Ten Thoughts on VBAC
There has been some discussion recently in the blogs and the twitterverse about VBAC. Some have expressed a concern that not enough women are being offered VBAC, and that not enough doctors are supportive of it when the facilities are available. I have a few thoughts on this.
VBAC, or Vaginal Birth after Cesarean, is something that gets a lot of discussion, because any discussion about VBAC is basically a discussion an inverse interplay between fetal and maternal well being.
The underlying fetal concern is that in very rare cases, the previous uterine scar can rupture in labor, which can result in fetal injury or death. Most large series demonstrate a risk if about 0.5% in natural labor, and about 1% in pitocin augmented labor, assuming that the woman has had a single low transverse hysterotomy (cesarean scar.) These risks increase for low vertical hysterotomies (1-3%) and even further for high vertical (classical) scars. Some large series have shown slightly lower or higher rupture rates. In cases of uterine rupture that happen in hospital, most patients can successfully have a emergent cesarean delivery and deliver an uninjured baby, but in some cases (10-20%) there will be fetal injury or death. This risk can be eliminated by choosing to do repeat cesarean deliveries prior to labor.
But there is another side to this coin. Choosing repeat cesarean is less risky for the infant, but now exposes the mother to surgical risk and recovery issues that would be avoided with a successful VBAC. While generally safe in any one case, in aggregate cesarean delivery exposes the mother to small but real risks of significant complications. Minor risks include wound infection or separation, while more major risks include severe bleeding requiring transfusion, hysterectomy, or even death. These major risks are very rare, but when looking at thousands of cases we will see them. Furthermore, any woman who has a repeat cesarean delivery has a longer recovery course and more pain than a woman who is able to successfully have a VBAC, and may have other problems such as breastfeeding difficulty.
So here are a few of my thoughts on this issue:
1) VBACs are unquestionably higher risk than routine vaginal deliveries. Though the risk of uterine rupture is small, it is real, and should not be ignored. ACOG recommends that VBACs occur in hospital where there is in house anesthesia and obstetrics and the ability to emergently perform a cesarean delivery. This is a wise recommendation, and should be followed. Uterine rupture can be managed by an efficient and skilled team, but if things are not handled quickly and correctly it can result in severe fetal injury or death. We should not forget that.
2) VBAC should not happen at home. I have recently referred to that as a game of Russian Roulette, and defend that view here. In this case the gun has 100 barrels, but the bullet will kill the baby just the same. If a woman can honestly say they are willing to take a 0.5% to 1% risk of disaster, then fine, but to me that risk is way too high. I think home birth is an acceptable option in many cases, but VBAC is not one of them.
3) VBAC should be encouraged when the facilities are available. It is a shame when doctors who work in facilities that have the ability to provide VBAC services aren’t willing to do this. It is also a shame if doctors overemphasize the fetal risks of VBAC, which are minimal if properly managed.
4) Those that fight for VBAC rights need to understand that physicians are under great pressure from malpractice carriers, and in some cases hospitals, to not provide VBAC. Malpractice carriers in some cases will not allow their covered physicians to VBAC, as uterine ruptures are unpredictable and carry a high risk of litigation if they occur, despite thorough informed consent prior to the VBAC attempt. Hospitals also accept liability by providing VBAC services, which amounts to financial payout, without getting much in return. When they provide VBAC services they do so in order to provide more comprehensive care, but do so at some liability risk. It is important to understand that given legal liability, doctors and hospitals are encouraged to take predictable risks (cesarean complications) over unpredictable risks (uterine ruptures.) Legal protection for physicians and hospitals who have predictable VBAC complications would go a long way to increasing VBAC availability.
5) Physicians also must stay in or near the hospital when a VBAC attempt is going on, which can be logistically difficult. Obviously midwives don’t have this problem, but midwives also can’t do the emergent cesarean delivery if it were needed. The reality is that for a small private practice physician to stay in house for an entire VBAC labor likely costs that physician several thousand dollars in income, and all the while his or her office overhead continues to accrue. This is avoided in large groups that have a permanent in house covering physician or academic practices, but in small practices this can make VBAC very difficult to work into a practice.
6) The choice whether or not to VBAC has a lot of things that goes into it. The number of children a woman wants to have is a big issue. If a woman plans only 1 more child after her first cesarean, the absolute risk to that woman is very low with her first repeat. Risks start to rise substantially as she has more repeat cesareans, so a woman who plans 5-6 children gets a relatively greater benefit from the first successful VBACs (and presumably subsequent VBACs) than the woman who has only 1 VBAC. A woman who wants to be sterilized is sometimes encouraged to have a repeat cesarean and sterilization at one time, but I would not recommend this. Hysteroscopic sterilization can be done after a successful VBAC at 10x less risk than an open procedure (though risks for either are very low.).
7) VBAC success rates are difficult to predict, and vary greatly on the provider who is deciding when to quit and do a cesarean. There are many models for calculating success rates out there, but are difficult to extrapolate to different providers. Women who had a cesarean for breech tend to have the highest VBAC rates, then women with cesarean for fetal distress, then women for cesarean for arrested labor. Importantly, even the lowest success rate groups have a 60-65% or greater chance of successful VBAC in most series, which is not substantially higher than underlying cesarean rates. There is very little evidence that we can predict VBAC failure reliably in any woman, and substantial evidence that the majority of women can successfully VBAC.
8 ) It is unlikely that rural (and some semi-rural) areas will have VBAC access, due to the infrastructure that is required to provide it. We can lament this all we want, but this is a reality that is unlikely to change.
9) Given the current medicolegal climate, some women may need to travel some to do a VBAC in a hospital that has the infrastructure to provide it. Having a VBAC in a hospital not equipped to handle a uterine rupture quickly and efficiently is a bad idea.
10) The single most important thing we can do to deal with VBAC issues is to not have them at all, by avoiding the first cesarean section. Many cesareans are absolutely necessary, but when possible we should achieve vaginal deliveries. I’m willing to push some grey cases that others might deliver by cesarean. Sometimes that means being more patient with a slow labor. Sometimes that means operative vaginal delivery. Because of that, more of my patients will have easy multiparous second labors rather than having to worry about VBAC issues. There is a receiver operator curve for cesarean necessity. Most OBs should push their needle a little towards “specificity”.
Academic OB/GYN 
I like the way you think and how you explain the issues regarding VBAC. Yes, the biggest issue is to avoid the C/S to begin with. I have worked with physicians that are like you (and loved it) and physicians that like to cut at a drop of a hat and have no trust or faith in a woman’s body. Unfortunately, as you pointed out, the bottom line is money, risk, and the health insurance companies that dictate.
LikeLike
“2) VBAC should not happen at home. I have recently referred to that as a game of Russian Roulette, and defend that view here. In this case the gun has 100 barrels, but the bullet will kill the baby just the same. If a woman can honestly say they are willing to take a 0.5% to 1% risk of disaster, then fine, but to me that risk is way too high. I think home birth is an acceptable option in many cases, but VBAC is not one of them.”
It is probably inaccurate statements like this which do scare a lot of women, however, your figures are off. First, no one is pit-inducing homebirth women so the 1% figure is out. And only 1/3 of uterine ruptures end in serious injury/death to the baby, so the true risk is 1/3 of 0.5% or 0.17%, a much different thing. So…yes, I’m personally comfortable with those odds, and have done it twice. When I add up the various iatrogenic risks of merely stepping in the door of a hospital including morbidity, infection, interventions which lead to “complications”, not to mention the huge risk of ending up with an unnecessary cesarean, I sleep pretty well at night. Let us be responsible when throwing around inflammatory figures/phrases when judging women as aiming a gun to their baby’s head by their educated choice of birthplace.
LikeLike
>> And only 1/3 of uterine ruptures end in serious injury/death to the baby
The problem with your statement is that you don’t take into account that the vast majority of uterine ruptures occur in hospital where rapid action can be taken. If you truly believe that a ruptured uterus outside of the hospital is not going to be a major problem, I just have no idea what to say to you. I’m not talking about a little scar dihiscence, I’m talking about uterine rupture. The uterus is getting 1-2 liters of blood flow through it every minute at term pregnancy, and is very vascular. If you tear the uterus open it can bleed, and very quickly.
The fact that you have done it twice means you were in the large majority of people that will be fine, but means nothing about the overall safety of the practice. I am quite comfortable with my view on this, my metaphor, and my feeling that out of hospital VBAC is a foolish thing to do.
LikeLike
Can I hug you? Seriously! You said what I couldn’t find the right words to say when reading that section! I know your comment was a few years back, but if you see it then ty for speaking out for those of us who are making INFORMED CHOICES and ARE doing what is best for our child. Is the ‘Russian Roulette’ analogy true? Sure, in theory… but the same could be said about being in a hospital. I labor long and I labor hard and my body doesn’t follow the ebs and flows defined in the text books. I would never be properly supported to allow for a vbac in a hospital setting. My first was an UNNEEDED c/s (even the ob who did it 5 years ago questions now why he did it. I don’t believe for a moment that he had malice or ill intent. He followed his training and his training says that I’m broken). With the support of a home birth midwife and an amazing support team, my 2nd was a planned home-birth. We moved since then (back to the town where my c/s was done) and the hospital now has a vbac ban as does all but 1 or 2 of the ob’s in the next 2 counties over. The local birth centers aren’t allowed to take vbacs, the local home-birth midwives are on the other side of the state line and aren’t allowed to come here to attend me (but aren’t allowed to attend me in their birth centers either… only in a home-birth on their side of the state line). So my CLOSEST option is over 6 hours away and my husband will be deployed at the time. So I will have to drive myself over 6 hours in labor or go to a local hospital and spend a long, hard labor fighting with staff and ‘policy’. Or spend lots of extra dollars on a hotel room starting at 37/38 weeks, plus at least a week postpartum, with 2 small children in tow. Yup, a planned home-birth with a highly skilled, highly experienced traveling midwife sounds a whole lot safer for me than my alternative options…. both physically and mentally. Instead of trying to scare women out of the ‘no more *unsafe* than a hospital in the current *women have no rights* birth climate’ option of an hbac, the writer should focus energy towards fighting for a woman’s right to make her own choices during labor. Fighting to make sure women have access to facts and not inflammatory scare tactics. I do hope that in the years since this article the writer has taken to helping women rather than trying to tear them down.
LikeLike
My words do not tear women down. They inform them of the facts regarding VBAC and uterine rupture rates, and give the perspective of someone who has operated on ruptured uteri. No one with this experience would call home VBAC anything but folly.
It is truly unfortunate that you do not have hospitals nearby that are supportive of VBAC. The political and legal climate has driven VBAC out of small hospitals, which is a shame. I would love to see this change.
This doesn’t change the fact that uterine rupture, while rare, could be disastrous if it happened at home, possibly resulting in death of mother or baby. People like to say this is ‘playing the dead baby card’, which is ridiculous. It is just the truth, but home VBAC supporters like to pretend it is not. “I deserve to have a VBAC” somehow becomes a willful ignorance of the actual dangers of the practice, and why one should do it with continuous monitoring in a hospital.
As I said, I think homebirth is a reasonable thing to do for some women. Home VBAC is taking it too far, taking risks to mother and baby. I wish such mothers would focus more on their child and less on their birth.
LikeLike
Delurking… your perspective is refreshing. Were I to need an OB, you’d be on my short list 🙂
In all the discussion about VBAC, it’s often thrown out there that if a hospital can’t offer VBAC because they don’t have readily available staff for emergent sections, those hospitals should not do any labor and delivery, as they would not be prepared for any childbirth emergencies. Does this argument hold water for you?
LikeLike
Honestly I think that’s not a fair argument. There are hospital all over this country that have varying standards of care for obstetrics. ACOG recommends that a hospital should be able to start a cesarean within thirty minutes of calling a section. In my hospital, we can do it in five minutes if needed. Others need longer than 30 minutes. If you look at a rural hospital that delivers a hundred babies a year, you are talking about a anesthesiologist that is at home, and likely a OB that is at home. You may also be dealing with labor and delivery nurses that are less experienced, and potentially aren’t specially trained at all. In these situations, a uterine rupture would be very difficult to deal with. There aren’t a lot of hair on fire emergencies in obstetrics, but a baby in the abdomen with a briskly bleeding uterine rupture is one of them.
Hopefully hospitals and the staff OBs make a reasonable assessment as to whether they can safely VBAC patients and decide whether to offer them. In a hospital that keeps its OB and anesthesiologists at home until they are needed, VBAC is not likely as safe as it would be in a more fully staffed hospital.
LikeLike
You state: There aren’t a lot of hair on fire emergencies in obstetrics, but a baby in the abdomen with a briskly bleeding uterine rupture is one of them.
Agreed, but let’s take a look at this type of hair-on-fire emergency. Of the one-half-to-one percent of VBAC labors that result in a rupture, how many are the “baby in the abdomen with a briskly bleeding uterine rupture” variety versus the “plain ol’ garden variety dehiscence”? (No lack of respect for the garden variety — or the hair-on-fire variety — intended with that question, please understand.) What other obstetric emergencies would you consider of the “hair on fire” variety? At what rates do those emergencies occur? Are these likelihoods similar? I’m willing to bet that they are.
You state:
“If you look at a rural hospital that delivers a hundred babies a year, you are talking about a anesthesiologist that is at home, and likely a OB that is at home. You may also be dealing with labor and delivery nurses that are less experienced, and potentially aren’t specially trained at all. In these situations, a uterine rupture would be very difficult to deal with.”
Would not your other “hair-on-fire” emergencies be equally difficult to deal with in that hospital? The hospital is as equipped as it’s going to be to handle an emergency — any emergency. If it chooses not to offer VBAC and cites its inability to handle the emergency should it arise as its reason for doing so, then you simply can’t successfully argue that it IS equipped to handle the other emergencies, as you have done above. Now, if the hospital states it won’t offer VBAC because it’s unwilling to accept the liability, there’s no argument necessary. The point being, let’s all call a spade a spade, ok? 😉
However, just as you state, all of this logical reasoning wouldn’t be necessary if more folks shared your judgment. The problem is…while good medicine generally demands data and science and detail and precision, this particular issue boils down to judgment. And that’s awfully difficult to institutionalize.
LikeLike
Honestly, rural hospitals tend to offer a lower standard of care for just about everything than larger city based hospitals and tertiary centers. Its just a matter of volume. Any hospital that does a lot of something will be better than a hospital that does only a little of that thing, as they will have more resources to devote to the issues.
I find it funny/strange that you would have a problem with a small hospital not being able to provide quite the standard of care that a big hospital could provide, yet support the idea of delivering outside of any hospital at all.
LikeLike
You are right that liability is one of the key issues. We didn’t create that though. I don’t know why that culture exists, but it does exist. Believe me, if patients signed a binding release that prevented litigation for a naturally occurring event, VBAC would be more widely available.
Doctors aren’t too upset about the idea of being sued for a legitimate mistake. We don’t like the idea of being sued for a naturally occurring event that in hindsight we had some potential to prevent. We don’t live in hindsight. We do the best we can with the skills and judgement we have, and cannot prevent all ills.
LikeLike
Great perspective from a physician’s point of view. Thanks for sharing. Another important point to has to do with the arbitrary time limits women are given re: having a VBAC. There are providers/hospitals who will say you can have a trial of labor IF you have spontaneous labor by 39 weeks. I think all thinking minds will agree that inducing a woman who has had a previous cesarean is not a good choice to make. With that in mind these rules surrounding VBAC requiring delivery by 39 weeks is in essence saying “We really only pretend to support VBAC as a viable option… lets go ahead and schedule your repeat cesarean”
It’s sad that more and more women feel forced to make the decision between home birth, (both assisted and unassisted) and repeat cesarean because VBAC providers are few and far between. Women really should have choices.
You definitely made the best point… avoiding the FRIST cesarean is the way to go! Let’s have some patience with the birthing process.
LikeLike
If a woman wants to VBAC, I would certainly wait until 41 weeks before calling it quits, and would also talk to the woman about induction at that point if she were interested. Induction does increase the risk of rupture somewhat, but is still worth discussing, especially if the cervix if favorable.
LikeLike
I agree with Mira – If a hospital and doctor cannot provide emergency services to a VBAC mother, they shouldn’t be delivering babies at all. OBs like to argue that things can (and do) go horribly wrong in first time, low-risk labors, and that intervention is sometimes required in a matter of minutes. Yet the story somehow changes when that doesn’t fit their agenda. Uterine rupture isn’t the only thing that hurts moms and babies. As a part of a cesarean support group, I see infected cesarean scars, post-traumatic stress, blood loss, lack of bonding, and other highly unpleasant side effects of cesarean delivery. Too bad about the malpractice, but your insurance isn’t going to keep that cesarean from causing me infertility or horrible depression.
And what you fail to address about the HBAC births here is that in many cases, home delivery is the only option for a VBAC mother. If hospitals and doctors won’t provide them, then you leave us with no other choice – (and no, the “choice” isn’t to give up our right to informed consent.) A VBAC mother often has nearly a 100% chance of being coerced into into a convenience-based repeat cesarean if she chooses to stay with an OB, rather than moving into her own safe, birth space.
I wish more providers tried to avoid the cesarean all together. But I’m sure you can’t think they do. Not with our statistically embarrassing cesarean rate. NY state teeters at 50%. Do you really think those cesareans were even close to necessary? Surely not. The human race would never have survived.
LikeLike
Sadly the litigation rate in NY has driven the cesarean rate well above where it should be.
It is a shame that in some cases women are driven to home VBAC because there is no local hospital or provider that will allow it. That doesn’t change the underlying safety of the practice. Your assessment that home is a safe birth space for a VBAC is not consistent with my definition of safety.
LikeLike
Well, you’d have to look at the long-term consequences of forced repeat cesareans. If a mother is forced to have multiple cesareans (and we all know each extra uterine scar compromises the mother’s health) then the decision to birth at home where she will not be cut open could potentially be the healthiest possible choice for her (and all future pregnancies).
I, personally, like any other mother who’s decided to try for an HBAC, am far too traumatized by the hospital system to step foot back in one. After the horrifying fight I had to put up to prevent from being unnecessarily cut open, just the sight of a maternity ward sends me into an episode of PTSD. (And if you’re interested, I invite you to read my birth story as an example of what to never, ever do/say to a woman in labor: http://thefeministbreeder.com/jules-michael-birth-story/ – this story is the reason I decided to go into Health Law.)
Home is most definitely feels like the safe space for mothers like us, and we deserve to have that option. If doctors are so worried about us laboring at home, you’d think they’d try to help us, instead of shutting us out. I would love to have an OB attend my HBAC. But in my state, that’s not a possibility.
I realize that doctors blame medicolegal reasons for forcing women to VBAC, but how can they, in good conscience? Isn’t the code “Do No Harm?” I’m pretty sure that means to the patient, not the doctor’s pocket book.
LikeLike
I’m just wondering how OB’s can continue to deny that planned, attended homebirths are safe (even safer) than hospital birth when there is evidence to prove this? http://www.ncbi.nlm.nih.gov/pubmed/19720688
I realize it does not fit the Obstetricians’ agenda, but denying the evidence doesn’t make any of us thinking women trust you medpros too much. This, ultimately, will drive more women into the arms of alternate types of birth attendants. The more women find out the truth, the angrier they are at the system and the proponents of the system.
LikeLike
Thanks for your comment, though I think you are giving way too much meaning to this study. There is data that would go in both directions, so its not as clear as you think. The data you are quoting certainly does not demonstrate the conclusion you are stating it does.
“The rate of perinatal death per 1000 births was 0.35 (95% confidence interval [CI] 0.00-1.03) in the group of planned home births; the rate in the group of planned hospital births was 0.57 (95% CI 0.00-1.43) among women attended by a midwife and 0.64 (95% CI 0.00-1.56) among those attended by a physician. Women in the planned home-birth group were significantly less likely than those who planned a midwife-attended hospital birth to have obstetric interventions (e.g., electronic fetal monitoring, relative risk [RR] 0.32, 95% CI 0.29-0.36; assisted vaginal delivery, RR 0.41, 95% 0.33-0.52) or adverse maternal outcomes (e.g., third- or fourth-degree perineal tear, RR 0.41, 95% CI 0.28-0.59; postpartum hemorrhage, RR 0.62, 95% CI 0.49-0.77). The findings were similar in the comparison with physician-assisted hospital births. Newborns in the home-birth group were less likely than those in the midwife-attended hospital-birth group to require resuscitation at birth (RR 0.23, 95% CI 0.14-0.37) or oxygen therapy beyond 24 hours (RR 0.37, 95% CI 0.24-0.59). The findings were similar in the comparison with newborns in the physician-assisted hospital births; in addition, newborns in the home-birth group were less likely to have meconium aspiration (RR 0.45, 95% CI 0.21-0.93) and more likely to be admitted to hospital or readmitted if born in hospital (RR 1.39, 95% CI 1.09-1.85).” I pulled the actual article to get some more insight into this.
The study you quote is a large population based study that has a number of control issues. The latter mentioned outcomes are improper to compare, as homebirthed children have no access to the interventions that were made, such as oxygen and treatment for meconium aspiration syndrome, and as such the comparison is improper. This is called a ascertainment bias, where different members of each group have different opportunities to be assessed for the risk factor under consideration. Similarly, readmission from prior hospitalization cannot be fairly compared with primary hospitalizationn, as prior hospitalization provides information not available to the homebirthed group. There is further ascertainment bias throughout the study, caused by the fact that documentation of various complications are far more likely to occur in hospital than in home births. Diagnosis of third and fourth degree laceration requires advanced knowledge of pelvic anatomy, something that homebirth providers may lack.
The study showed a relative risk of 0.55 for neonatal death in the homebirth group versus in hospital, but with a confidence interval of 0.06 to 5.25. As this confidence interval crosses 1, the data does not show a statistically significant association between birth location and neonatal death. In fact, the only neonatal outcome that was statistically different between groups was readmission to the hospital. It is dissapointing that the editors of this journal allowed the abstract as published, at is implies a difference between groups that is not present. By not showing the confidence intervals or p values they obscure their lack of statistical significance, which is not apparent until you read the full manuscript. I do not believe this article would have been accepted as published in a larger journal, such as Obstetrics and Gynecology or American Journal of Obstetrics and Gynecology, or in JAMA (the american equivalent of this article’s origin journal)
The data is interesting and worth consideration, but in no way condemns obstetrical or in hospital birth. Despite the large numbers, it also fails to show homebirth to be safer than in hospital birth, from a neonatal death perspective at least. We are not denying evidence.
Ultimately people will choose what they want to do. I support the availability of multiple birth settings, as long as people understand the available data.
LikeLike
You’re right that multiple cesareans can be a problem, but still its rarely something that a skilled surgeon cannot handle. I’d rather not have women have four or five cesareans, but personally I would rather my wife have that than try to VBAC at home. As I mentioned, doctors tend to be more comfortable with the known predictable risks than the unknown unpredictable ones. Choose your poison on that one.
LikeLike
I really hope you’d give your wife a say over whether she has “four or five” cesareans. I’m guessing you’ve never had to recover from a cesarean (being a man) so you cannot understand how it feels, and trying to take care of “four or five” children after a surgery seems like absolute torture.
A friend of mine almost died after a cesarean infection. The wound became so infected that she ended up hospitalized for weeks. I’m guessing her kids and husband would have preferred to have their mom/wife around. The “predictable risks” of a cesarean can be just as devastating.
LikeLike
My wife’s an OB! She would have no part with any homebirth, VBAC or not. I think she’d go for an in hospital VBAC if she needed one. It would be up to her of course. She doesn’t listen to me anyway.
LikeLike
>> A friend of mine almost died after a cesarean infection. The wound became so infected that she ended up hospitalized for weeks.
Sorry that happened. That does suck. I don’t know how to prevent it all. Obviously if she had delivered vaginally and had no problem that would have been better. If she had tried to deliver vaginally and the baby got hurt or died, that would have sucked more.
LikeLike
Serious post cesarean infections most commonly follow long labors complicated by intrapartum infection. This type of complication is exceedingly rare after an elective repeat cesarean or a cesarean after a short bit of labor. Obviously I know nothing about the case in specific, but we don’t know if she could have delivered vaginally at all.
Puerperal sepsis prior to the onset of antibiotics was the #2 cause of death in pregnant women (before hemorrhage). These days death from infection is nearly unheard of. Perhaps your friend would have fared worse in past times. Sorry she had troubles though.
LikeLike
Of course the MPH student (TFB) who flunked out of introductory epidemiology would not understand statistical significance and CIs.
I am sure that she will post a blog soon about how awesome this study is, and do what other uneducated homebirthers do – share mis-information that leads to the needless death of a baby.
LikeLike
I’m just curious what your thoughts on requiring an epidural are, and how you feel about subsequent VBAC after two or more cesareans.
Another issue we need to look at here is insurance for women. Some are being denied insurance based on the fact that they have had previous cesareans. If a hospital won’t deliver by VBAC, and insurance is saying that a woman won’t be covered unless she doesn’t have anymore children, that pretty much takes away any choices regarding how many children they will have.
LikeLike
Epidurals are great if a patient wants one, but I don’t think VBAC has anything to do with it. There is no data that I am aware to suggest that an epidural increases or decreases safety in VBAC deliveries.
Patient’s not being insured because they had a prior cesarean? That’s ridiculous, but I don’t have much else to say about it. The insurance industry needs strict regulation, in my opinion. I’d be for a mandatory single payer system supported by federal tax dollars (and tax increases), and destruction of the for-profit medical insurance system.
LikeLike
I think one thing left out of the HBAC argument is the ability of midwives to recognize the symptoms of impending uterine rupture (http://www.vbac.com/uterine.html) early on, due to the fact that they are WITH the mother during the entire labor and birth. Most midwives have excellent training in this, and their statistics reflect it. Not to mention the fact that they will educate a known VBAC client about how to recognize those symptoms as well, so the woman knows if something is very wrong.
Granted, a woman needs to make sure the midwife she hires to care for her has had this training, and has well-laid plans for quick transport.
An OB spends very little time with each patient, due to the volume of women they see, and must rely on machines to tell them what’s going on with mom and baby. How much more in tune with a woman is a midwife than the “machine that goes PING?”
I think it can be said that a midwife will catch things like this far sooner than a machine, and give the mother the time needed to successfully transport – in MOST cases.
LikeLike
I like to think of my obstetrical team, made up of many physicians and nurses, as more than a Monty Python metaphor. Reading fetal heart rate monitors is tough, it would sure be nice if they just went PING instead of all that complex data that had to be continuously examined.
You are right that OBs don’t spend the entire labor at bedside. We have a whole team of people, all well trained, that work together to provide care, and together we do provide continuous care for every patient, especially those having VBACs.
I wish I could Vulcan mind meld with a few of your folks so you could see the inside of a woman’s abdomen after a uterine rupture had occurred. Seeing that, I have no interest in it happening outside of a hospital.
>> I would love to have an OB attend my HBAC. But in my state, that’s not a possibility.
What would I do? Certainly a midwife will do for a home birth if that’s what you wanted. Shall I do a cesarean and repair the uterine rupture with a butter knife and a ballpoint pen? Do you keep crossmatched red blood cells in your freezer? Surgeons aren’t much without operating rooms and the team of people they work with.
LikeLike
What’s so funny to me is that the predominance of midwives and doulas and such in my comments (which are appreciated) makes it look like a substantial portion of the world thinks that home VBAC is safe, when in reality this is an very fringe view. 100% of OB/GYNs, who are the only people who actually operate on women and deal with uterine ruptures, would say its profoundly dangerous.
You are all so worried about process. I’m care about process, but I’m most concerned about outcome. In this case, the outcome I want to avoid is a dead baby, and delivering a VBAC at home makes that far more likely. Do I have randomized data on this? Nope, just reasonable thought and years of experience with this.
LikeLike
I appreciate this discussion. It is rare to see VBAC discussed much in the blogosphere between parties of opposing viewpoints. Usually it is a group who all agree with each other shouting down a few dissenters.
I think your analysis is very good. Personally, I don’t like the idea of VBAC at home either but if I had the choice between a forced ERCS and a HBAC, I can’t say for sure I’d sign up for the ERCS. There are still variables to consider, as a metro medical center is better able to handle a VBAC than a rural hospital, a woman who leave 5 minutes from a tertiary center is in a better position for HBAC then one who is 60 minutes, IMO.
I’m planning my 8th VBAC for this June. I am one of ‘those’ women who OB’s are quite happy has successfully VBAC’d over the last 15 years, as am I. Although a C-section is always a possibility I can’t imagine voluntarily choosing one, knowing I have to come home and care for my other children. My last baby was in the NICU for a week. It was hard enough doing the NICU routine (standing by a warmer for hours, pumping, walking back and forth to the unit….) recovering from a VBAC over an intact perineum and PIH. If I had had a C-section??? I am in the process of switching providers. I live in a major metro area, medical school, multiple large medical centers, many IIIb level NICU’s…How many care providers do VBAC’s? About 5 OB’s and a group of CNM’s. I’m leaving the group with two of the OB’s, the CNM’s won’t take me as I’m too high risk. That doesn’t leave a whole lot of options and I have insurance everyone takes. If I didn’t? It is so different from my first VBAC in 1994 when it was assumed I would VBAC. There wasn’t even any discussion. Same with the baby in 1996 and 1999. Then 2001 rolled around and things started to change. My the time my 2006 baby was coming I had an OB suggesting an ERCS (after 5 successful VBAC’s) because my ‘scar could go anytime’. I understand the whole medico-legal issues, liability, provider availability etc…..I’m still just sad about the whole thing. The last thing any pregnant woman wants is conflict and as a VBAC it seems our pregnancies are conflict from beginning to end.
LikeLike
Is it possible that being in the hospital during the VBAC labor increases the risk of a catastrophic uterine rupture? This is an honest question.
I don’t know anyone (and yes, I work in those circles where women are getting HBACs) who would argue that there isn’t some degree of extreme risk with an HBAC. Most of us just seem to think that it is for the mother to decide what she wants. You seem to be a fantastic, respectful doctor, so perhaps you can’t imagine the trauma that some women experience at the hands of their medical professionals, and how this impacts their decision making process.
LikeLike
I think the mere fact that midwives, doulas and childbirth advocates (not to mention mothers) are so concerned about process should indicate that maybe there is something about the process that is important. If it weren’t, we wouldn’t be so concerned about it, right along with outcome. I think we can all agree that EVERYbody involved in any way with pregnant women and babies wants a good outcome. And I also see that most doctors are sympathetic (up to a certain point) to the process, but many (including you, by your last statement) are a bit baffled by how strongly some people feel about it, and about the types of risks they’d be willing to take in order to achieve it. Or to turn it around, to avoid a bad process. And most who would go to such lengths to avoid a bad process, even to accepting increased risk either to themselves or their babies, do so for a good reason: they do it because of experience.
To illustrate the importance of the process: breaking the hymen occurs whether it was achieved through tender and passionate lovemaking with the love of one’s life or whether it was through gang rape. The outcome is the same. The process was not.
And please, I’m not saying all hospital births are like gang rape. But you have to see that *some* women experience their birth as such. And some of these women become extremely vocal advocates of home/natural birth, and extremely vocal opponents of hospital-based practices.
Whether you agree or share their views is irrelevant. It’s their experience, and they lived it like that. If you have any personal experience that you could compare that to, being bodily violated against your will when you are at your most vulnerable, perhaps you could begin to understand why risking the minuscule probability of great bodily harm might begin to outweigh the quite large probability of moderate bodily and emotional harm.
The more I think about it, the more the losing virginity analogy holds water. Most women would prefer a meaningful, tender and loving experience for both – in addition to being safe.
The process matters.
LikeLike
The process matters for everyone, but not everybody wants the same process.
You all seem to profess that the process you proscribe is what every woman should have, and I can tell you that a hell of a lot of women have no interest in a labor outside of a hospital without an epidural.
As a physician, to me the outcome is the most important thing. Process is important, but when push comes to shove I will not take what I think is a clinically significant risk of fetal death or other bad outcome in order to achieve a process change. If people choose to do that, they may, but they generally do it against the recommendation of their obstetrician.
I agree with you all that women should be able to labor in the process they want, as long as they are properly informed of the risks and benefits of that process model. It is a shame that in some communities women are forced into a process that they do not desire.
LikeLike
I disagree with the above, because the objective of breaking the hymen at the end of the process is neither here nor there (some hymen’s break spontaneously, some women will go to their grave with hymen intact – I don’t have a view about either option). By contrast, the objective of having a living child and mother at the end of the birth process is something that is almost universally regarded as important, at least at an individual level (of course, we can argue at the population level and the NNT).
The evidence I always bring to this debate on place of birth with regard to VBAC is Gordon Smith’s study using the Scottish data.
http://www.bmj.com/cgi/content/full/329/7462/375
In the findings.
“However, the risk of perinatal death due to uterine rupture was significantly higher in hospitals with < 3000 births a year (one per 1300 births) than in hospitals with 3000 births a year (one per 4700; 3.4, 1.0 to 14.3, P = 0.04)."
They speculate that the better outcomes at the larger hospitals were a because size of facility is a surrogate for more specialist obstetric and neonatal facilities. In any case, it is something to ponder and the implications for home birth should be explored.
In the UK we have never had the anti-VBAC backlash, though some hospitals are more encouraging of VBAC than others. We also provide an infrastructure for VBAC at home, insofar as women can decline to be hospitalised in labour and we still have a duty of care which means attending at home. I would always rather that a woman with previous caesarean laboured in hospital. As long as the woman understands that:
unlike many labour complications, uterine ruptures don't "impend" they simply happen.
in the event of uterine rupture happening at home (I would quote 1:200, it may be less due to lower rates of induction/augmentation, but we don't have the data) the risk of the baby dying or being permanently disabled is likely to be very high, perhaps close to 100%
In the event of uterine rupture (again I would quote 1:200), her own life is at risk and all efforts will be directed at saving her life, not that of the baby.
I think presenting the information dispationately is important for women making an informed choice about place of birth. I would still attend someone having VBAC at home (duty of care) but I would be twitched and would have a low threshold for transfer for any maternal signs (tachy, increased resps- even if the woman was totally asymptomatic).
Of course, I have the luxury of being in a unit that actively supports VBAC, so we don't have the problem so much of women choosing VBAC at home due to lack of choices.
LikeLike
Let me just put my biases out there. I have my masters degree in healthcare policy. And I have had 3 VBACs, two of them at home. I really appreciate the respectful dialogue here. I wish more doctors shared your view of #10. My OB let me labor for a very very long time before giving up on my trial of labor. But her idea of letting me labor was to check in every couple hours, leaving my lying on my back and turning up the pitocin. My next birth, a VBAC, was only achieved by my active participation, changing positions, trying the birth tub. We need to reinvent the wheel. All first time uncomplicated moms should be given the one on one in depth care provided by midwives and doulas then step the care up as needed. This is the method in most countries with great maternal and infant outcomes. Our method is like sending all people with a yeast infection to a urologist.
I’m not here to convince you that homebirth VBAC is safe. I was 100% informed on the risks of home VBAC vs repeat cesarean and I chose to birth at home. I’m glad that I had the choice to make and had a skilled midwife and supportive physician back up. 100% of all OBs do not think that home VBAC is a bad choice.
Put yourself in my shoes. I had a horrible cesarean. I ended up with ecoli and staph in my incision, trouble nursing and post partum depression. Then I had a beautiful easy VBAC (in the hospital). Imagine being told that you have no other option but to have another cesarean because of some policy.
It is my view that hospital policies and routine practices set us up to fail. Because our”failure” can be easily “fixed” in the OR. When I did plebotomy during my undergrad. I was amazing. I could draw the tiniest babies with ease. I could get people in and out quickly. But I often forgot that the stick still hurts. I became immune to it because I did it so often and the focus was the outcome.
LikeLike
>> Imagine being told that you have no other option but to have another cesarean because of some policy.
That would suck.
>> But I often forgot that the stick still hurts.
You’re right. We do need to remember that events that are routine for us are not routine for our patients.
>> I’m not here to convince you that homebirth VBAC is safe. I was 100% informed on the risks of home VBAC vs repeat cesarean and I chose to birth at home.
That’s great. Informed consent is a key to autonomy and ethical practice.
LikeLike
Dr. Fogelson,
With respect to cesarean complications, I wonder if you believe anybody really knows how common they are. I’ve had five cesareans – all but the last performed either without my consent, or after *extremely* heavy pressure from my doctors. I was not okay with them then, and am not okay with them now. Everything didn’t turn out fine, but my doctors (GP and OB) both believe everything did. They don’t want to hear it, and anything I say is dismissed with either “that has nothing to do with your c-section” or “well, at least you’re healthy”.
I’ve had wound infections twice. These are considered minor complications. They are minor, in some ways. But, has the medical community ever seriously considered the logistics of trying to care for 2 or 3 children, with an open, infected wound across one’s abdomen? With my third child, my incision didn’t fully close for almost two months. This probably isn’t even reflected in my records as it was treated topically, and I wasn’t ever readmitted to the hospital. Even in a study of post-op complications, I wouldn’t show up.
In addition to the minor (even I know it was minor) infection, I suffered from numbness from that cesarean. In my experience, numbness is shrugged off by the medical community and is treated as a minor complication or as no complication at all. When the numbness affects bladder function (I haven’t had full bladder sensation for over 4 years) and sexual function, the numbness isn’t “minor”. I lost all feeling in my clitoris for almost a year. That also doesn’t show up in my records – not anywhere. I attempted to discuss it with my GP *once*. I’ll never bring it up again. It was completely brushed off with, “at least you’re healthy”. As far as I can tell, in obstetrics, “healthy” means “alive, and not suffering anything directly life threatening”. As that applies to me, I’m “healthy”. I’m not. The medical community treats women like me as if we dodged a bullet. I feel as though it hit me in the stomach.
I truly don’t think your profession has a real grasp of scope of cesarean related complications, and undesirable effects.
Thank you for this article. I’m far from agreeing with everything you have to say, but it’s refreshing to see a doctor writing about cesareans and VBAC who doesn’t seem to feel that cesareans are a walk in the park, and far better for moms and babies than labour. I do wish you had touched on the fact that cesareans aren’t all positive for the babies, either. I’ll never forget being told, after expressing concerns about my daughter’s breathing, that “breathing problems like that are very common in c-section babies”. She was the only one of my children “born” without any labour at all…and the only one with breathing difficulties. It might just be a coincidence, but I have my doubts.
LikeLike
Numbness after a cesarean around the scar is common, as several small cutaneous nerves are often damaged during the pfannenstiel fascial entry. Sometimes with careful dissection they can be preserved, but its difficult to do and often unsuccessful. As these nerves are part of the peripheral nervous system, they do grow back slowly, but it can take 6-12 months to get back full skin sensation.
I’m wasn’t familiar with clitoral numbness as a side effect of cesarean, but I don’t doubt the problem you had. The innervation to the clitoris is through nerves that travel deep in the pelvis, and are really nowhere near a cesarean incision. These nerves can be compressed by the fetal head, however, and this may be the origin of your numbness. I’m sorry you are having trouble. A neurologist might be able to help, or at least confirm the problem and suggest a plan of action.
LikeLike
I appreciate your writing and think you seem very internally consistent about what is and is not recommended to deliver in facilities that don’t have immediate OR access (which would include home, I’m getting the impression?). I think you also appreciate the points many women are bringing up – that sometimes HBAC is the only choice, that this to you is regrettable, and that you’d still rather a repeat c-section than an HBAC (or VBAC in a hospital without immediate OR availability). To you, a VBAC is best but ultimately the outcome (healthy mom, healthy baby) is the most important thing.
So I think it’s important to also acknowledge that while “process” (if by process you mean birth experience) is important to VBACing women, their goals and the goals of most VBAC-friendly minded women (often doulas, midwives, etc. as you point out) are the exact same: a healthy mom, a healthy baby. It may feel like the focus on vaginal birth begins to overwhelm those goals, but I don’t know a single VBACing mom who doesn’t have those outcomes at the top of their priority list. If it ever seems like they don’t, I suggest reflecting on what many VBAC moms experienced after their first c-section: that a “healthy” mom and “healthy” baby (and as several women have pointed out, there can be significant morbidity associated with c-sections even when they are considered “healthy”) are the most important goals but not the only goals. To feel respected, to be have care providers who trust the birth process, and to have a chance to make sound decisions based on the evidence are also important goals. I think VBACing women and those who support them recognize that you don’t, and shouldn’t, have to choose between the two.
LikeLike
>> To feel respected, to be have care providers who trust the birth process, and to have a chance to make sound decisions based on the evidence are also important goals. I think VBACing women and those who support them recognize that you don’t, and shouldn’t, have to choose between the two.
I agree
LikeLike
Here’s the deal. If I do a cesarean and a woman gets a wound infection, that is lousy and I wish it had not happened, and the woman would have to deal with the issues of that complication. But if I ignore my internal judgement and experience and not do a cesarean when I really think it is needed, and a baby dies or has irreversible injury, I would feel much worse. And I think the mother would also feel much worse than she would with the wound infection. Its all judgement call, and ultimately I can only recommend for my patients what I think is best, and they can take that advice or not. I can’t and won’t do a cesarean on a woman who does not agree to it, but I can give my advice. If I truly believe that a baby is at substantial risk of injury or death without a cesarean, I would be remiss not to advise my patient of that. A woman may look at that later as being pressured into a cesarean, but I can’t control that. To bite my tongue and say nothing is such a situation would not be doctorhood as I understand it to be. We cannot operate as if we know the future. We only can make our best judgement call at the time. One of the most important things a woman can do to have a great birth experience is choose a provider, whether it be OB, midwife, or whatever, that has enough in common with them that they can communicate well and have similar goals and ideals. If something does go amiss in that case, hopefully the patient and practitioner can both feel good about how they will handle it.
LikeLike
Please note that the risk of uterine rupture only reduced, not eliminated, by planned ERCS; see http://www.storknet.com/cubbies/vbac/4studies.htm. (Apologies for posting the non-academic summary rather than the individual Pubmed abstracts, but it was a lot faster.) It’s the uterine scar that’s the primary risk factor, not the method of delivery.
On a more personal note, while “maternal vs. infant outcome” is fair, I hate to see VBAC reduced to “process vs. outcome.” The incision is most assuredly part of the outcome. It may be the least bad of all available outcomes, sometimes, but it’s a bad outcome nonetheless. A woman with a fresh incision in her abdominal cavity that’s big enough to pull a baby through is not “healthy” by any reasonable definition, even if the recovery is uncomplicated.
LikeLike
You are right. Some uterine ruptures occur prior to the onset of labor, sometimes much earlier. This is very rare, but more common with classical (over the top) uterine incisions than with the low transverse uterine incisions typically used with term cesarean deliveries. Classical incisions are sometimes performed in preterm deliveries, as the lower uterine segement can be inadequately developed to allow a low transverse incision in some of these cases.
LikeLike
Dr. Amy Teuter, who I am sure most of you just love, made a great and absolutely true comment about the effects of litigation on the cesarean rate:
“Yet the C-section rate can be too high. When you get to the point that you are saving 1 baby every 10 years, the C-section rate is clearly too high. However, a tremendous premium is placed on the life of each and every baby. That societal value is reflected in the fact that our judicial system operates as if we believe that if a C-section had even a remote chance of preventing the death or disability, that C-section should have been done, and because it wasn’t done, the parents should be compensated.
The above graph represents what we appear to believe about the value of the life of each baby. Personally, I think the standard should be different. The number of unnecessary C-sections done to save one baby every decade should not be unlimited. The standard for determining fault in an obstetric malpractice case should not be to show that a C-section “might” have prevented a baby’s death or disability; the standard should be that the doctor could have reasonably foreseen (based on the evidence available) that a C-section was necessary to prevent the baby’s death or disability.”
LikeLike
Ah. My apologies for misattributing another’s comment to you. It has been a busy thread and I misread.
>>> I think hospitals and doctors are doing their own part to perpetuate a culture that can’t and won’t accept the very real fact that…yes, as sad and horrible and awful as it is, babies do die. And that isn’t anyone’s fault any more than it’s someone’s fault that the sun rises in the morning. A hospital (or doctor) stating that “we have all the modern equipment, staff, and training” to meet any emergency is setting itself up for someone or some event to prove them “wrong” …and get sued for it.
I think have some legitimate point here, but I think it gets overstated by a lot of people. I have never guaranteed any results to any of my patients, nor do my colleagues. Patients regularly sign written consents that detail potential issues that can come up, up to and including fetal death. We do not “consent” patients for vaginal delivery, as most do not feel that it makes sense to consent someone for a natural process. I’m not sure who is out there yelling that we can fix any problem, but it certainly isn’t doctors. Maybe that’s the message people hear when they watch hospital advertisements, but it certainly isn’t in the text of any of those ads. Personally I think the expectation of perfection is perpetuated by the one source that stands to profit from it – plaintiff’s attorneys.
You’re right that home VBAC is a personal decision, as is any decision. As I noted somewhere above, autonomy is a key and necessary part of ethical medical practice. But I do assume that prevention of fetal death is something that is tantamount to a reasonable mother, and in that vein I would never recommend a home VBAC to anyone. If that assumption is incorrect, then have at it!
I certainly would not consider a choice to put oneself in a position where a predictable, though rare, complication cannot be properly managed to be a choice of colors. It is a choice of valuing some elements of process over the outcome of fetal death, which to me does not make sense. But as long as people understand that small risk, and feel that it is a reasonable tradeoff for whatever benefit they perceive from a home VBAC attempt, it is ethical and proper that they should make that choice.
** edit 12/22/09 – I realize my use of the word “tantamount” was incorrect. “preeminent” would have been more appropriate 😉
LikeLike
Thanks for a thoughtful post on a controversial issue.
When I selected an article on VBAC for our medical school ob/gyn interest group journal club, our faculty sponsor said we shouldn’t even waste our time, since no one is doing them any more. That is certainly true for our area, where most practices and hospitals refuse to allow trial of labor attempts for VBACs. We are hardly rural. I know of an ophthalmologist who had to hire a concierge obstetrician and pay $10,000 up front to get any obsterician to attend her VBAC. She had one prior successful spontaneous vaginal delivery and a cesarean for twins. Practice patterns are obviously not the same everywhere, especially when it comes to obstetrics. She had her cesarean in another part of the country, and was assured by her obstetrician that she would be a fine candidate for a future VBAC attempt. If she hadn’t moved, it probably wouldn’t have been an issue.
I have another local friend whose physician refused to attend a VBAC attempt she requested (her prior pregnancy ended in preeclampsia, a failed induction and a cesarean at full term). When she showed up a few days before her scheduled cesarean in spontaneous labor, they sectioned her anyway, even though an article in that month’s Green Journal found that emergent cesarean after onset of labor to be the most expensive choice in their study of VBAC with the worst maternal and fetal morbidity. Why not let her attempt the trial of labor, especially since she expressly asked to be able to do so, and prominent medical opinion found it to be not only a reasonable choice, but an easily defensible one?
And, the area primary cesarean rate, which is above 45% in most hospitals, means that less of our primips are “successful” at an attempted vaginal delivery (I put “success” in quotes because I think a safe delivery, even if by cesarean section, is still “successful”) than even the conservative estimates you quote as “success” rates for VBAC attempts in the original post in point #7. (I have usually read of a “success” rate of about 75% in several articles, but outcomes vary.)
But, ACOG’s Practice Bulletin on VBAC says women who are good candidates should be offered a trial of labor. And, practice patterns vary in different parts of the country, and many physicians and hospitals still offer VBACs, and the current literature seems to consider it to be a reasonable option and continues to publish articles on VBAC. But, when I did a history on a woman switching care to a midwife in her third trimester, she said her doctor told her he’d refer her to a psychiatrist before he’d let her attempt a VBAC. So, there’s obviously a wide range in opinions on how to interpret the risks.
This article on explaining obstetrical risk by Lyerly et al is one of my favorite articles I have read on the topic. It states that “Although rates of delivery-related perinatal death are indistinguishable between VBAC and primary vaginal delivery, there is a genuine differential in the rate of uterine rupture–related hypoxicischemic encephalopathy. Such perinatal morbidity is indeed devastating. It is also extremely rare. In a recent large prospective study, the probability of this outcome was 0.00046 in infants whose mothers underwent a VBAC trial at term compared with no cases in infants whose mothers underwent repeat cesarean delivery.” (Emphasis mine)
I think that indicated that there is some validity to the argument that anywhere that it is safe to allow a premip to labor and deliver, it should be safe to allow a good candidate to attempt a VBAC. However, some may disagree about where it is safe to deliver at all. Some may find the risk of a home birth not only acceptable but preferable to a medicalized birth experience. Others may only be comfortable with a delivery at a facility with on site 24 hour anesthesia and obstetricians, and a Level IIIC NICU.
I don’t want to paint all obstetricians with one brush, but neither do I want to disregard the possibility that out of hospital births can be safe. Well managed out of hospital births may have risks similar to real obstetrical care in many hospitals, which unfortunately is not always evidence based care optimizing good outcomes. But, women are not always given an unbiased view of true risk, whether it be the risks of a HBAC or the risks of an induced, augmented VBAC attempt or the risks of repeat cesareans. The Lyerly article concludes that “[T]hese tendencies in the perception, communication, and management of risk can lead to care that is neither evidence-based nor patient-centered, often to the detriment of both women and infants” when discussing the way obstetricians present these risks. I think the natural birth community can probably be equally possible of have members on the fringes who would de-emphasize the risks of a home birth VBAC or an unassisted VBAC.
LikeLike
You’ve got some good and thorough ideas! Maybe you should push for that journal club article after all. Saying that nobody does VBAC anymore is certainly not true, but the sentiment against it may be growing. These kinds of discussions help to move that needle, so keep it up!
LikeLike
I’m happy to say we did still use the article on VBAC success, and got great insight from the same faculty adviser, who practiced for decades and has witnessed significant changes in the politics of VBAC.
LikeLike
Thank you for your thoughts on this. The issue I have with the “risks” you list of VBAC and financial strain on a doctor for a Vbac are present for a regular birth or not. My doctor and midwife team has a requirement for a doctor at hand regardless if it is a vbac, c-section, or natural birth without previous complications. Regardless if you choose to stay at home or at at the hospital for a natural birth without previous cesarean would also include slight risks, you can never take risks/complications completely out of child birth. It is unfair to make a women choosing a healthier mode of childbirth (in my opinion VBAC or natural birth) seem reckless. Having a c-section meant I have had physical therapy for 2 years and my son had to spend an extra 5 days in the nursery from “normal side effects of cesarean.” It also means because of the mom’s increased difficulties and post-partum depression that the child will have a more stressed environment. I suppose all of this seems like an easy choice for me because I live in a major metropolitan area and yes I do have the options available to me.
LikeLike
>> My doctor and midwife team has a requirement for a doctor at hand regardless if it is a vbac, c-section, or natural birth without previous complications.
That’s good! Many hospitals only require the doctor in house if the patient is on pitocin. In many cases a doctor can have an office “on hospital campus” (nearby) and be considered in-hospital. This may be bending the rules a bit, but its pretty common.
LikeLike
Great post!
Lay people, and many midwives have difficulty understanding what low risk really means. Consider a neonatal mortality rate of 1.5/10,000 for VBAC (a relatively conservative estimate). Most lay people and midwives look at that and consider it so low as to be negligible. Since the risk of any individual woman losing a baby during VBAC is only 1.5/10,000, it doesn’t really matter much.
But low risk is not no risk, and the distinction is crucial. If the neonatal death rate for VBAC is only 1.5/10,000, that means that for every 1 million VBACs 150 babies WILL die. That’s 150 babies who probably would have survived if delivered by repeat C-section. That’s approximately 150 lawsuits that are virtually indefensible since the fundamental claim of the suit — that the baby would be alive if delivered by C-section — is almost certainly true. And it also means 150 pairs of parents who are stunned because they didn’t believe it could really happen.
So the question for VBAC activists is: Is it ethical to pursue a policy that WILL result in 150 dead babies who might have lived if they were delivered by C-section? That’s really what’s at stake, not autonomy, not choice.
I believe you can make an argument that it is “worth it” but that argument involves acknowledging that some babies will die unnecessarily, not pretending that the risk is so low that it isn’t worth considering.
LikeLike
Thanks for your comment.
>> Is it ethical to pursue a policy that WILL result in 150 dead babies who might have lived if they were delivered by C-section?
I think it is. To only consider these 150 babies is one sided, in my mind, as there will substantial levels of complications and even deaths born by the mothers who undergo all the repeat cesareans. In this country, we do allow mothers to make self interest driven choices about their pregnancies that may put the baby in jeopardy, even up to the point of allowing abortion for any reason prior to viability. It is certainly well within that freedom for a mother to take a small incremental increased risk of fetal death to get a benefit for herself.
You are right about the lawsuits, and that is a shame. Perhaps doctors who are hesistant to offer VBAC should ask patients to sign a waiver that releases them from any liability stemming from complications secondary to a uterine rupture. I believe most patients understand the risks of VBAC, and seeing that they are very small on an individual level, are willing to take that risk, and in turn would be willing to sign such a release prior to the labor.
LikeLike
“I think it is.”
I think it is, also, for the reasons that you state. Most obstetricians also agree, but the decision has been taken out of our hands, and it is important for VBAC activists to understand why. Hospitals, and particularly insurers know that babies WILL die as a result of a liberal VBAC policy, lawsuits will be filed and large monetary awards will be paid.
I don’t think that VBAC activists understand this at all. They look at low risk and consider it to be the same as no risk. They don’t accept the fact, because they don’t acknowledge the fact, that babies WILL die preventable deaths as a results of a liberal VBAC policy.
Of greater concern is that VBAC activists, because they don’t understand that babies will die, tell women that the risk is so small that babies won’t die. Then when deaths occur, as the statistics tell us they will occur, women are truly shocked and refuse to accept responsibility for their own decision. Indeed, in VBAC lawsuits women often argue that they didn’t “understand” the risks. They were informed of the risks, but they didn’t understand the THEIR babies could die.
It’s not about autonomy; it’s not about choice; its not about anyone “forcing” surgery on anyone else. It’s about the babies who will die and whether women and VBAC activists are willing to accept responsibility for the decisions that they advocate.
LikeLike
Hmm.. Perhaps we should work together to create a model consent form that clearly explains those risks and then asks a patient to indemnify the physician against liability stemming from a uterine rupture. Want to work on it?
LikeLike
While you’re at it, can you create another form that similarly explains the risks stemming from a repeat c-section and indemnifies the physician against liability based on those risks?
LikeLike
At that point you would be saying I won’t do either option unless you promise you won’t sue me, which is not the way medicine is practiced. Nobody is limiting access to repeat c/s, on liability grounds or otherwise.
LikeLike
“asks a patient to indemnify the physician against liability stemming from a uterine rupture.”
Unfortunately, it’s not possible for a patient to indemnify a physician against a charge of malpractice. The right to sue for malpractice cannot be waived. You could get someone to put her signature to a document stating that she waived her right to sue, but it wouldn’t be worth anything in most, if not all, courts.
LikeLike
We may have to ask a plaintiff’s attorney to be sure. I imagine that a general waiver against malpractice is impossible, but a very narrow waiver that precludes liability secondary to events during or subsequent to a uterine rupture might be possible.
I put the question up on Mahalo, we’ll see if a lawyer has a good answer.
LikeLike
My husband is a trial lawyer. He is not an expert on the law in every state, of course, but he says that as a general matter, people cannot waive their right to sue for malpractice.
LikeLike
I wonder if home birth midwifes worry about liability. I’m sure they do, but it doesn’t seem to affect whether or not they do VBACS. I would also be curious how often home birth midwifes get sued for something happening at VBAC’s.
LikeLike
You’re painting with an awfully broad brush. VBAC activists — by definition, the most passionate and learned ones — know very well that babies die. They’ve seen it happen to people with whom they’ve held hands, with whom they’ve shared raw emotions, and for whose babies they’ve attended funerals. They know all too well. And yes, they still advocate for choice, option, and autonomy. You can draw from that fact many things, but the conclusion can not logically include obliviousness and naivete.
This thread has included many broad brush strokes — of liability-weary physicians, sue-happy patients, and money-hungry attorneys — and both “sides” commenting on this thread have accepted each of them as generally valid (with acknowledged exceptions, of course). But your broad stroke isn’t valid, even in a “general” sense.
LikeLike
“VBAC activists — by definition, the most passionate and learned ones — know very well that babies die.”
Can you identify any websites or books ny VBAC activists that explicitly state the number of babies who will die each year as a consequence of a liberal VBAC policy? I’m not aware of a single one.
LikeLike
Nice Non Sequitur, Amy. It won’t fly with me, and hopefully not with the rest of the readership either. Your reputation precedes you.
LikeLike
tkhansen,
In other words, you can’t identify even a single website or book promoting VBAC activism that is honest about how many babies will die. That’s exactly my point.
How can anyone claim to be educated on the topic of VBAC if they don’t know how many babies will die because of them?
LikeLike
Um, actually, no…your words aren’t “other words” for what I said. I said your argument is a non sequitur. Or, if you do require “other words”…I said this: the existence (or lack thereof) of a VBAC activist-based web site that states the number of babies that will die each year is not proof that VBAC activists do (or do not know) that babies will die. Your argument doesn’t follow — thus, I won’t further the fallacy with requested “evidence” or counter “evidence”. Never said I couldn’t identify such a website, only that I wouldn’t. I’ll not continue to engage in the nonsense you play, but I also won’t have words put into my mouth.
LikeLike
Such a great conversation until Dr. Amy showed up. Starting to look like she ran Dr. Fogelson off his own blog. Amy, if we wanted to hear your opinion we’d be reading your blog. I am so glad to know many providers who disagree with you and, unlike you, are currently practicing medicine. I especially love to read the posts when they call out your flimsy interpretations of research. Unfortunately for you, your reputation does proceed you. Keep up the good work, just fuel for the fire. If you only knew how much you help rally the troops, you probably wouldn’t sleep too well at night.
LikeLike
I’m not run off by anyone. I was just enjoying the fact that my blog has enough community to carry on a conversation without me!
I care about everyone’s opinions, even if I can’t agree with them all. Being an OB/GYN, I actually share a lot of views with Dr Tuteur, though we choose to express these views somewhat differently. I have posted on her blog from time to time, and welcome her here too. This blog is, after all, Academic _OB/GYN_.
I will say this though
>> Dr Tuteur “Can you identify any websites or books ny VBAC activists that explicitly state the number of babies who will die each year as a consequence of a liberal VBAC policy? I’m not aware of a single one”. – this is a bit of an unfair statement, as the opposing side would be to ask if we could explicitly state how many women will die or be injured from acute or delayed complications from repeat cesarean if we were to adopt a no-VBAC policy, and I don’t think everybody explicitly knows this answer either.
Epidemiology is very useful, but one cannot practice medicine by epidemiology alone. Statistics remove the outliers by mathematical definition, so they will not and can never define every case. They only define the average case.
The important thing is for patient to have a reasonable level of education about the decisions they are making, including appropriate estimates of both fetal and maternal risk, before they choose whether or not to VBAC.
LikeLike
“as the opposing side would be to ask if we could explicitly state how many women will die or be injured from acute or delayed complications from repeat cesarean if we were to adopt a no-VBAC policy”
I think we can provide an estimate, and that indeed we are required to provide an estimate. For example, Cesarean Delivery and Peripartum Hysterectomy (Obstetrics & Gynecology:
January 2008 – Volume 111 – Issue 1 – pp 97-105) estimates the risk of future hysterectomy as a result of a C-section, and the mortality rate from a peripartum hysterectomy. There are other studies on the risks of infections, hemorrhage, future pregnancy outcomes, etc.
A VBAC consent form that lists all the risks of VBAC should also list the risks of elective repeat C-section in order for women to make an informed decision. Don’t you agree?
LikeLike
Absolutely. We do know that there are risks to both choices, VBAC tending to create more fetal risk and repeat cesarean tending to create more maternal risk. I’m not sure there is any documented facts about what a nationwide policy of repeat cesareans would do to maternal morbidity though, which was sort of my point. I suppose one could calculate it, or perhaps look at stats in upper class Brazilian practice, where cesarean rates approach 100%. Its a tougher stat though, that straight fetal death from uterine rupture, as there are so many different paths that morbidity can take (ie direct injury at time of cesarean, delayed injury due to abnormal placentation, delayed bowel adhesive disease,) in the case of a policy of repeat cesarean delivery.
Ultimately discussions of the widespread impact of a VBAC only or RCS only policy is academic, and in some ways creates a straw man target for either side to argue against. While different patients will prefer different methods, all patients benefit from informed options.
LikeLike
“Ultimately discussions of the widespread impact of a VBAC only or RCS only policy is academic, and in some ways creates a straw man target for either side to argue against. While different patients will prefer different methods, all patients benefit from informed options.”
My concern is that VBAC activists do not explain the risk in ways that women can understand.
Consider this information from VBAC.com, a prominent VBAC activism site (http://www.vbac.com/uterine.html).
First there’s an effort to obfuscate the actual risk of rupture and to convince women that it is not really that important:
“For women whose labors begin spontaneously, uterine rupture is reported to be less than 1% and the risks similar to or less than the risk of any other unpredictable complication of labor and delivery.
Medical experts state that the risk of a uterine rupture with one prior low-horizontal incision is not higher than any other unforeseen complication that can occur in labor such as fetal distress, maternal hemorrhage from a premature separation of the placenta or a prolapsed umbilical cord.
Respected studies have concluded that the probability of any woman needing to have an emergency cesarean those other complications is approximately 2.7% or up to 30 times as high as the risk of uterine rupture.”
Then comes the effort to downplay the consequences if rupture occurs:
“The majority of studies report that in the rare event of a uterine rupture, if the labor was carefully monitored, the birth attendant was trained to attend VBAC births, and if the medical response was rapid, mothers and babies usually do well. One study in a large California hospital which had 24 hour emergency coverage reported that outcomes for babies were better when the response time was 18 minutes or less.
With access to a rapid cesarean, fetal death from a uterine rupture is an extremely rare event.
The Vermont/New Hampshire VBAC Project findings show the overall risk of infant death from a VBAC attempt is 6 per 10,000 compared to 3 per 10,000 planned cesarean births.”
Every effort is made by the author of this site to minimize the risk and it would probably surprise women to learn that according to these statistics, for every 1 million VBACs, 300 babies will die.
I worry that such discussion of VBAC that does not make it clear that some babies WILL die from VBAC and is therefore not an honest discussion. I certainly get the feeling that VBAC activists feel that the risks are so low as to be negligible and that deaths almost never happen, but they’re not negligible; they’re very real.
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?
LikeLike
I agree that the quotes you cite downplay the risk of a uterine rupture, but the facts are pretty much correct. I do hate how they write “medical experts” and “respected studies” as this is usually what somebody write when they are either a) making it up or are b) to lazy to actually cite the real source.
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
LikeLike
Worth reading the entire conversation, just for this… some clarity. There are lots of risks in a lot we do. The choices we make have to add up for the individual and what will work for one would not work for another.
LikeLike
Your point should be generalized to the scope of all births. No information, no websites, tell women in general the real risks of losing a baby. The fact is that babies die, mainly in the hospital and very few of those deaths are part of a VBAC labor. Women are not informed about the true risks of infant mortality in any pregnancy. Why are you arguing for transparency of VBAC or homebirth deaths when they are not available to a non-VBAC mom? Why are we not appalled and why is there so much red tape involved in trying to address the fact that 16 in 1000 babies die in XYZ zip code in Kansas City? Gestating and giving birth in XYZ zip code is way more dangerous than VBAC or homebirth or home VBAC. The number of deaths and injuries in non-VBAC births is exponential compared to the number of VBAC incidents. But still the penchant to discredit the VBACers and the homebirthers who in general are very well informed, way better than the average mom. For once why don’t you take a stand for the babies that are already needlessly dying. I’d take my chances on homebirth a millions times over living and giving birth in XYZ zip code.
LikeLike
It is very important to consider denominators when we make these statements. Most fetal deaths occur in the hospital, but this in and of itself does not have meaning without a comparison to what portion of babies are delivered in hospital. Most fetal deaths also occur in non-VBAC labors, because despite the increased risk of of fetal death in VBAC labor, the vast majority of labors are not VBACs, and thus the majority of fetal deaths are not in VBAC labors. This says nothing about the underlying and relative safety of VBAC.
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.
LikeLike
“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”
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.
LikeLike
“VBAC was originally greeted warmly by everyone. No hospital, and no insurance company had a problem with it until women began suing and winning.”
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.
LikeLike
In regard to the case of Duffy v Flagg, it really ought to be noted that the appellate court decision you referenced above was reversed by the CT Supreme Court
Click to access 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.
LikeLike
“VBAC was originally greeted warmly by everyone. No hospital, and no insurance company had a problem with it until women began suing and winning.”
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.
LikeLike
That is pretty interesting and useful information. Thanks!
LikeLike
I have not read all of the comments on this thread yet so forgive me if this has already been addressed.
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?
LikeLike
My point is not about the situations surrounding the deaths, my point is if we’re going to call for transparency, let’s do it across the board. I find it interesting that you think it’s more important to be transparent in the case of VBAC because it’s a choice. This is quite sad because most of the infant mortality I speak of is very preventable. And truly the lack of choice, the lack of adequate information is critical to saving these babies lives. Bottom line, it’s about the weight or value that our legal system, our hospitals and our doctors have placed on different choices. Where would our focus save more lives?
LikeLike
>> This is quite sad because most of the infant mortality I speak of is very preventable.
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.
LikeLike
Thank you for your balanced discussion of VBAC. I especially appreciate your repeated comments that women are allowed to place relative value on their own health and well being.
I wanted to make one comment about rural hospitals. My rural hospital now has what has been called a de facto VBAC ban. We do have rules that state we allow VBACs, but in practice no one does them anymore. This was driven by pressure from our perinatal referral hospital (we are a small community hospital with a level 2 nursery, and as such are required to have a formal referral agreement with a tertiary care referral center to provide our MFM and neonatology care.) Prior to the change in rules, we activiated a “contingency plan” when we had a VBAC client in labor. The anesthesiologist stayed in the hospital, and the OB surgeon (at that time we had only one) stayed within minutes of the hospital (either in house or across the street in his office.) As a family doc, when I attended a VBAC, I notified OB (who would have already consulted prenatally on the client as well) and anesthesia, and I stayed in house for the whole labor, which allowed the OB to continue to see patients in his office across the street. In the event of an emergency, I’d be hightailing it to the operating room with the patient and anesthesiologist, and he’d be running across the street while we were prepping. Our perinatal center did not feel this continingency plan was good enough, and so the hospital rules were changed to state that we only do VBACs if anesthesia and OB and a surgery team (a scrub tech and circulator) were in house all the time. The hospital decided it was not financially viable to pay a surgery team to stay when they are most often not needed, and the OB is not willing to stay in house vs. across the street when he is able to, and so we no longer do VBACs. In our community, this means the majority of clients with one previous cesarean have a repeat cesarean with their next pregnancy. Some choose to drive to the referral tertiary care hospital 1 1/4 hours away for a VBAC attempt.
What was interesting, is that the perinatologists in our referral center didn’t feel that calling everyone in to be in house was “good enough” and stuck instead to a stricter interpretation that we did not have 24 hour in house anesthesia, citing concern that a VBAC client could walk in at anytime and have an emergency before anesthesia or OB could get here. Of course, that can still happen (or any number of other emergencies can happen that we are not best prepared to handle, as you mentioned in your comment about rural hospitals) It was sad to me to have to eliminate VBACs, which I felt we provided care for as safely as possible in a rural setting. For the majority of clients, driving 1 1/4 hours for prenatal care and during labor is not really an option. I don’t think the rules change is providing safer care for our clients with previous cesarean section.
LikeLike
Thanks for the comment. It is too bad that your hospital feels the need to have another hospital set your internal policies. I am in a tertiary referral center. Perinatology and general OB/GYN staff certainly would be happy to give another hospital an opinion, but I don’t feel we would have the right to dictate how another hospital should set policy, within an acceptable norm. I don’t think your previous practice is outside of an acceptable norm.
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.
LikeLike
“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 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.
LikeLike
Each practitioner is an individual. Some practice differently than others, and some practice in a way I don’t approve of. What you describe does not sound like great management to me, but not being there its hard to say. I would say that out of every 20 times I start to think that another doctor is doing something that is really wrong, 19 of the times I eventually find that I was missing some key pieces of information that made their somewhat unusual actions appropriate. Not explaining a plan to do forceps and get at least verbal consent is hard to justify, unless there was truly a critical emergency, which is pretty rare.
LikeLike
No, I was talking specifically about infant mortality. I used to work on the Maternal Health Coalition in Kansas City. A group of community leaders and those involved in maternal/infant health. Our specific goal was to decrease infant mortality in Kansas City. We broke down the deaths by zip code and did case studies on each death. If we could remove a couple zip codes, our infant mortality rates in KC would be stellar. You’re telling me you have never seen an infant death that could have been prevented? Amazing. Our proposed solution was to put a free standing birth center directly in that neighborhood staffed by CNMs. Before you go off on birth centers, the zip is blocks from a large academic medical center. I’ll give you one guess which members of the coalition stone walled that one.
LikeLike
Again I think you are missing the mathematical nature of things. It is absolutely predictable that the tertiary center will have the highest infant mortality statistics, as they are delivering the highest risk pregnancies. They probably deliver nearly 100% of the IUGR and anomalous babies that are at the highest risk for perinatal death. You would need a heck of lot more data that you are presenting before you could claim that some sort of management issue was to blame for what you are observing. Every tertiary center will have the highest infant mortality if you compare them to a lower risk center. I would hope that home births have a very low infant mortality, as they are hopefully an exclusively low risk population.
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.
LikeLike
I would also add that tertiary centers are often county hospitals that serve a predominantly lower socioeconomic class, which often have higher rates of underlying comorbidity and therefore higher rates of neonatal mortality.
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.
LikeLike
I’m really interested in the staffing issue in rural US hospitals, and what it means for VBAC. There are no UK maternity hospitals that don’t have 24/7 anaesthesia and obstetric cover. It’s possible that this is just a consequence of higher population density/smaller distances. However, the cover is also provided by a team, and there is no concept that the woman will get care from *her* obstetrician when in labour. (in fact, all the care will be provided by a midwife unless there is reason in labour to involve the doctor). I’m wondering how much of a difference this makes to the organization of care and the ability to staff a theatre round the clock if needed. We do have freestanding midwifery-led units (birth centres) with fewer births but generally previous caesarean section is an exclusion criteria.
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.
LikeLike
Most rural hospitals that deliver babies have OBs or family physicians on call, but they are not in hospital all the time. Some hospitals like these deliver only a few hundred babies a year, sometimes less than 100. They usually have anesthesia on call as well, but also not in hospital all the time.
LikeLike
I can’t speak for all rural hospitals, but we don’t staff 24 hour in house anesthesia or OB due to our low numbers of births. We average about 20 births a month. During the day there is always at least 1 anesthesiologist and 1-2 CRNAs (certified registered nurse anesthesists) in house. At night, generally our anesthesiologist is on call. Some of them choose to sleep in house, and all the others stay in rental housing, all within 2 blocks of the hospital. We have 1 OB in town, and 3 others in a town 18 miles away who have privileges at our hospital, and 3 family doctors (including myself) and a semi-retired OB who has the same privileges as a family doc and no longer does surgery. It is just not cost effective to pay everyone to be in house all the time.
As a practicing rural physician, I feel strongly that we have to be aware all the time of our limitations, and have good protocols in place to make our care is as safe as possible. So many people in the US live in rural areas, it’s not practical to cluster all higher risk care near population centers, so we have to be prepared to do the best we can in rare situations, because there is not always time to get someone to a higher level of care. Since we don’t do the number of births a large hospital does, keeping the nurses’ and doctors’ skills up is very important. We try to drill rare events and have emergency protocols and a rapid response team organized for emergencies – especially postpartum hemorrhage, shoulder dystocia, and neonatal resuscitation. With our low number of births, it might take a nurse several years to see a big postpartum hemorrhage or a true shoulder dystocia, so we try to prepare as much as possible with protocols and drills, which is never as good as real experience, but at least in an emergency, I do not want to have to explain what I mean by McRobert’s position, or suprapubic pressure! By state law, every hospital in our state had to develop a postpartum hemorrhage protocol this year, and that led to a lot of analyzing of our resources and the best way to be ready.
On the positive side, we can provide 1:1 nursing for all labor patients, and the grand majority of labor patients are cared for by their own physician, which eliminates at least the issues of hand-offs of care and not having the records available, which was always a problem where I was a resident.
LikeLike
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
LikeLike
First of all, we’re talking KC, 99% of the babies in this area are born in large hospitals, none of the hospitals are handling predominantly more high risk cases than the others. KU is handling just as many high risk cases as Research. So we weren’t comparing them to any low risk centers.
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.
LikeLike
>> First of all, we’re talking KC, 99% of the babies in this area are born in large hospitals, none of the hospitals are handling predominantly more high risk cases than the others. KU is handling just as many high risk cases as Research. So we weren’t comparing them to any low risk centers.
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.
LikeLike
Again, I do not believe I have ever seen a fetal or neonatal death occur in my care or the care of one of my colleagues that could have reasonably been prevented. Babies are remarkably robust, and when they die it is generally because of a serious force of nature disease.
LikeLike
But I think we’re getting a little off topic. But what the hell.
LikeLike
I didn’t mean that pediatricians are cows, or that OBs were like horses. Just that we are different animals. Maybe like aardvarks and elephants, or tigers and banana slugs.
LikeLike
“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”
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.
LikeLike
We started with the possibly preventable VBAC deaths, then you say we need to focus on other preventable deaths in the hospital, I say “what deaths?”, and you say they are because of the ills of society. Huh?
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.
LikeLike
I have not read the other comments so you may have addressed my question already. I would like to know why VBAC labors are induced and augmented if pitocin/syntocinon raise the risk of uterine rupture from .5% to 1%, making the woman twice as likely to rupture, and twice as likely to have a dead baby? It seems to me that a repeat cesarean would be safer for a baby than a VBAC labor with pitocin, prostglandin, or Cytotech aka “miso”.
LikeLike
>> It seems to me that a repeat cesarean would be safer for a baby than a VBAC l
labor with pitocin.
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.
LikeLike
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.
+++++++++++
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.
LikeLike
Along these lines, do things that some midwifes use, (like castor oil, black cohosh, nipple stimulation effect the rate of uterine rupture also? I live in a area where women love to use alternative methods of inductions (even if they are going to the hospital), so I’m just curious.
LikeLike
I am not aware of any data on these interventions, either that they are effective or that they affect uterine rupture rate.
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.
LikeLike
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.
LikeLike
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.
LikeLike
Can I ask how roughly many births a year you have at your hospital? How are there sufficient births to support a Level II neonatal unit, but not to support 24/7 obstetric theatre cover? Presumably this must be because you have a lot of transfers in from other, more rural?, hospitals without neonatal services?
LikeLike
Not sure who you were directing this to, but I practice in a tertiary academic center will full service NICU and just about every medical subspecialty. We do about 3,000 deliveries a year I think
LikeLike
We average about 20 births a month, around 240 births a year. We do have a 24 hour operating room – just the whole stafff that we normally have present for surgery is not in the hospital 24 hours a day, and have to be called in from home if a surgery is needed. By hospital bylaws (and also generally considered acceptable standard) we have to be ready to start an emergency surgery within 30 min of decision. In practice, we are usually faster than that – all of our anesthesia and delivering docs are close by, and there is always staff in house that can start the ball rolling.
Level II refers to our capabilities – we are able to do some specialized care such as oxygen therapy and tube feeding for sick/premature newborns, but not more specialized care such as ventilators or even CPAP. These are services that a general pediatrician (of which we have just 1) or a family doctor can provide and don’t require a lot of extra resources. We do not accept transfers from other hospitals, just are able to keep some babies who need some extra care in their home community.
LikeLike
@Nicholas. Presumably with 3000 births a year you can easily provide 24/7 cover (and you do VBACs), right?
@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.
LikeLike
I am at a large tertiary hospital, we do VBACs and just about everything else. The only thing we are missing that I am aware of is a pediatric cardiothoracic surgery program, which we have in the other tertiary center in the state.
LikeLike
I’m late to the party but compelled to comment. Disclosure: I am a (mostly) out of hospital (OOH) – rural home and birth center – midwife. I also have hospital privileges at a small community hospital. Our practice did 462 births per year and last year and 14% of them were in hospital. Those numbers include mostly our intrapartum transfers, VBACs, and a few elective hospital births. Last year our primary VBAC rate was 92% and our secondary VBAC rate 100%. Prior to my 6.5 years here, I worked in hospital as an L&D nurse and midwife for 9 years.
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 —
LikeLike
Thanks for your thoughts! I sounds like you have a good practice that serves a lot of people!
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.
LikeLike
Thanks for your response, doc. I’m on your side on the miso issue and also don’t understand the “birth activist community” anti-miso stance particularly. I mean, back when appropriate dosage was not known and it was used on VBACs, there were problems. But there is ample evidence on it’s safety now.
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.
LikeLike
I’m contemplating a vbac currently. I am so confused by all of the data out there and especially, as I think you mentioned because it’s hard to discern whether current trends are a result of malpractice concerns, or true concerns about the safety of the mother and baby.
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!
LikeLike
You are asking some really good questions, but I can’t really dispense specific medical advice on the site, for a number of reasons. We are here to discuss issues in general, but not specific cases.
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!
LikeLike
This is a very old discussion, but it is the only one I have found that addresses the issue I am seeking help with, so here goes:
A dear family member and her baby have just died in an HBAC. We are all traumatized, of course, but let’s leave our personal situation out. I know that she did not appreciate the risk she took when she chose to vbac at home. I am wondering if there are any statistics being kept on cases like hers (rupture/maternal death–in this case, the experienced midwife missed all the signs, though in hindsight they are obvious). I am dealing with our terrible loss in part by trying to tell people that the risk is real. Are there data that track these deaths given that most of it does not occur at the hospital?
LikeLike
My first was a successful vaginal birth. My last 2 were delivered via cesarean. I have greatly regretted my c-sections… I want to try a VBAC with number 4, but have not found anyone in my area who will perform this… What can I do? What are my options???
LikeLike
There are few physicians that want to attend VBACs for mothers with two prior cesareans. You might try a large or tertiary hospital like a teaching hospital.
But more importantly, why do you regret your cesareans? I’m sure they were done with the best of intentions, and presumably they resulted in healthy babies – and that is what is truly important.
While the reduction of cesarean delivery rates is a good goal, we can’t lose sight of what matters most – the safe delivery of a healthy baby.
LikeLike
I am also considering an in hospital VBAC. I had one prior C-sec due to untreated GD. My son was nearly 11 pounds. My new OB is taking an aggressive approach to ensure I have a baby of normal birth weight. Is there any statistics of successful VBACs specific to my case? Given the second delievery is of normal weight. Is there a correlation of increase Uterine rupture with a babies weight? How much time should elapse between a CS and a VBAC? Some literature states 18 months between deliveries while others state 24 months between delivery and conception. Also, my prior OB sutured my uterus in 2 layers stating this would lower my rupture risk. Is there any documented proof that the risk is lowered with this procedure? Can you describe what qualifies a person to be deemed a good VBAC canadet? I hope this helps me in this very difficult desicion. It’s a terrible spot to be in, choosing to risk your health or your child’s.
LikeLike
You sound like a good candidate, assuming that the infant is of relatively normal size in this pregnancy. That said, I don’t think we have data on fetal size and rupture rates.
Your uterine rupture rate should follow the general norms – about 1 in 200 for a non-augmented/induced labor, and about 1 in 100 for an induced labor.
Data on single layer versus double layer closures are mixed. Some studies suggest that a double layer closure is better, though there may be an impact from what kind of suture is used. There is not a good comparison between single layer or double layer Vicryl (polygalactin 910 – a delayed absorbable suture). With chromic gut suture double seems to be better than single.
As for the choice, either is reasonable. Try not to stress over it so much, as with either path the likelihood of a healthy infant is very high. Consider your long term childbearing plans. If one is going to have many more pregnancies, one may give greater consideration to a VBAC attempt as a success may avoid many future cesareans, which become more likely to be complicated as the number of repeats increases.
Good luck! Talk to your doc who should be able to help you make a good decision for you.
LikeLike
That’s not something a man would understand I’m afraid . Having to go through a c section can be depressing at times for a woman. It can be very distressing emotionally . Go to an ICAN group online and you’ll see how c sections really impact women. You can be glad your baby is healthy while still grieving that you had to have a major surgery to have your baby .
LikeLike
I would like to thank you for the original article. After finding out I am pregnant with my 2nd child, I have sought medical discussion from both sides of the VBAC arguement. Many sites choose to only side with the “woman’s choice” debate. All I need to know are the risks my child will be facing- so I can make the choice that brings a healthy baby. If I can try to give my child the best chance for a complete life, then I believe I can handle numbness, decreased sexual pleasure, infection, scary anestesia, or whatever. I am sorry if my statements seem offensive to some of you. We live in a time of extensive medical knowledge, why is the choice of experience greater than the lifelong condition and quality of health for our children? (Honest question) Anyway, thank you again for providing information I can utilize in making the best decision for the delivery of my child.
LikeLike
I am trying to decide what type of birth setting is right for me and my baby and have found your article helpful. I will be having a VBAC for the birth of my second baby. Dr. Fogel, what is your take on a VBAC mom being at a free-standing birth center, 3-5 minutes drive time from a major hospital (not including getting in the car/ambulance, getting to the OR, prep time, etc.)? For the purpose of answering my questions, let’s assume there is always an anesthesiologist and OB available for an emergency c-section, should the rare occurrence of a uterine rupture present itself. Thank you!
LikeLike
My feeling is that it is only a little better than being at home. Uterine ruptures are rare, but when they happen the require quick action to optimize outcomes. In a birth center there is usually no continuous fetal monitoring, which may delay the diagnosis of a uterine rupture. Once diagnosed, it will take quite a while to get from the door into an operating room, even if one is only 3-5 minutes away. You correctly mention the other issues that will slow transfit into an operating room, something that many people seem to miss.
My feeling that if a uterine rupture occurred in a birth center, the likelihood of a good outcome would be much lower than if it occurred in a hospital. That is why I do not recommend home VBAC and think that they represent an undue risk.
If you choose to go this way, the likelihood is that everything will be fine, as uterine ruptures in spontaneously laboring women are rare.
LikeLike
Thanks for taking the time to answer my question, Dr. Fogelson. I’m trying reconcile what I have heard when asking birth center and home birth midwives, with what you and hospital providers say. The home birth midwives and birth center midwives I have interviewed, monitor every 30 minutes with a Doppler, and every 15 minutes (if I remember correctly) as delivery nears. The birth center midwife I interviewed (3-5 minutes drive time), said that If an emergency arises, they call the hospital to prep for the emergency, while we are transferring, which means that there is little to no time lost. What do you think about that statement? Also, the home birth midwives mentioned 30 minutes from decision to incision. My impression is that 30 minutes can be too long in a true emergency, such as uterine rupture or cord prolapse (vs. fetal distress from Pitocin, like in my first delivery). Can you shed some light on this?
And, there’s the question of laboring at home for part of labor. I don’t plan to go to the hospital or birth center the moment I’m in labor, especially during early labor. Am I correct that the chance of uterine rupture is more likely to happen closer to delivery, when the uterus is working harder?
Thanks again.
LikeLike
First c-section was one layer of stitches. Second I went to hospital @ 7cm against Dr’s wishes to schedule surgery and met a fierce opposition by chief of surgery (Tampa General Hospital is “VBAC friendly”) He said I had a 50/50 chance of success and if I fail baby or I could die. Literally no discussion of death or brain damage for the surgery before I was taken and baby was born with no complications. Sure I signed the consent form and Im sure it alluded to it.
Can a rupture go unnoticed? Whats my chance of death from a spinal/csection? I know that were estimating the risks at best. I dont care about recovery. I want to know if one way is safer than the other. I feel like my counseling would be different if I signed a release of liability from the start. ( I’ll sign if it changes your answer : ) Not just a consent.
I feel like a first time low risk mother has chances of death that we don’t escape by having surgery? Im ready for a stork on this pregnancy.
LikeLike
I can’t give specific medical advice on the blog, but in general:
The risk of uterine rupture with VBAC attempt is between 1/200 and 1/100. The rate of VBAC success (not having another cesarean) is between 60 and 70%, depending on the reason the first cesarean was done.
The fact that there was a single layer of sutures is of unclear significance. It may depend on what kinds of sutures were used. Some data suggests that a double layer is better than a single layer, but the data is not conclusive. A single layer of Vicryl may be as good as a double layer of Chromic suture. Either way, I would not let the number of layers be a deciding factor on whether or not to attempt a VBAC.
In a monitored labor, uterine rupture will likely be recognized fairly quickly, though small ruptures may go unnoticed for a period of time.
The chance of death from a cesarean delivery is extremely low, in the range of 1 in many thousands.
In general, the choice to attempt VBAC confers a small risk to one’s infant in return for somewhat reduced risk to the mother. The choice to do a repeat cesarean confers a small protective benefit to one’s infant in return for somewhat greater risk to the mother. With either choice, both parties are likely to be fine. The differences between outcomes are very small, when measured in large groups of women. The courses of individual women can vary.
VBAC counseling is a sticky issue with some hospitals. I suggest that you talk to an obstetrician that attends VBACs and discuss your particular situation, with a careful review of the previous pregnancies and deliveries.
LikeLike
I am that one 1% who ruptured. I am no longer a believer in Vback. it’s been over twenty one years since my rupture and i have lived with the guilt of making a wrong choice. The devastation this left me is for a life time. I will walk a life a grief as my baby died from this until the day i die. its something you never get over. My oldest daughter recently had a emergency csection her doctor and the nurses were talking to her about attempting vback next time. I thought I was going to lose it but then she told them its not a choice they went on to tell her the risk is low, she looked at them then looked at me and she said ” i know the risk, I know it’s only 1% see my mom over there? she is that 1%. They looked at me and i said yes, I am that one percent . I am also fortunate to be alive today to tell my story and i was blessed to have had my son 2 years later. not very many women get the chance to go onto having another child and or live., But God blessed me.
I honestly feel my story has been pushed aside because it is reality and it can happen, it does happen and it happened to me.
if i could go back in time i would have had a repeat c -section from the start . This changed my life in many ways destroyed it. took a big toll on my marriage which ended up in divorce. If you are considering going vback. think about it long and hard. I know the percentage is low and you don’t think you can fall into that 1 % you can. I did and I thought it would never happen to me.
LikeLike
You make a very good point, which that rare events are very serious when they happen to you, and in retrospect make the decision feel very different.
I think this applies to great deal of obstetrical decisions. Some women choose to take small risks in order to have a greater likelihood of the birth they desire, which work out the vast majority of the time. When they don’t work out though, they may look back and feel that the decision was not well made.
I think in the right environment VBAC makes a lot of sense, as it decreases our cesarean rate without undue risk. In the right setting, a uterine rupture should be both rare and almost always manageable if it does occur. VBAC performed in the wrong setting, however, is a mistake in my opinion.
The view of a certain population that VBAC should be safe in any location where it is safe to deliver a baby is foolish and ignorant of the realities of the situation.
LikeLike
I know you said you experienced a rupture about 22 yrs ago. I was just curious to know if your vbac attempt was with a previous vertical incision or a low transverse ? I’m
Attempting a vbac but I have a low transverse incision . I know vertical incisions were more common in the past and some women actually had vbac attempts with vertical incisions which are actually higher risk than the less than 1% with a low transverse. Thanks. Sorry about the loss if your baby .
LikeLike
That was very helpful to me! I just started sewing a couple of months ago and have always wondering about the different feet out there. Great job! I learned something new and very helpful!
LikeLike
What are your thoughts on pelvis size? I was told by my OB my chances of VBACing were slim because he says I have a small pelvis. My daughter was 9 pounds, 2 ounces and 21 inches. She was discovered to be asynclitic during the csection. She was born with torticollis and plagiocephally as I was allowed to push for a couple hours before my OB took me in for a csection (both issues have since been corrected and she is doing just fine). This was after 44 hours of labor. She was born 10 days past my due date.
My son was my hospital VBAC and here after only 12 hours of spontaenous labor counting the 30 minutes of pushing and episiotomy (done after a nurse came in to tell him there were multiple patients waiting for him next door at the clinic, which I found strange and I was demanding him not to). My son was 8 pounds and 14 ounces and half an inch shorter than my daughter and born 2 days after his due date.
Would the 4 ounces my daughter had on my son at birth have really made that much difference?
LikeLike
This my question though . If the hospital isn’t equipped to handle an emergency during Vbac how are they equipped to handle other obstetric emergencies Like a prolapsed cord or placental abruption , or a baby severe distress ? If they can’t handle it maybe They shouldn’t be handling obstetric care at all . I think all women should have access to equal quality obstetric care no matter their birth choice.
LikeLike
I wish more hospitals, insurance companies, women and doctors would move over to your way of thinking. Many women are “feared” into cesarean, because they are not familiar with the risks, as well as the future childbearing implications. I lean toward the hospital setting, but would like to include a study done in a small birthing center in Amish country. The birthing center has experience midwives and physicians available and in a community where homebirth is the preference, their study demonstrated a 96% VBAC success rate for all births (Deline et al., 2012). A 4% cesarean rate is a far cry from the national average of 32%. We could all learn from this small community. Thank you for sharing.
Reference:
Deline, Varnes-Epstein, Dresang, Gideonsen, Lynch, & Frey. (2012). Low Primary Cesarean Rate and High VBAC Rate With Good Outcomes in an Amish Birthing Center. The Annals of Family Medicine, 10(6), 530-537.
LikeLike