Category Archives: OBs and midwives who support VBAC

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.

Ask Questions 3d button

Want a VBAC? Ask your care provider these questions.

While there are care providers who may mislead you about your risks, benefits, and options, this article is written assuming that you are meeting with an ethical care provider who supports the option of VBAC.  Read more on how to find a providers like this.

Ask Questions 3d buttonIf you are a good candidate for VBAC, the single most important decision you can make that will have the greatest impact on your chances of VBAC success is who you hire to attend your birth.   This is why it’s important to interview several care providers and ask specific questions.

You will often receive different information when speaking to the doctor or midwife directly than you would from the people who answer their phones.  When calling their office, be sure to state that you want to have a consultation.  Ideally, you want to meet in an office, not in an exam room.

How to present yourself

Go to your consultations like you would a job interview.  You are not hanging out with your girlfriends.  You want the care provider to perceive you as an intelligent, thorough, and reasonable woman who has done her homework, collected all the info, and would really appreciate the opportunity to VBAC/VBAMC.  Trust is fundamental here and flows both ways. If you can make a human connection with the care provider, then all the better.  Humor is an excellent way to do this.

  • Wear your most professional looking clothes.
  • Get a babysitter for your younger kids if possible so you are not distracted.
  • Bring your medical records and operative reports from your prior cesarean(s).
  • Read, be familiar with, and bring a copy of the 2010 ACOG VBAC guidelines.
  • Google the care provider, their practice, and the hospital/birth center and note any special awards or recognition they have received.  Bring this up in a complimentary way during your appointment.

Remember, a lot of care providers are concerned about being sued, so they are sizing you up as much as you are them. They want to know that you understand the risks and benefits of your options and that you have realistic expectations.  Be sure that you don’t repeat birth myths while speaking to them as that will reflect poorly on you.

Once you connect with them on a human level, and they see that you are an educated, rationale, and reasonable woman, then you can determine how willing they are to negotiate on some of their terms (if necessary.)  For example, if they require moms to stay in bed during the entire labor, ask if their hospital offers telemetry units (wireless fetal monitoring).  Some hospitals even have them in a tube top so they don’t move around as much and are less noticeable to moms.

It’s very important to not come across as angry or argumentative, because that decreases the likelihood that they will attend you.  Express your frustration, anger, and pain with support groups online.

The three types of care providers

There are three types of care providers: those that are VBAC supportive, those that are not, and those that pretend to be until the last minute.   When an care provider says that they are VBAC supportive, but every single one of their clients got risked out for VBAC, ask yourself what is more likely: For every single one of their patients to develop a medical condition that ruled out VBAC or that they really weren’t supportive in the first place? This is why it’s a huge red flag if your care provider says, “We can wait later/ until your third trimester/ 36 weeks to talk about that.”  Your care provider should be comfortable discussing their VBAC philosophy with you now.  You deserve to know if they are genuinely supportive or not so that you can hire another care provider who is more in-line with your goals if needed.  You don’t want to be in a position where you are 36 weeks and your care provider says, “Let’s schedule a cesarean at 40 weeks just in case.”  You can switch providers late in pregnancy, but it can prove difficult.  Keep in mind that you may have better luck getting names when speaking to someone face to face.  Sometimes, people don’t want to give out names to someone they don’t know over the internet.

To give you an idea of how some non-VBAC supportive care providers talk, and what you should look out for, please read:  Another VBAC Consult Misinforms, Scare tactics vs. informed consent, and Hospital VBAC turned CS due to constant scare tactics.

If your husband/partner wants more information, direct him to: A father says, Why invite the risk of VBAC?

Top 18 Questions

Here is a list of questions that are relevant to all birthing women, VBAC or not. What I’ve added is my commentary on how I think their answer reflects how supportive they really are of VBAC.

I think the most important questions relate to going overdue and suspecting a big baby.  Many women have been risked out of VBAC as a result of these two variables, so I will address those two questions first.  Then I will list the rest of the questions in the order of their importance from my perspective.

What is their philosophy on going past 40 weeks? ACOG’s latest VBAC Guidelines, Practice Bulletin No. 115, (which from here on out I will refer to as “PB115”) states that going overdue should not prevent a woman from planning a VBAC.

What is their philosophy on “big babies?” PB115 states that suspecting a big baby should not prevent a woman from planning a VBAC.  Further, ACOG Practice Bulletin No. 22, which appeared in the November 2000 issue of Obstetrics and Gynecology, found no value in inducing for “big baby” since it simply doubles the CS rate and does not prevent shoulder dystocia or reduce newborn morbidity.  Nor do they support cesarean section for suspected “big babies:”

While the risk of birth trauma with vaginal delivery is higher with increased birth weight, cesarean delivery reduces, but does not eliminate, this risk. In addition, randomized clinical trial results have not shown the clinical effectiveness of prophylactic cesarean delivery when any specific estimated fetal weight is unknown. Results from large cohort and case-control studies reveal that it is safe to allow a trial of labor for estimated fetal weight of more than 4,000 g. Nonetheless, the results of these reports, along with published cost-effectiveness data, do not support prophylactic cesarean delivery for suspected fetal macrosomia with estimated weights of less than 5,000 g (11 lb), although some authors agree that cesarean delivery in these situations should be considered.

How many VBACs have they attended? Word spreads fast on pro-VBAC OBs.

Of the last 10 women seeking VBAC from them, how many had a VBAC? If it’s less than 7 or 8, I would ask what happened in those 2-3 labors that ended in a cesarean.  This would give you a great idea of how they manage labors.

Do they attend VBACs with an unknown or low vertical scar? PB115 states that an unknown or low vertical scar should not prevent a woman from planning a VBAC.

Do they have any standard VBAC protocols that differ from a non-VBAC mom? If so, ask what they are.  Compromises almost always have to be made in order to birth in a hospital.  If your care provider requires an intrauterine pressure catheter, you can read more about those here.

Under what circumstances would they induce a VBAC?  It is a myth that a VBAC mom should never be induced.  Inducing a VBAC mom increases the risk of uterine rupture which should be weighted against the reason for the induction.  “Big baby” (less than 11lbs) and “over due” (meaning you are 40 weeks, 1 day) are not legitimate, medical reasons per ACOG.

However, if a medical reason for induction is present, women should be given that option rather than required to have another cesarean.  As a Southern California OB, recently shared on my FB 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.

If I was overdue and my care provider was concerned about the baby, I personally would request a biophysical profile to check on baby and as long as baby and I are fine, I would request to wait for labor to start instead of inducing or scheduling a repeat cesarean.

However, if my provider was unwilling to wait for spontaneous labor, or if there was a medical reason for the baby to born, and it was the difference between a VBAC and a repeat cesarean, and I had a favorable Bishop’s score (download the app), I would consent to a Foley catheter or low-dose Pitocin induction (not Cytotec or Cervidil).  If I was induced with Pitocin, I would be comfortable with continuous external fetal monitoring.  My personal preference would be to have telemetry (the wireless monitors) because I need to move during labor.

What methods do they use? PB115 states “Misoprostol [Cytotec] should not be used for third trimester cervical ripening or labor induction in patients who have had a cesarean delivery or major uterine surgery.”

PB115 also said, “Induction of labor for maternal or fetal indications remains an option in women undergoing TOLAC [trial of labor after cesarean.]”

Landon (2004) reviews how uterine rupture rates vary by drug: 1.4% (N = 13) with any prostaglandins [such as Cytotec or Cervidil] (with or without oxytocin), 0% with prostaglandins alone, 0.9% (n = 15) with no prostaglandins (includes mechanical dilation with or without oxytocin), and 1.1% (N = 20) with oxytocin alone.  Women who were not induced or augmented had a rupture rate of 0.4%.  Overall, they found 0.7% of women experienced a true uterine rupture with an additional 0.7% experiencing a dehiscence.

Do they attend vaginal breech births? 3% of babies are breech at term, so it’s good to know what would happen if you were in that 3%.  Some hospitals do support vaginal breech birth.

Do they attend vaginal twin VBACs? PB115 states that suspecting twins should not prevent a woman from planning a VBAC.  Read stores of twin/multiples VBAC births.

How many uterine ruptures have they witnessed? This can be an indicator of their induction rates or simply how many VBACs they have attended.  It’s a numbers game.  The more births you attend, the more complications you see.

What kind of monitoring do they require? PB115 states, “Most authorities recommend continuous electronic fetal monitoring.  No data suggest that intrauterine pressure catheters or fetal scalp electrodes are superior to external forms of monitoring…”

CIMS asserts in Mother-Friendly Childbirth: Highlights of the Evidence,

Routine continuous electronic fetal monitoring (EFM), compared with intermittent auscultation, increased the likelihood of instrumental vaginal delivery and cesarean section and failed to reduce rates of low Apgar scores, stillbirth and newborn death rates, admissions to special care nursery, or the incidence of cerebral palsy.

In June 2009, ACOG released new heart rate monitoring guidelines where they affirmed,

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

What is their CS rate? This seemingly simple statistic is actually quite complicated. If they are a perinatologist who specializes in high risk births, then a higher CS rate would make sense.

As the 2009 edition of the World Health Organization’s “Monitoring Emergency Obstetric Care: A Handbook” states,

Both very low and very high rates of caesarean section can be dangerous, but the optimum rate is unknown. Pending further research, users of this handbook might want to continue to use a range of 5–15% or set their own standards…. Earlier editions of this handbook set a minimum (5%) and a maximum (15%) acceptable level for caesarean section. Although WHO has recommended since 1985 that the rate not exceed 10–15% (125), there is no empirical evidence for an optimum percentage or range of percentages, despite a growing body of research that shows a negative effect of high rates (126-128). It should be noted that the proposed upper limit of 15% is not a target to be achieved but rather a threshold not to be exceeded. Nevertheless, the rates in most developed countries and in many urban areas of lesser-developed countries are above that threshold. Ultimately, what matters most is that all women who need caesarean sections actually receive them.

Do they perform an automatic CS if waters have been broken for more than 24 hours, even if there is no evidence of infection and mom and baby are fine? If they say yes, this could be a red flag.

Do they have a time-limit on how long your labor can be before they c-section you? Generally, as long as mom and baby are fine, labor should be permitted to continue.

Do they require epidurals for VBAC? PB115 states that pain medication “for labor may be used as part of TOLAC, and adequate pain relief may encourage more women to choose TOLAC.”  One reason that some OBs require epidurals is because if they deem a cesarean necessary, you are already numb.

Do they require an IV or heplock? IVs can restrict your movement. A heplock means they put a line in your arm, but it isn’t connected to a bag.  Heplocks & IVs can be annoying and get you into the “patient” rather than “healthy, birthing mom” mindset.

Are you permitted to move and deliver in your position of choice? Laying on your back or the “on the edge of the bed with your knees by your ears” are great for their viewing, but may not be the most effective positions for you. It’s always nice to have options other than the standard birthing position, such as those demonstrated in this chart or using items like a birth/squat bar or a birth stool (which has the same concept as the bar, but you can sit) for delivery.

Additional questions for out-of-hospital providers

I’ve collected the follow questions over the years as I saw various discussions of questions to ask an out of hospital provider.  Not all of the issues raised here are relevant to every woman, but I include them all so you can pick and choose which ones speak to you. Since OOH providers are often women and midwives, those are the terms I will use.

Her background

  • How many births has she attended?
  • How many years has she been attending births?
  • Number of births attended as primary midwife vs. doula vs. assistant?
  • What is her training?  DEM, CPM, CNM?
  • What equipment does she bring to each birth?
  • How often does she use it?
  • What is her post-partum hemorrhage protocol? Does she carry Pitocin or Methergine?
  • What is her position on ultrasounds?
    • Does she recommend them for HBAC/HBAMC?
    • How many weeks gestation?
    • Where would you have this done?
    • How does payment work?
  • Would she attend you at home as a monitrice and then transfer to hospital as a doula?

Other birth professionals

  • Does she recommend/offer concurrent care with an OB?
  • Is she required to have OB sign-off for HBAC?
  • When and how often would you meet them?
  • Does she have partners or is she a sole practitioner? What is their training/ experience?
  • Does she have assistants? What is their training/ experience?
  • How many midwives and assistants will attend your birth?
  • How many births does she attend per month?
  • How often does she miss births?  Reasons?
  • Does she have a backup midwife? What is their training/ experience?
  • Does she recommend a doula?
  • Which doulas does she work with most often?

Licensing & payment

  • Does her state offer/require licensure?
  • Is she licensed?  Why/why not?
  • Can she legally attend HBAC?
  • How would you get a birth certificate?
  • Does she carry liability/ malpractice insurance?
  • What insurance reimbursement should you expect?
  • What is her fee?  Does she offer payment plan?  What is the payment schedule?

Transport

  • What is her transport rate?
  • What’s her transfer protocol?
  • Does protocol differ for emergent v non-emergent transfer? Different hospitals?
  • What is the transport time by car and ambulance?
  • What are the most common reasons for transfer in her practice?
  • Has she experienced a cord prolapse, shoulder dystocia, placental abruption, or accreta?
  • Will/can she stay with you upon transfer?
  • Has CPS been called on past clients?
  • Does she have familiarity with the local hospitals?
  • Does she have a hospital contact that she can call in the event of an emergency transfer?
  • Do you have any particular concerns/issues from prior births?  How would she handle them?

You might have to interview several providers until you find one who is truly supportive of VBAC. If you do find such a provider, refer all your friends, VBAC or not, to this provider so that they can reap the benefit of someone who supports non-interventive birth! I really think that true change won’t occur in the medical community in terms of supporting natural non-interventive birth and VBAC until the OBs and hospitals see their revenue decrease. For this reason, we all need to support OBs, midwives, and hospitals that support VBAC.

Last updated October 11, 2013

The Three Types of Care Providers Amongst OBs and Midwives

Care providers, OBs and midwives, can be broken down into three categories:

1. The ones who tell you outright they don’t to VBACs.  While this is annoying, it is more honorable than the second type of care provider because at least they don’t…

2a. … tell you they are supportive, but then put so many qualifications on their support that it’s almost impossible to have a successful VBAC with them.  I call this a “circus act VBAC.”  They want you to think that if you just jump through all these hoops, you will VBAC.  But what you don’t know as a typical pregnant woman who trusts her OB is, it’s almost impossible to meet the standard they require and, one way or another, you end up with a another surgery.

  • if your baby is less than X pounds
  • if you consent to an IV
  • if you consent to an epidural
  • if you consent to continuous external, or internal, fetal monitoring
  • if you stay in bed the whole time
  • if you come to the hospital as soon as labor begins
  • if you have the baby within X hours of labor starting
  • if you have the baby within X hours of your water breaking
  • if you agree to have a cesarean scheduled at X weeks “just in case” you don’t go into labor
  • if you agree to be induced at X weeks
  • if you go into labor by X weeks and if you don’t, you agree to have another cesarean or be induced
  • it goes on, and on, and on…

2b. Or they tell you that they are supportive, but as your due date gets closer, they start focusing more and more on the risks of VBAC.  Of course, they minimize, or don’t even mention, the risks of having a repeat cesarean.  It eventually becomes clear to you that they will find some excuse either during your labor, or before labor begins, to give you a cesarean.  At which point, how can you trust their medical opinion?  But, they have strung you along for so long – usually this starts in the last couple months of your pregnancy – that you feel stuck and you think that it’s to late to find another provider.  Sometimes it is, and sometimes it isn’t.  It never hurts to check out other providers, regardless of how far along you are.  When you have a provider like this, what do you have to lose?

3.  The smallest group of care providers out there are the ones who are truly supportive of VBAC.  You can find care providers by going here and interview them using the questions here.

A Midwife Responds to the Hastings Indian Medical Center VBAC Ban

A couple days ago, I posted the statement dated December 2007 from Hastings Indian Medical Center explaining why they no longer offer VBAC.

A midwife responded in the February 2008 edition of the same publication. Below find my favorite sections and below that is her entire piece.

Lisa Allee, CNM sums up ACOG and hospital VBAC policies so beautifully,

The change from pro-VBAC thinking to pro-repeat cesarean delivery occurred when ACOG came out with a recommendation (not a requirement) that physicians (doesn’t specify anesthesia) should be immediately available (no definition supplied).

Dr. Gahn, the author of Hastings’ statement, defended its cesarean rate of 37%,

I propose that every time a healthy mom walks out of the hospital with a healthy baby, we have succeeded in our mission.  Is our cesarean delivery rate too high?  Until I see the definition of “too high”, I’ll argue with you.

Ms. Allee suggests,

As a department, or even better as an interdisciplinary team or service unit, review the World Health Organization and USPHS Healthy People 2010 recommendations for cesarean delivery rates. Both of these respected and esteemed organizations have clearly and repeatedly recommended cesarean delivery rates in the 10-15% range. This clearly answers the question about whether a cesarean delivery rate of 37%, which is more than double to triple these recommendations, is too high and gives a very good indication as to what is too high for a cesarean delivery rate.

She also specifies how a woman should be counseled on VBAC vs. repeat CS,

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.

Finally, she says something that is so obvious, yet, remains a foreign concept in obstetrics.  This is what every pregnant woman dreams of hearing from her provider,

Most importantly we need to respect the women we care for as the ones who are giving birth and realize that, therefore, it needs to be up to them where, how, and with whom they will do so. We are here to provide information and care—to serve not to dictate.

We need more care providers like Lisa Allee. 

Below is her entire response.  The emphasis below in the body of the article is mine.

 

Allee, Lisa, CNM. “Midwives Corner.” CCC Corner 6.2 (February 2008)

 

Midwives Corner – Lisa Allee, CNM

1.) AI / AN women are really successful at doing this
2.) The evidence supports this
3.) Women want and benefit from this

What is this win3 best practice process?
(a.k.a. win / win / win)

It is vaginal birth after cesarean
(We need to provide them)

The following is in response to the comments of Dr. David Gahn regarding VBACs at Hastings Indian Medical Center that appeared in this column in the December issue of the CCC Newsletter (see link below). This following is a conglomeration of my and other midwives’ responses.

First, here is some overall VBAC information to ponder.

We must all remind ourselves of recent history. The change from pro-VBAC thinking to pro-repeat cesarean delivery occurred when ACOG came out with a recommendation (not a requirement) that physicians (doesn’t specify anesthesia) should be immediately available (no definition supplied).

This recommendation was based on a poorly done study of discharge diagnosis codes that actually demonstrated the same statistics on uterine rupture as previous studies of VBAC, but the authors came to very different conclusions (Lyndon-Rochelle 2001) Unfortunately, much of this country went wildly swinging to the extreme end of the pendulum’s arc and stopped offering VBACs. Luckily, some kept their heads and a plethora of research has been published since which show VBAC to be a safe and reasonable option for the majority of women with a history of cesarean deliveries and many benefits to VBAC over repeat cesarean delivery.

(Please see the many citations that have been reviewed in December Obstetrics section of this publication – link below plus this month’s Abstract of the Month. More citations were supplied by Neil Murphy and Sheila Mahoney on the Indian Health Midwives listserv discussion related to VBACs.)

Among the places that have remained sane and continued to offer VBACs are many of us in the Indian Health Service ( Alaska Native Medical Center even got an award from the American College Nurse Midwifes) and a group in the Northeast, the Northern New England Perinatal Quality Improvement Network (NNEPQIN). (link below) The folks in the New England coalition have come out with useful guidelines on deciding about VBAC and providing quality care. Their work also helped us all face a bigger picture—how we handle emergency surgery in general and how we can improve. Their suggestions include improving teamwork, communications, and skills via drills. This has the potential to improve responses to emergency birth needs beyond the very few situations related to VBACs. Those of us in IHS who have continued VBACs have shown continued success with excellent statistics and outcomes (see 2007 Indian Health Data Tally Sheet below)

Overall, the pendulum is hopefully beginning to swing back towards a more rational approach to VBACs—there was even a quote from an ACOG official that suggested a possible move towards revising their “immediately available” statement (see August 2006 Midwives Corner below)

Second, let’s go over some of the specifics raised by Dr. Gahn. Since, according to Dr. Gahn, none of the physicians or midwives at Hastings are anti-VBAC, I thought I would use the responses from other midwives and myself to formulate some suggestions to help overcome the barriers to VBACs at Hastings which were elucidated by Dr. Gahn. These suggestions can also be used by the few other IHS sites that may be experiencing problems with offering VBAC services.

  • Have a journal club to present the overwhelming amount of evidence that supports providing VBAC services. Make sure to include the materials from the Northern New England Perinatal Quality Improvement Network and IHS VBAC statistics. Invite (coerce attendance, i.e., pizza or desserts, as needed) all members of the perinatal team including anesthesia and executive staff members who supervise the provider staff. This will help ensure that all involved have the information to begin providing evidence based care and should help to start the efforts to develop a functional interdisciplinary team. This should also help those obstetricians who “are not anti-TOLAC/VBAC”, but are not on board with the VBAC plan to start their process of getting on board.
  • Start doing drills for obstetrical emergencies. This will help to improve skills, as well as, teamwork and communication between anesthesia, surgery, midwifery, obstetrics, nursing—your second step in team building. This should help a number of issues. It should help to impress all on-call staff to do what is necessary to improve response time with the goal of your med-staff-rules-and-regulations-required 20 minutes becoming reliable. Maybe this will help folks come to the conclusion of having key personnel located close by—i.e. a call room or on campus housing. This would solve the problem of anesthesia not being available when a VBAC patient is laboring. When the larger picture of response to any emergent surgery is focused upon then the VBAC topic, which represents a very small proportion of the potential emergency surgeries, is automatically included.
  • As a department, or even better as an interdisciplinary team or service unit, review the World Health Organization and USPHS Healthy People 2010 recommendations for cesarean delivery rates. Both of these respected and esteemed organizations have clearly and repeatedly recommended cesarean delivery rates in the 10-15% range. This clearly answers the question about whether a cesarean delivery rate of 37%, which is more than double to triple these recommendations, is too high and gives a very good indication as to what is too high for a cesarean delivery rate.
  • 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.
  • 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.
  • Consider IHS as a model for the local standard of care. Since we are not controlled by insurance companies, we in IHS often have more opportunity then our colleagues outside IHS to provide care that is evidence-based. VBAC care is one of those situations and we can proudly stand up in the maternity care community as a model of excellent care.

Most importantly we need to respect the women we care for as the ones who are giving birth and realize that, therefore, it needs to be up to them where, how, and with whom they will do so. We are here to provide information and care—to serve not to dictate.

Please feel free to contact me for any questions or comments and for requests for links to the above mentioned resources atlisa.allee@ihs.gov.

Resources

Midwives Corner December 2007 CCCC

http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#MidWives

Indian Health Maternity and Women’s Health Data Tally Sheet, 2007

http://www.ihs.gov/MedicalPrograms/MCH/F/documents/DataTally81107.doc

Lydon-Rochelle M, et al. Risk of uterine rupture during labor among women with a prior cesarean delivery. NEJM 2001; 345:3-8. (Level III)

http://www.ncbi.nlm.nih.gov/pubmed/11439945?dopt=Abstract

Obstetric Hot Topics December 2007 CCCC

http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_HT.cfm#ob

Northern New England Perinatal Quality Improvement Network

http://www.nnepqin.org/

Midwives Corner August 2006 CCCC

http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0806_Feat.cfm#MidWives

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Finding a VBAC Supportive OB or Midwife

There are a ton of resources to find a good, truly VBAC supportive, OB or midwife. If you know of any others, please leave a comment with the info!

Note that some of the groups are not explicitly about childbirth, however, there is a tremendous amount of overlap between say, those who homeschool and those who VBAC or have homebirths. Also, those who have unmedicated births, or VBAC, or homebirth, are more likely to breastfeed beyond the first year, which is called ‘extended breastfeeding,’ and go to La Leche League meetings. They are also more likely to seek out fellow crunchy moms at Holistic Moms groups or attachment parenting groups.

You might have never considered yourself ‘crunchy’ because you think that only hippies are crunchy, but rest assured, VBACs, homebirth, homeschooling, and extended breastfeeding are things that appeal to the super liberals, the super conservatives, and everyone in between. No matter where you are on the political spectrum, you will find someone just like you in these groups.

Also keep in mind that there are traveling midwives, so if there are no care providers in your area, this is an option. Check out the ICAN email support group for referrals.

Once you have found a provider, you are going to want to ask a ton of questions. Call and make an appointment to discuss VBAC. Don’t go in for an exam and try to have an intelligent conversation while sitting on an exam table with no underwear on wearing a thin paper gown. This is not a position of power. Remember, you are hiring someone to support you with your VBAC. Please interview at least as many vendors as you would to paint your house or install your air conditioning. This is a huge decision and you will be very happy if you take the extra time to screen your care provider.

I have a list of the questions I find particularly important because the one big thing you want to avoid is the old ‘bait and switch.’ This is when an OB or midwife essentially leads you on. They act all supportive of VBAC in the beginning, but as time goes on, they start to change. They want to do an ultrasound to make sure the baby isn’t ‘to big.’ They start to talk more and more about uterine rupture. They want to schedule that repeat cesarean at 39 or 40 weeks, just in case you don’t go into labor – even though I have yet to meet a woman who was pregnant forever. This happens all the time. All you have to do is join the ICAN email support group to find woman after woman after woman who experienced just this and end up racing around at 37 weeks trying to find a new provider – not an easy task. So grill that provider! Make sure that they are truly supportive and you do this, not by just using your GYN because you like them, but by searching, interviewing, and actively SELECTING your care provider. This is why finding someone through referral is an extra bonus. You can no only get info from the care provider, but since you know someone who has already labored with them, you can get detailed info on how they really act.

Since finding a care provider is one of the critical decisions in working towards a VBAC, I would recommend starting your search before you even become pregnant. That way, you don’t have the crazy emotions of pregnancy pumping through your bloodstream and you can be a little more rational. You also won’t feel like you are on a timetable or be fighting morning sickness and exhaustion. And won’t it feel nice to have all your ducks in a row so when that little plus sign appears, you feel excited and supported? But, if you are already pregnant and looking, it’s not to late. Take the time to find a provider, you won’t regret it!