project.

CCRMC developed the VBAC program in close collaboration with the Institute for Healthcare Improvement, a not-for-profit organization based in Cambridge, Massachusetts that works with health care providers and leaders throughout the world to achieve safe and effective health care.  “At a time when many providers have shied away from offering women the VBAC option because of the challenges involved, it’s very gratifying to see this hospital make such a strong commitment to doing what it takes to give patients this opportunity,” said Peter Cherouny, MD, chair of the Perinatal Improvement Community with IHI. “They’re clearly putting their patients first and doing what’s best for both mother and child.”

“We know that there are times that we have no choice but to perform a C-section,” Dr. Bliss said. “But today women have the option of having a non-surgical delivery knowing every step has been taken to assure their safety and their baby’s. To see mom and newborn together right after the birth – skin-to-skin, breastfeeding, with their families nearby – lets us know that our efforts and our vigilance are paying off.

Go here to see a video about CCRMC’s award-winning “Vaginal Birth after Cesarean (VBAC) Improvement Project.”

Finding VBAC statistics for your hospital and state

Update 3/25/16: Another excellent resource for California residents is California Quality Care.

Update 4/11/12: Since I wrote this article, the brilliant Jill Arnold from the Unnecesarean started a new website where she shares cesarean rates by hospital: CesareanRates.com.  I would recommend checking this resource first before trying out the strategies I describe below.

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Jeri left this comment at 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

Response to OB: Scare tactics vs. informed consent aka why I started this website

I receive this comment on the post Hospital VBAC turned CS due to constant scare tactics:

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.]

Slide 103

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 imagemacrosomia 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

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

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

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

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

Don’t hospitals ban VBAC because it is dangerous?

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

What role does malpractice insurance play in VBAC availability?

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

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

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

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

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

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

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

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

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

How do VBAC bans impact hospital revenues?

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

How do VBAC bans impact women seeking VBAC?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

June 19, 2009   10:04 AM EDT