Response to OB: Scare tactics vs. informed consent aka why I started this website
I received 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.
Uterine Rupture 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) 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.
[Note from me: I used the chart they provided here and combined it with uterine rupture & infant mortality/morbidity stats for use in the VBAC Class I teach.]Taken on their own individual merit, most of the above common urgencies and emergencies occur more frequently than 0.5 percent. Taken as an aggregate, the risks above far outweigh the risks of VBAC. Now seeing the above risks, if you feel you need to re-evaluate offering obstetric intrapartum care because the above risks, then please contact me as soon as possible.
Scare tactics are simply saying, “VBAC is dangerous” or “Is it worth your baby’s life?”
Informed consent is having a thoughtful thorough conversation where you ascertain if this is the first time the woman has heard about the risks of uterine rupture, or if she is an informed patient who is well aware of her risks, benefits, and options.
I do believe that coming back to the risks of VBAC again and again during a pregnancy conveys to the patient that you really think this is a considerable risk, and not one worth undertaking.
Lisa Allee, CNM, wrote this in response to a hospital that instituted a VBAC ban. The hospital said that their ban wouldn’t impact many since only 2 patients a year pursued a 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 feeling 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 pleased” when the patient expressed her desire to VBAC.
- OB began NST at 37 weeks. Patient lists no reason for this.
- OB does not put the process and significance of dilation into context. Patient seems to believe that no dilation at 37 weeks and no change till 40 weeks is a bad sign. Patient does not understand that dilation is not a hard sign of labor.
- OB tries to scare patient by telling her that her baby was big and it “could be a very hard delivery” for her. It is this scare tactic, and the subsequent recommendation for cesarean based on suspected macrosomia that convinces patient to schedule a cesarean. Baby ends up weighing 7lbs 2oz. ACOG does not recommend cesarean for suspected macrosomia unless the baby is 11lbs (ACOG’s Practice Bulletin No. 22 on Guidelines for Fetal Macrosomia published in the November 2000 issue of Obstetrics and Gynecology).
- OB makes a “threatening call” to patient upon her spontaneous labor and lies by saying that if patient doesn’t have the “C-sec at the decided time, [OB] was not going to be available for the entire week and that some random doctor from the hospital” would perform her surgery.
- OB gets caught in this lie when the nurse tells patient that OB “has asked to be informed about your progress [and] will continue to be there for you.”
- OB then has a colleague tell patient that “she was sure it was going to be a very tough delivery” because of “baby’s head was big” and would weigh “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.
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.