A Rural Hospital Defends its VBAC Ban
I love reading why hospitals ban VBAC. There are opportunities to learn about how that particular hospital operates, specific insurance issues they face, internal politics, and personal philosophies. And it’s always interesting to see things from the OBs perspective.
It’s very telling that when they offered VBAC, only 2 women per year opted for VBAC after being “counseled by a physician.” Most women who have been “counseled by a physician” on VBAC vs repeat CS can tell you how that conversation goes. It typically leaves the woman with the impression that VBACs are dangerous and repeat cesareans are not. Women are lead to believe that if you VBAC, you are putting yourself and your baby at risk, and if you have a repeat cesarean, you and your baby will be fine.
Since their VBAC ban, they “recommend a repeat cesarean delivery and tell patients of our policy. We occasionally have a patient that refuses a recommended c/s (breech, previous c/s, macrosomia, history of shoulder dystocia with permanent injury) and we have them sign a consent form and take care of her very well. This is all well within the standard of care.” I wonder how much that “occasional” patient must fight in order to have a VBAC. If it’s like most hospitals, very hard.
“On a similar topic, we don’t offer women elective primary cesarean delivery even if the patient should decide this is her preferred method of delivery. In this case, we do refuse to allow women to give birth the way they choose.” I would hope that if I came in and asked them to remove one of my lungs, without any medical reason, they should deny me as well. Should they be congratulated for not performing major abdominal surgery without a valid medical reason?
“None of the physicians in our department are concerned with our cesarean delivery rate. One quote I heard is, ‘My cesarean delivery rate is 100% for everyone who needs a cesarean delivery.'” And everyone who has had a prior cesarean “needs” another one, right?
Gahn, David, M.D.. “Vaginal birth after cesarean (VBAC) in rural hospitals.” CCC Corner 5.11 (December 2007)
Vaginal birth after cesarean (VBAC) in rural hospitals
Counterpoint: David Gahn, M.D.
At Hastings Indian Medical Center, the Ob/Gyn Department decided to stop offering VBAC’s routinely. None of the physicians or midwives is “anti-TOLAC/VBAC” but we considered several factors:
1) Our anesthesia department refuses to participate in a management plan to facilitate VBAC despite any data we may present. If we request them to be in house during a VBAC, they will refuse. Then I have to document in the chart that I requested anesthesia and they would not come in. That is a terrible way to do business. Our anesthesia department does provide excellent care to our laboring patients and are pros at emergent cesarean deliveries. They are skilled professionals, but the department is not staffed well enough to provide a CRNA or anesthesiologist dedicated solely to L&D.
2) Even though our Med Staff Rules and Regulations require on call personnel to able to present themselves within 20 minutes, this is not reliable. Also, we have only one OR crew and only one anesthesia person available in the evening. We have a protocol for an emergency c/s when the OR crew is already operating, but nothing is workable to do a cesarean hysterectomy with no anesthesia or OR crew. If you have ever done an emergent c/s under local with a CNM and an L&D nurse, you will appreciate this.
3) We also considered the local standard of practice. The one insurance company that covers physicians in the entire state of Oklahoma will not cover a physician who performs TOLAC/VBAC’s. Therefore, there are no physicians other than federally employed physicians and Oklahoma University in Oklahoma City 3 hours away (they are self-insured) who will allow TOLAC. While this doesn’t apply to the Federal Tort Claims Act, it does apply to the physician tort database, our licensing authorities, the physician’s reputation, and the hospitals reputation. (Tort claims are printed in our local newspaper.)
4) In order for us to offer TOLAC, all 6 of our Ob/Gyn’s need to be on board with the plan and they are not, mainly because anesthesia is not in house. There is data that supports VBAC without anesthesia present in the hospital, but you don’t know our anesthesia department or how busy we are in the evenings.
5) Unfortunately, the national data on c/s rates is usually 2-3 years behind, and our hospital has matched those rates. We deliver about 975 babies per year, and our c/s rate to date for CY 2007 is 37%. Should we be ashamed of the number or proud of the good outcomes? The balance between risks and benefits in this regard in tenuous.
6) 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. I disagree with the argument that our rate is what it is because we take care of higher risk patients. I don’t think that is a reason. We do have a high teen pregnancy rate, diabetes, massive obesity, hypertension, etc., but we haven’t studied it that closely. We would love to decrease the c/s rate, but obstetrics is a treacherous business and each physician is held responsible for the health of patients, mom and baby. We have to face reality – if a patient does not have a perfect baby, the physician will suffer a tort claim. (And I do mean suffer.)
7) We can’t and don’t force women to have repeat cesarean deliveries, for that would be assault. We do recommend a repeat cesarean delivery and tell patients of our policy. We occasionally have a patient that refuses a recommended c/s (breech, previous c/s, macrosomia, history of shoulder dystocia with permanent injury) and we have them sign a consent form and take care of her very well. This is all well within the standard of care.
On a similar topic, we don’t offer women elective primary cesarean delivery even if the patient should decide this is her preferred method of delivery. In this case, we do refuse to allow women to give birth the way they choose.
8) When we did offer TOLAC, we had about 2 per year. We take this to mean that the others, after being counseled by a physician, opted for repeat c/s. Considering this, our c/s rate would not appreciably change if we offered VBACs.
9) Please don’t condemn us for a policy that does not recommend VBAC’s. Recognize that the data and ACOG support both options, and also recognize that the data has to be applied to the hospital. Because of the number of deliveries we perform, we have reliable data on post-operative infections (half the national average), TTN, transfusions, IUFD’s, etc. Also know that we have excellent collaboration between our 6 physicians, 7 midwives, and 1 nurse practitioner. We don’t make policies like this lightly and we examine the data carefully and applied it to our current practice.
So the bottom line is we might be more aggressive with TOLAC/VBACs if we had additional support. None of the physicians in our department are concerned with our cesarean delivery rate. One quote I heard is, “My cesarean delivery rate is 100% for everyone who needs a cesarean delivery.” While this a bit crass, it is germane – the decision to perform a c/s rests solely with the physician charged with the care of the patient and the patient. I would love for our cesarean delivery rate to be 15%, but not at the expensive of a single injured child or mother. I fully support TOLAC in the right environment. That environment does not exist at Hastings Indian Medical Center. David.Gahn@ihs.gov
What do you think?
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Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at a hospital, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. Even more have accessed her trainings online. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is the Secretary for the California Association of Midwives and the California Association of Licensed Midwives. Her favorite flavor of ice cream is peanut butter chocolate. And mint chip. And coffee.