Dr Amy, I hear you speak of VBAC activists as if they are doctors in charge of informing clients of the risks they are potentially undertaking. What makes you think they have so much power? And that once a woman brings these issues up with her care provider she will not be given more accurate facts?

I am really surprised at how much weight you are giving to the VBAC activists and their websites. Do you have any evidence to suggest that lawsuits have risen in proportion to the number of VBAC activist blogs?

I can say that a 1% risk of death to mother or baby with a VBAC is incorrect. 1% uterine rupture rate is accurate, but in a tertiary center death or injury to the baby would be much lower than that, perhaps 1 in 1000. Death of the mother would also be extremely unlikely, certainly not 1%. Also, I don’t believe any physician could achieve a 0.00005% complication rate with cesarean, which would come to 1 complication in 200,000 cesareans. 2-3% minor complication rate (wound infection) with a 0.5-1% major complication rate (bladder injury, major hemorrhage, bowel injury, or major wound complication) is more realistic.

Many OBs recommend not attempting VBAC after two cesareans, as the uterine rupture rate is somewhat higher.

Sounds like you have a difficult decision. You need a OB you trust to help you with it. Good luck and thanks for reading the site!

I’ve had 2 c-sections. The second was because of the malpractice/insurance coverage issue and the first, I really think could have and should have been avoided. In the 2nd’s post-op notes it did say that my uterus was thin down low and could be cut with one swipe of the knife.

It’s been almost 4 years since that second c-section. There don’t appear to be any problems with the pregnancy or the baby. I’m 35. The only dr. I have found that would be willing to take me (after 2 c-sections)lives in a town about 2 hours away. He said he would want to induce 10 days early so I could be monitored the whole time, but agreed he would wait on induction if I would come stay in the town to be near the hospital. The hospital is big and I think has the highest level nicu possible. I think he’s a proponent of induction, as long as the cervix is ready and I think he also likes for the mother to be stationary during the last part of labor so that the baby can be monitored more accurately. He also wants me to go to the hospital as soon as I think I’m in labor so that I could be monitored the whole time.

I’d much prefer a vaginal birth to a c-section, but obviously the most important things are the safety of the baby and me. I’m very confused about the decision. I appreciate any of your comments and insight.

I was going full throttle for the vbac, but I met with another dr. today and he told me that a repeat c-section is much safer than a vbac in terms of death to the mother and death to the baby. Like 1% vbac v. .00005% c-section.

Thanks in advance!

In hospital we monitor before and after administration and then – a mom can labor just like at the birth center (using the jacuzzi, intermittent monitoring, etc). Knowing we can do all that at the birth center, our medical director approved it use in select candidates out of hospital (typically term PROM or post dates with reactive NSTs). We used it judiciously and would certainly first consider foley bulb, AROM if feasible, etc. Our medical director is not one of our back-up physicians. Anyway, that group has stated they do not support the use of miso out of hospital, and they won’t back us up on any transfers who have received it. So we pretty much have had to stop its use, which will increase our transport rate. In caring for our highly motivated to stay out of hospital, no/low liability families, this is a tool we will miss.

To address a few of your points:

>>> By the way, isn’t the risk of fetal loss due to amniocentesis about equal to about 1 percent?

No not nearly that high. We used to quote a 1/300 risk for genetic amnio, but that was based on old pre-ultrasound data. Newer data derived from the randomized FASTER trial showed a much smaller risk than that, though can’t quote it right now (primary author Mary D’Alton – you can look it up). The concern is preterm rupture of membranes, which has decreased a lot by the routine use of ultrasound and modern amnio needles. I’ve only seen one membrane leak after an amnio in my career (10 years) and it sealed over.

>> But please be aware and respectful of how deep that lies for a lot of women.
I appreciate the comment, but I hope to find out what each individual patient values and not act on what I think “a lot of women” value. A person can only speak for themselves. I think sometimes the midwife and homebirth community feels the right to speak for “all women” or “most women” that is unjustified. When a patient puts a very high value on vaginal delivery, I do whatever I can safely do to get it for her.

>> also several cases of brain injury due to vacuum delivery.
Vacuum, like pit, like episiotomy, like cesarean, like (insert intervention here) can be used inappropriately. Used appropriately I think its pretty safe. But I have some strict rules on how to prevent problems, more stringent than ACOG suggestions. Vacuum used without clear thought on why and how it is being used can definitely be dangerous. I learned from the guy that invented the Kiwi vacuum, and I think what he taught me has served me well in that department. I’ll post on it some time.

>>Can you do a post about your thoughts on the safety of miso for labor induction sometime
I’m not sure why. People that hate miso are going to hate it. There is plenty of data showing no change in neonatal outcomes despite a change in tachysystole and meconium rates. It works well. ACOG supports its use. To my OB audience I would be speaking to the choir, and would just get attacked by the other audience. I do use it selectively though, not in compromised infants and obviously not on VBACs.

First, in response to your comment about “preventable” mortality in hospital, yes, I have seen too much in hospital. Sometimes due to malpractice (delee suction connected to 02 rather than suction, bilateral pneumo, delayed response, HIE — Hemabate rather than HbIG given to a newborn, twice AROM at 1 cm (I don’t get it) and high station with cord prolapse and HIE) but also several cases of brain injury due to vacuum delivery. (Let’s discuss the stats on the safety of vacuum sometime, which too many OBs use much too easily). I have seen iatrogenic maternal morbidity as well: several uterine inversions due to inexperienced management of the 3rd stage, a completely unwarranted hyst due to a dire H&H when it turns out the blood was drawn right above an open IV line and hence diluted, literally hundreds of 4th degrees after unnecessary episiotomies. Add on iatrogenic infections and surgical complications…

I aspired to become an out of hospital midwife because I honest to goodness believe that healthy, low risk women are safer with me than the average run of the mill (typically non evidence-based medicine, “daylight obstetric”) provider. I well understand we have the advantage of “healthy and low risk” compared to your average higher-risk population, and how that equates to muddy statistics. We also have the advantage of patience, and that makes every bit as big a difference in better outcomes. We also have much better statistics than hospital only CNMs. We are a practice of very experienced CNMs who have all worked in hospital. We have excellent collaborative agreements with OBs and a stringent criteria of risking out of home or birth center birth, both in the AP and IP periods, and an established transfer system. Though we are rural and usually 20-40 minutes away from our referral hospital, I think we provide an exemplary OOH birth model.

I am absolutely a “VBAC activist” but am also tempered by wisdom, as I have have personally attended two seemingly straight-forward VBACs (one primary and one secondary) gone terribly wrong (moms and babes did well but “code 911″ crashes were truly indicated). The only VBACs we attend out of hospital are those who deliver precipitously: we have perhaps one of the highest rates of grand multiparity of any practice in the nation (serving a majority of Amish families).

So… what are your thoughts on the risk of rupture after multiple VBACs? There is NO data about this as far as I can tell. Is that scar stronger or weaker as a result of being tested 5-10 times? Given the high parity, prevention of the primary c/section is so important to us, and stubborn breeches our bane! Especially now that our back up docs won’t vert anyone with an anterior placenta.

Our VBAC clients all have OB consults in the 3rd trimester, and every single one of our 4 collaborating docs quotes a different risk statistic. As far as I can tell, there is NO consensus on the real risk of uterine rupture in a VBAC, spontaneous or augmented. I have found good data quoting a 1-3/1,000 risk, and some data quoting a 0.5% risk, but most of our OBs quote 1-3%. I can’t understand, given that 30% of American women have scarred uteri now, why it is so hard to come up with a hard and fast statistic.

By the way, isn’t the risk of fetal loss due to amniocentesis about equal to about 1 percent? Why is it that so many OBs are violently against a mom’s right of informed choice to accept a, say, 1% risk of fetal loss due to home VBAC and yet… so supportive of a woman’s right to accept the same via amnio?

Finally, please never let a doc underestimate the danger of multiple repeat c/sections. In 6.5 years here we have had THREE cases of placenta accreta among women with numerous c/sections, equaling one hyst and all three with transfusions and complicated recovery (obviously, these women are not attended OOH and not even at our backup hospital).

A last thought – the VBAC activists and moms on here, never mind the ones that have battled Amy Tuteur and other OBs for years – I just want you to stop and realize _how important_ vaginal birth is for many, many women. Most OBs will never get it: I don’t expect you to understand it, I’m not even sure I can explain it. But please be aware and respectful of how deep that lies for a lot of women.

I definitely understand and feel for the burden of malpractice, etc, that OBs face. I know the majority are doing the best they can. But there is so much need to clean up OB to focus on evidence-based medicine. I think you strive to do exactly that, and I appreciate it, Dr. Fogelson.

Can you do a post about your thoughts on the safety of miso for labor induction sometime? Thanks –

Nipple stimulation does cause endogenous pitocin release, sometimes at a very high level. Rationally this would be at least as dangerous a exogenous pitocin, though I don’t believe there is actual data on this.

@Jen. I’m so used to working in a large unit (5,500 births and rising) with 15 NICU (Level III) cots and 15 SCBU (Level II) cots, plus transitional care, that I forget that you don’t need dedicated space/staff to provide the standard of care.

+++++++++++

Isn’t it also possible that use of prostaglandins (vs. oxytocin) is associated with cervical status, and that uterine rupture is more associated with induction with low bishops score? Not to say that people should be using prostaglandins to induce in VBAC, but that the normal circumstances of prostaglandin use may make them look worse than they really are. I’m not sure a proper comparison of PGE2 vs. oxytocin has been made (taking account of cervical status as a confounder) for induction with previous CS.

Funny, that’s not the way I remember the history. Many, many women (in the 70s and 80s) had to deal with conflicts with hospital administrations, change providers, travel to more-distant facilities, etc, to (hopefully) find a “warm welcome” for a trial of labor.
The momentum really picked up in the early 90s when third-party payers realized that VBAC could be a huge cost-saving procedure. That’s when some women who would have preferred ERCS were instead forced by their insurers to attempt VBAC if they had no medical conditions to rule it out. And in order to stay on insurer preferred provider lists, some hospitals changed their policies to encourage VBAC attempts, and try to meet arbitrarily-set VBAC rates. That is, I think, when the litigation issue loomed large – due to bad outcomes among women who were not necessarily choosing VBAC of their own accord, but had limited personal choice due to third parties.

I think that the issue is indeed about autonomy and personal choice. In obstetrics, as in other fields of medicine, a patient who is treated as a full partner in medical decision-making is less likely to become a future litigant. Women who are not interested in pursuing a VBAC attempt should not be forced to do so for financial or other reasons; and women who wish to avoid repeat surgery should also have access to resources and support for that decision.

http://www.jud.state.ct.us/external/supapp/Cases/AROcr/CR279/279CR132.pdf

“The judgment of the Appellate Court is reversed and
the case is remanded to that court with direction to
affirm the trial court’s judgment.”

ie, there was no new trial and the court affirmed that the defendant (doctor) had provided the information considered adequate for a “reasonable person” to give informed consent.

No doubt, but the benefit of VBAC was never to the infant, its to the mother at the expense of the infant. When a VBAC mother gets to 41 or 42 weeks, one typically would do either do a repeat c/s or induce. Continuing the pregnacy risks a low rate of intrauterine fetal demise. Certainly it is preferable that a woman enter labor spontaneously and avoid pitocin augmentation, but given the choice between induction and repeat c/s, induction is a reasonable choice for many.

Inducing with prostaglandins (miso or cervidil) is a big no-no, as it substantially increases rupture rates. I think this practice is firmly outside of the standard of care, and would likely be enough for an OB/GYN to fail their oral boards if they were doing this.

Yehudit :What sorts of distances/transfer times are you typically talking about for rural hospitals? The only UK equivalent would be in the Scottish highlands and islands, where we have quite a number of birth centres staffed by community midwives and GP units/community hospitals.
More relevant might be this project in BC, Canada http://www.ruralmatresearch.net

I practice in a rural setting that is not nearly as rural as many in the US. If the weather is suitable for flying, we can transport a patient by helicopter in 25 minutes to the tertiary care center. In practice, that usually means an hour or more, because we have to get a helicopter to fly here, get the patient packed up to go, and then they have to fly back. If we have to go by ambulance, it’s about 1 1/4 hours driving time. We don’t transport patients in active labor, for obvious reasons, but we do try to do maternal transports rather than neonatal transport whenever possibe, as sick/premature neonates who are born in a hospital with neonatogoly services do better than those that have to be transferred after birth. We are a level 2 nursery, capable of providing care to infants generally 32 weeks and beyond. We do have more services than some rural hospitals – a blood bank, 24 hour lab and diagnostic imaging – in some rural settings there is no blood bank, or only very limited laboratory capabilities outside of standard working hours. In practice, we tend to transfer more at the edge of our abilities, rather than risk having a baby have to be transferred later, so even though we have the capability to care for many 32-weekers, in practice we generally transfer mom out if we expect delivery prior to 34 weeks, as I’d rather transfer mom, and have her baby do great and go home with her, than have to ship the baby while mom is still hospitalized in my hospital. I can catch a 28 weeker as easily as a 40 weeker, but that 28 weeker is much better off being born where there is a NICU.

Some fetal deaths could be averted if the world was different, but it isn’t. It is what it is.

I completely get your point here, and we are really far afield from your original post!
I do think that some factors in medical care can be changed to promote better care, though. It’s not the same as saying a doctor failed to do X, so a baby died a preventable death, but having medical care be truly accessible and culturally relevant can’t hurt. I think of my residency hospital, where women would be instructed to do antenatal testing, for example, but were 2 buses and a long walk away from the hospital where it was to be done, and their toddlers/preschoolers were not allowed to come along. Or the gestational diabetes clinic which all gestational diabetics were supposed to attend, which had no appt times, everyone was just to show up at 8 am, even though they might not be seen until noon – we were always complaining about how “non-compliant” our diabetics were. I did see a full term fetal demise in a type 2 diabetic in residency, that may have been averted (or maybe not, you never really know, do you?) She hadn’t had her scheduled biweekly biophysicals in 2 weeks due to logistic issues, and had been very poorly controlled during her pregnancy due to “non-compliance.”
Patients constantly complained about the lack of continuity in the resident’s OB clinic – they might never see the same resident twice, or even be in the same attending’s clinic, and then would be delivered by yet another strange face at the end. Coupled with a poor records system, a huge amount of staff turnover among the medical assistants/receptionist, and sometimes language barriers and important issues seemed to fall through the cracks a lot.
Not, of course, that doctors are responsible for everyone’s social situation, it’s just that some care environments are pretty darn hard to negotiate for the most vulnerable clients they are supposed to be serving. Hard to say if that is an individual doc’s problem, but it can’t hurt to know what the obstacles in your community are.
To try to bring this comment back to your topic . . . I worry that declining access to VBAC, especially in the setting of rising primary cesarean rates is another systemic aspect of care that can lead to worse outcomes, both from the morbidity (and even mortality) of multiple repeat cesareans, and women feeling they are forced to choose out-of-hospital settings with care providers who are not connected to the “system” to attempt a VBAC if it’s important to them.

No question that poverty and poor overall health contribute to neonatal death rates. We can see that in the varying rates of neonatal death rates throughout different socioeconomic strata, even controlled for access to medical care.

But in the end, when a life dies it is because some major system in that life stopped working – cardiac, respiratory, hematogenous, etc.. sometimes more than one at a time. When I think of a preventable death I think of a natural process that was going to lead to fetal death, that could reasonably be diverted. I don’t think of babies dying from abruption from maternal crack cocaine use as being preventable by anyone but the mother. Clearly if a medical practitioner made a real error that injured or killed a baby that would be preventable, but as I said before I have never seen that happen in my career.

Some fetal deaths could be averted if the world was different, but it isn’t. It is what it is.

I do disagree with this. Socioeconomic status does has an impact on if a baby survives or not. Not that practitioner’s can always remove a woman from her social situation, but cases I think of include drugs, abuse, nutrition (albeit not seen as much in this country). More research would have to be done, but I wonder if the socioeconomic status was paid more attention to, would we have better outcomes. Just a thought.

Plus, the mom may have issues afterwards feeding or caring for the infant. Without an effective network, that could be an issue sometimes. I understand that ob’s don’t see that as part of their job description, but it can be difficult to have the care broken up that way.

“My underlying point is that you need a hell of a lot more data than you have quoted, and the ability to control that data, before you could fairly and justifiably know that a particular hospital has an unjustifiably higher neonatal death rate.”

Completely agree with this, though. And you would need more data to know what exactly is causing these deaths, but it appears that they did do case studies on the deaths in this Kansas study. I would actually be quit curious to know what they found in this study as to why the infants were dying.

More relevant might be this project in BC, Canada http://www.ruralmatresearch.net

All of your hospitals have the same amount of high risk deliveries? That is a unique environment. Most areas have one or several tertiary centers and lots of other lower risk community centers. My underlying point is that you need a hell of a lot more data than you have quoted, and the ability to control that data, before you could fairly and justifiably know that a particular hospital has an unjustifiably higher neonatal death rate.

>> It’s about getting to know her, patient education, nutritional counseling, finding out what else is going on in her life that might be affecting this baby, the birth.

I appreciate your comment, but don’t understand your point. All these things are important, and we all try to do these things, but to link the presence or absence of these social factors to a “preventable fetal death” is way way out there and completely speculative. Babies and fetuses are biological organisms that die for physiologic reasons, not because the practitioner didn’t care enough about the woman’s social situation. Babies do not die in utero or postpartum from maternal malnutrition in developed countries. Hell even in periods of starvation babies do reasonably well. They are very effective at getting what they need, at mother’s expense if need be.

OB are not pediatricians. Asking an OB to be one is asking a horse to be a cow. Some family medicine doctors do OB and pediatrics, though they have less training in either than an OB or Pediatrician has in their own field. I do routinely see my patient’s babies, and if I am honored enough to care for them for many years, I get to see their babies grow into children as well. Part of the medical system is that we have a network of colleagues that can help us when our patients have problems outside of our expertise. When a baby is born, it has immediately gone out of my expertise, and that’s fine.

You’re right that anesthesiologists don’t often see their patients back, and might underestimate the number of patients with minor epidural complications and sore backs.

And you make several great points. Thankfully the deaths are very low in number. The great thing about this is that we can do in depth case studies on all of them. You also do a great job here: “And no, I do not believe I have ever seen an infant death that could have been prevented by an appropriate obstetrical intervention.”. See, this is where we fundamentally disagree. You’re talking pitocin, vacuum extractions and monitoring the EFM. The birth is not just about what happens after the woman goes into labor. Birth cannot be just reduced to some obstetrical intervention. It’s about getting to know her, patient education, nutritional counseling, finding out what else is going on in her life that might be affecting this baby, the birth. My experience of the obstetrical model of care is one where my OB had to look at my chart to remember my name. And I saw her weekly for 26 weeks. Your intervention should be the preventative one, the caring, time consuming, whine about managed care and not making enough money type of care.

And your comment about not caring for children. That reminds me of the anesthesiologist I had with my second pregnancy. I was concerned because I’d had problems with the spinal in my first pregnancy. when I told him about complications I’d had with my previous experience, he assured me that he had never had that happen to any of his patients. But how would he know? I never saw him again? I reported the problem to my OB. How would he ever find out about the complications I had. OBs and Peds are an integral team when it comes to the health of that newborn. How you intervene during the birth and the method of prenatal care affects the baby. You can’t reduce your job to starting pitocin through cutting the cord. You can’t compartmentalize the care into three exclusive periods. They all overlapped and intertwine.

Before you go into the whole managed care, got to pay my insurance, see as many patients as possible excuses. That doesn’t fly with me. Midwives do it. And some great OBs and FPs out there do it too. OBs are a highly specialized autonomous group with phenomenal lobbying money backing the profession. Yet, no group of specialists has allowed themselves to be backed into a corner the way OBs have. In fact, it is my feeling that ACOG set itself up to be vulnerable to lawsuits by the way they word their VBAC policy.

There are so many issues to consider here, which is why going off a zip code search is inadequate as a research methodology. There are so many things to control for that would require detailed information from each care site. You are basing the conclusions off uncontrolled observational data, which at best is enough to ask a question, but certainly not enough to know the answer.

So, I’d be interested in how many births per year the rural hospitals are doing and whether the inability to staff a theatre quickly is a consequence of a low number of birth per annum, or to do with the way that care is organized.

And no, I do not believe I have ever seen an infant death that could have been prevented by an appropriate obstetrical intervention. As for pediatric interventions, I cannot comment on that as I am not a pediatrician and do not take care of children.

I think this is a huge issue and really needs to be addressed. What I would consider VBAC activists that I know, though, are very aware of the risks and are much more of the mindset that their decisions are theirs and, I don’t believe would sue. Of course that doesn’t mean they wouldn’t, but that’s just the general impression I get from those I do know.

In any case I think we can all agree that the litigation environment in this country is a huge hindrance to VBAC.

I’m in favor of VBACs; when I practiced I offered them to everyone who was eligible, most women accepted and I had a very high VBAC success rate. My concern is about the malpractice liability that has led hospitals and insurance companies to severely restrict VBAC. I think that VBAC activists are not intellectually honest in the way they present information and that makes it difficult for women to understand that the risk is real.

VBAC was originally greeted warmly by everyone. No hospital, and no insurance company had a problem with it until women began suing and winning. They won even though they had signed consent forms acknowledging the risk. In some cases, women argued that they hadn’t “understood” the risk.

In one case, a woman claimed that her doctor withheld material information about the risks of VBAC. Although the obstetrician had told the patient that not only could a uterine rupture happen, she had seen one happen, the patient asserted that she wasn’t adequately informed because the doctor did not mention that the baby in that case died:

“… Flagg advised the plaintiff that, statistically, there were risks associated with the procedure, including uterine rupture and even a small chance of death of the child. Flagg reassured the plaintiff that all necessary steps would be taken to minimize or eliminate the risk to either the plaintiff or the plaintiff’s decedent and that the risk was “very, very small . . . .” … [T]he plaintiff asked … whether Flagg had had any negative outcomes. In response, Flagg stated that one of her previous patients suffered a uterine rupture as a result of a VBAC delivery. She did not mention, however, that the uterine rupture had caused the infant’s death and had placed the mother’s health at risk.”

When patient lost her original lawsuit against the doctor, she was appealed using a new theory.

“The plaintiff’s informed consent claim rested on the allegation that Flagg had given an incomplete and misleading response to the plaintiff’s inquiry about prior experience with VBAC deliveries. The plaintiff maintained that Flagg told the plaintiff that, in a prior VBAC delivery, she had one complication that resulted in a uterine rupture, but failed to tell the plaintiff that the uterine rupture resulted in an infant’s death. The plaintiff asserted that this evidence supported her claim that Flagg had not provided her with adequate information required for informed consent … The plaintiff also claimed that if Flagg had informed her that the prior VBAC delivery resulted in the death of the infant, she would not have elected the VBAC procedure.”

The Appeals Court agreed with the mother and granted a new trial on the theory that the mother had not given informed consent.

Or consider the way that VBACs are described by this plaintiff’s attorney (VBACs Too Often Result in Injury and Death):

“While the promotion of VBACs may save insurance companies money, the risks simply cannot and should not be ignored. It is known that patients who fail a trial of labor are at increased risk for infection and death. Infants born by repeat caesarian delivery after a failed trial of labor also have increased rates of infection. Recent reports indicate that major maternal complications such as uterine rupture, hysterectomy, and operative injury were more prevalent in women who attempted a VBAC than those who underwent repeat caesarians.

If the uterine scar ruptures, it can be life-threatening for both the mother and the infant. For the mother, uterine rupture can require hysterectomy and can result in death.

For the infant, uterine rupture can result in both neurological damage and death. Uterine rupture can result in a sudden disruption in the blood flow to the fetus, resulting in deprivation of oxygen to the blood and tissues. This deprivation can lead to death of brain tissues and serious harm to other vital organs within only minutes. Accordingly, it is imperative that no VBAC be attempted at a facility where emergency staff are not capable of performing an emergency caesarian in minutes in order to prevent this potential harm or death to the infant and mother.”

If VBAC activists want the option of VBAC, they have an ethical obligation to be honest about the risks. Implying that the risks are negligible leads lawsuits when babies die. And lawsuits make it impossible to offer VBAC except under strictly defined conditions.

I think VBACs should be widely available, but that can’t happen unless women are properly informed of the risks; unfortunately, VBAC activists are often part of the problem, not the solution.

I think the obstetrical community has actually done a great job at decreasing the number of infant mortalities. I am wondering if she is rather referring to morbidity. I don’t have any numbers, but I could see making a case for an increase in morbidity(such as having to be in the NICU longer)due to interventions used that weren’t necessary (such as forceps, cesarean that may not have been necessary, pitocin that put an infant in fetal distress).

For instance, I was working with one physician that is known for being very impatient. Mom, had been pushing for a little less than two hours. Baby had been doing fine, mom had been doing fine and was pushing baby down(albeit slowly). At that point the physician came in, cut an episiotomy, and used forceps to pull it out. This baby was fine, and mom had no complaints. But, we all know that forceps can lead to problems sometimes. And the mom may have been able to push this infant out without the use of them.

My point is, that mortality may not be an issue, but morbidity may. This particular doctor did not say a word to the patient before he did anything. This is were I can see problems arising with informed consent not being given.

And since Amy is on here, I know this is not research, and I am not trying to prove any points. I realize that these are just my own experiences and thoughts, and no I have not looked up any research on the issue of infant morbidity so I would need to do that before I make a definitive statement. This is just an antidote, and I wouldn’t try and say that all doctors behave this way(though I do believe this doctor was wrong in the fact that he did not even talk to the patient about complications of both an episiotomy or the forceps. Neither did he ask her permission to perform them). I am also not trying to push any home birth, natural, or anti-medical agenda. (Am I missing anything here?)

Amy, I do appreciate some of your comments, and I believe the ones here on informed consent are interesting.

Also interesting is that the opinions were from perinatologists. I have many perinatology colleagues that I have a lot of respect for, but I don’t really think that VBAC policy is really a perinatology issue. Perinatology is sick babies, pregnant mothers with underlying illness, and babies with congenital anomalies. The management of VBAC is basic OB/GYN, and ultimately I think general OB/GYNs are well qualified to manage the issue, and set policy for it.

OK. Let’s hear some specific examples of infant death in hospital that you consider to be preventable. I am unaware of a population of babies dying in the hospital from preventable causes. In my career, I have yet to see one of these unfortunate infants.

I can tell you’re pretty upset about the 300 babies, but on the other side are 700,000 women who will have major surgery to prevent those, and probably 2-3,000 will have substantial complications. Women are allowed to place relative value on their own health and that of the fetus. In fact women are allowed to devalue the fetus completely, prior to viability, if they so choose. I think maybe you are thinking that women might read that statistic and immediately realize that VBAC is horribly dangerous, but many women feel OK with a small fetal risk in return for a potential benefit. Right?

We all take tiny risks every day that seem huge if we were to add them up to an entire population level. If we all drive every day, tens of thousands of people a year will die from traffic fatalities. Driving therefore seems unconscionable, no? That logic obviously doesn’t work, but its kind of what you are saying in your argument. On the individual level, the attributable risk of fetal death in a VBAC decision is absolutely tiny. It is real, but it is tiny.

>> When I practiced, I used a 3 page consent that explained all the risks in detail, so that’s what I’m used to. What’s the consent form like at your hospital?

Ours is a 1-pager

Consider this. A woman with a BRCA mutation (breast and ovarian cancer gene mutation) has an over 50% chance of getting breast cancer over the course of her life. Nonetheless, the vast majority of women who get breast cancer do _not_ have this mutation. This is because even though BRCA dramatically increases risk, there are so many millions more women with normal risk who can possibly get breast cancer that the vast majority of breast cancers occur in BRCA negative women.

In the same vein, even though VBAC does elevate risk of fetal death, most deaths occur in non-VBACs. This is not alarming, it is just mathematics.

Its hard to comment on XYZ zip code since you talking about it in code and not citing much evidence. I’m not sure which babies you mean that are needlessly dying. We do an amazing job at preventing neonatal mortality. We don’t prevent them all, but nearly all of them.

Women are not “informed” of the true risk of infant mortality in pregnancy because they do not have an option to decline having the child. Informed consent only makes sense when there is an option to accept or decline something. A pregnant woman does not have the option to not give birth to a child, unless she chooses abortion prior to viability. I am happy to discuss with women the underlying risk of fetal death in pregnancy, but as they have no real choice to not be exposed to that risk, there is no informed consent process to have regarding this.

Informed consent and transparency is required in VBAC attempts, because there is a choice – the choice to have a repeat cesarean. This option in delivery requires that we fairly assess the relative risks and allow the patient to make an informed choice.

There is no randomized data to suggest that the choice to deliver out of hospital confers or prevents risk of neonatal death. The observational data is mixed, and on an individual basis does not indicate a substantially higher risk either way, in low risk pregnancies.