Midwife Outlines Why VBAC Bans Don’t Serve Parents

by | Apr 12, 2008 | Hospital birth, Resources for unsupportive family members, VBAC Bans | 0 comments

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 at lisa.allee@ihs.gov.

Resources Cited

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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Jen Kamel

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 hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. 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 a board member for the California Association of Midwives.

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