Home
> Academic OB/GYN Podcast, Green Journal, Grey Journal, Journal Articles > Academic OB/GYN Podcast Episode 34 – Journals for June-Aug 2011
Academic OB/GYN Podcast Episode 34 – Journals for June-Aug 2011
Drs Browne and Fogelson discuss Cesarean Delivery Rates, VBAC Guidelines, Placenta Accreta, and the critical role of Flash the Cat in the Academic OB/GYN Podcast.
Academic OB/GYN Podcast 34 – Journals for June through August 2011
Categories: Academic OB/GYN Podcast, Green Journal, Grey Journal, Journal Articles
Academic OB/GYN 
Dr. Browne touched on the decreased availability of VBAC in the Columbia SC area leading to women seeking VBAC with “lay midwives and birth centers”. SC DHEC is very clear that neither Licensed Birth Centers nor Licensed Midwives may attend women with a previous cesarean section. So while it is true that patients may seek, it is not true that they find.
Lack of/dwindling VBAC access does drive some patients to unlicensed/underground birth attendants, however. Given the fact that Licensed Midwives already struggle with acceptance by the OB community which hampers continuity of care and has a deleterious affect on transferred patients, the effects of unregulated providers on patient care and access to a higher level of care as appropriate have me deeply concerned. As does lack of true informed choice for women seeking VBAC.
LikeLike
Nice to hear you commenting the research and talking so candidly. As a patient I keep oping I run into doctors like you 🙂 Thanks!
LikeLike
First of all, thank you, Dr. Fogelson, for all of the frank and thoughtful discussions via blog and podcast.
I had a few questions about VBAC, primarily about uterine rupture, and I wasn’t quite sure where to post about them, so I figured since you addressed VBAC policies in this podcast, it couldn’t hurt to post here.
I know previously you had mentioned a “1 in a 100” chance of rupture. I have been finding that number associated mostly with oxytocin-enhanced labors, whereas without the use of pitocin the number is stated as closer to 1 in 200. Do you think this is accurate?
Also, there are numerous articles to be found that list various risk factors for rupture, ranging from age to imbrication, but very little information on how these factors alter the general 0.5-1% statistic. Especially in terms of double-layer suture – does the 0.5% apply to double-layer sutures, or is it an all-encompassing stat that covers all styles of suture among patients attempting VBAC?
In terms of location of delivery, I wonder about the “call to cut” time for a cesarean following uterine rupture. I know this likely varies widely, but I’ve seen this interval estimated at about 20-30 minutes depending on the hospital. Is this accurate? Given this timing, would it be possible for a midwife at a free-standing birth center or home to call ahead requesting an OR theater for emergency surgery such that the “call to cut” interval is similar to that of a hospital TOL? Or is the concern more about uterine hemorrhage in the minutes prior to surgery?
Also with regards to hospital VBAC, do you support hospital practices such as continuous monitoring, IV placement, limits on labor time or nutrition for VBAC?
Lastly, have you had any contact with Saraswathi Vedam? She is a brilliant CNM up in BC with a passion for homebirth but also for evidence-based medicine. I respect both of your opinions, and notice that you differ on your opinions about home VBAC, and since you both seem very passionate about collaboration in the healthcare professions, I would love it if you could compare notes.
As you may have gathered, I am hoping to attempt VBAC and considering home VBAC as a potential future option following a very traumatizing cesarean birth. The painful irony is that I am myself training to be a physician, so according to many colleagues I “should know better.” The problem for me is two-fold: 1) I suffered severe PPD and I believe mild undiagnosed PTSD following surgery, so the hospital does not represent a safe space for me psychologically (therapy has helped only somewhat, I’m hoping that through my training on the wards I will build different and more positive associations through the humbling privilege of service) 2) I felt even in my first labor, there was an expectation of failure and anticipation of pathology among both nurses and physicians that disturbed me while at my most vulnerable, even at one of the most progressive hospitals in the country. In discussing VBAC with healthcare professionals, I have the distinct impression that in a hospital setting I will be treated as the 1 in 200 potential catastrophe, rather than the 199 in 200 who birth without rupture. Though it is arguably part of the job description, I think sometimes physicians underestimate the negative effect they might have on outcome just by expecting the worst. I wish I could explain how accutely sensitive a woman in labor might be to her environment without sounding “out there.” The problem is, this effect is difficult if not impossible to measure.
I don’t expect you to change your mind on home VBAC, but I wonder what you suggest for someone who feels anxiety that the medical profession will just be waiting for something to go wrong? My last labor was 3 days, (persistent OP/near brow presentation, 9lb baby with 38cm head circumference, arrest of descent), and I’ve known many women who had 3-day labors that ended in uncomplicated delivery, but this seems unheard of in a hospital. I felt from the moment I was admitted to the hospital, each new intervention was undertaken with more and more skepticism about non-surgical outcome, and this does not bode well for a labor that starts out with additional risk. I’m hoping that by the time there is a next time, assuming that I have a healthy pregnancy and am suitable for TOL, I will have healed enough psychologically that the prospect of surgery won’t feel as scary, but I would still like to do everything possible and reasonable to avoid it. What if things stall, if things get stuck temporarily, if there’s a bump in the road? Will I have to fight for a chance to ride it out, even as I’m fighting to get through labor? Should I just wait till the last possible minute to go to the hospital like I tried to do last time, and if I’m going to do that, wouldn’t I be safer with a midwife at home with me?
Just a bunch of thoughts and many questions. Family planning still has a possible future baby fairly far off on the horizon, but I was so impressed with your willingness to tolerate “unorthodox” discussion, that I thought it would be worthwhile to inquire. Thank you so much for your time and thoughtfulness.
LikeLike
Sarah – thanks for your comments and questions. Here’s a few thoughts.
First of all, thank you, Dr. Fogelson, for all of the frank and thoughtful discussions via blog and podcast.
>> I know previously you had mentioned a “1 in a 100″ chance of rupture. I have been finding that number associated mostly with oxytocin-enhanced labors, whereas without the use of pitocin the number is stated as closer to 1 in 200. Do you think this is accurate?
Yes. The rate in spontaneous labor is closer to 1/200 and closer to 1/100 with augmented labor.
>> Also, there are numerous articles to be found that list various risk factors for rupture, ranging from age to imbrication, but very little information on how these factors alter the general 0.5-1% statistic. Especially in terms of double-layer suture – does the 0.5% apply to double-layer sutures, or is it an all-encompassing stat that covers all styles of suture among patients attempting VBAC?
These numbers are based of different studies, so its hard today. Single layer chromic clousre seems to have a higher rate of rupture than double layer chromic. Single layer vicryl may be as good as double chromic. The studies that the overall ruptures rates are based on are not stratified by suture type, so its hard to say exactly where the numbers fall. Around 1% give or take 0.5% for most VBACs is most likely close to the actual risk.
>> In terms of location of delivery, I wonder about the “call to cut” time for a cesarean following uterine rupture. I know this likely varies widely, but I’ve seen this interval estimated at about 20-30 minutes depending on the hospital. Is this accurate?
ACOG standards suggest that if a cesarean is called emergently in a hospital, the baby should be delivered in 30 minutes or less. This doesn’t necessarily mean that this is quick enough in every case. A well staffed and trained L and D team with in-house anesthesia can likely get a baby out in far less time than this if pushed. Personally I find it unrealistic to think that a patient with a serious problem recognized at a birthing center is going to deliver within 30 minutes. Beyond transportation, there is time required to see the patient, get her on the monitor, and confirm what is going on. If someone is laboring without monitoring in a birthing center, in most cases the in-house obstetrician is going to want to assess the situation in a labor room for at least a few minutes rather than bring the patient directly back to the operating room.
Also with regards to hospital VBAC, do you support hospital practices such as continuous monitoring, IV placement, limits on labor time or nutrition for VBAC?
Continuous monitoring – in VBAC, absolutely yes. If you’re not going to monitor, VBAC at home. But don’t do that either.
IV – unless the patient has some kind of serious problem with it, yes. Why not?
Limits on labor time – not really, assuming that the fetal strip is reasurring. I think you have to individualize, but also be sensible about it. If the first cesarean was for arrest of dilatation and a person has been stuck at 6 cm for many many hours, I think you have a pretty good indication of what is going on.
Nutrition – NPO except for water is pretty standard, based on anesthesia edicts. I think the data on this is pretty weak, but its something that the anesthesiologists want, and isn’t obstetrician driven. Despite any large dataset, the individual patient who has aspirated during the anesthesia induction process is a nightmare for the anesthesiologist.
Lastly, have you had any contact with Saraswathi Vedam…
No
As you may have gathered, I am hoping to attempt VBAC and considering home VBAC ….
you should know better…. 🙂
I think a home VBAC, like any VBAC, is taking a very small risk of a really bad outcome, except that in the case of the home VBAC you have almost no safety net. With in-hospital uterine ruptures, our rate of fetal injury is around 10%. We have no data, but I think it is reasonable to assume that the rate with home VBAC would be much higher. I would avoid it personally.
I think what is important for you is to express what you have expressed here to an prospective obstetrician and see how they feel about it. If they seem to understand and want to work with you, then you probably can have the experience you want. If they cringe at the idea of homebirth and scoff at the idea that your previous labor was a serious emotional trauma, then you probably need to keep looking. There are definitely OBs out there that could help you have a good experience in a hospital.
Thanks again for listening to the podcast and good luck with your career and future pregnancies!
LikeLike
A dear family member and her baby have just died in an HBAC. 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 with no obvious risk factors [spontaneous labor, 1st pregnancy after cs]–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 the events leading to death do not occur at the hospital?
LikeLike
I’m not aware of stats, but my experience an OB would tell me that if the spontaneous rupture rate is 1/200 with spontaneous labor, somewhere around 1/500 of home VBACs are going to be a total disaster. I feel that those that would support such a practice haven’t seen how badly things can go, and are making such recommendations without enough knowledge. Certainly one could attend 100 such births and have them all go great, but ultimately that’s not skill – just luck.
LikeLike
Wonderful dialogue about the VBAC out-of-hospital issue. I am a CNM, completely support out of hospital birth, have worked in a freestanding birth center, yet feel very uneasy about VBAC’s in this setting. There was the study done by the American Association of Birth Centers (AABC) in 2004 that showed a higher rate of complications for women attempting a VBAC in birth centers who had one or more previous c-sections. This prospective study had such compelling results that the AABC and the Commission for the Accreditation of Birth Centers (CABC) recommended against VBAC in the birth center setting. See the abstract here: http://www.ncbi.nlm.nih.gov/pubmed/15516382
.
The CABC in July of 2008 began allowing accredited birth centers to provide VBACs for women with one or more previously successful VBAC. In addition, they agreed to allow a case-by-case basis for birth centers wishing to do primary VBACs. Clients wishing to attempt VBAC in an accredited birth center must meet the following indicators: “only one prior cesarean section, documented low transverse incision, ultrasound showing placental location not anterior and low lying, signed VBAC-specific informed consent, one or more successful prior VBAC, meets all over risk criteria of the birth center”… If it is a primary TOLAC/VBAC then additionally birth centers must be able “to transfer care to a facility with 24/7 availability of anesthesia and obstetrical attendance and it must be located in close proximity to the transfer facility” (they do not define distance). http://www.birthcenteraccreditation.org/2011/07/
The AABC has been collecting data on birth centers for many years now — the Uniform Data Set is a comprehensive set of questions regarding the antepartum/intrapartum/and post-partum care of ideally all clients in a participating home, birth center or hospital birth with midwives. Included in the survey are questions about those attempting VBACs including type of scar, double or single layer, medical reason for previous cesearn, patient’s beliefs regarding this reason, and outcomes of TOLAC. Whenever the data becomes available, it will be interesting to see their findings.
All of this being said, midwives take a variety of stances on this issue. I have homebirth and birth center colleagues that offer VBAC; I also know some CNM’s who have had very poor outcomes in hospital TOLACs and, for this reason, they feel very strongly about them in an OOH setting. As with many things, I feel much more confident when centers have pretty clear guidelines about who risks in and out and what criteria needs to be met when a client varies from “normal” for them to continue with birth center/out-of-hospital care. I also agree strongly that VBACs should be much more accessible in hospital settings.
Because I am still very much on the fence about this issue, I wanted to hone in on one of your comments in the podcast. At one point you said (the following is very much paraphrasing, so forgive me if I misremember) that other labor risks, such as prolapsed cord, happen in normal, low risk labors to more or less the same percentage as uterine rupture in VBAC (I’m assuming non-induced in an otherwise low risk pregnancy & labor). I don’t know these numbers, so I’m wondering if you could share the percentages. That being said: Is your concern with VBACs in the OOH setting that this is a KNOWN risk with potentially devastating consequences that women & midwives are taking? If the risks are more or less the same, then why would it be okay, for example, for a known case of mild polyhydraminos be given the go ahead for OOH birth when her risk of prolapse maybe greater. Or what about AROM in labor in the OOH setting? I am not trying to divert from the main issue, but I am very sincerely trying to clarify this issue for myself.
Anyway, I love your work and really dig your candor, insights, and enthusiasm in the podcast.
P.S. I also totally support your family planning discussion/access to safe abortion services in this podcast — keep at it and keep it strong. For those naysayers out there, my grandma was an OB-GYN back before Roe v. Wade and she told many a horror story of the “attempted home abortion” wards. They were real, they did exist, and they continue to kill women (many of whom are mothers already) in countries where abortion is not legal and accessible. Furthermore, the attack by the religious right claiming “religious freedom” for limiting women’s access to contraception is just such baloney and not family friendly at all. Poverty is real and we know families are healthier, stronger and more successful if they are planned, economically stable, and supported by their community. I don’t understand the push for policies that harm Americans by limit their access, control their choices, and in so doing, keeping them economically disadvantaged and oppressed. Ergh.
LikeLike
Thanks for reading the blog and for your thoughtful comments.
Uterine rupture is a very rare event in VBAC labors, but in some cases has similar frequency to other bad events like cord prolapse, etc. You ask a good question on why we treat uterine ruptures so differently that these other rare problematic outcomes.
I don’t have a definite answer, but I think ultimately it has to do with medicolegal risk and case law regarding uterine rupture and VBAC. I think in the case of a cord prolapse, the outcome is clear and fairly low risk – one is going to go to the OR and do a cesarean for a healthy baby. Uterine ruptures are far more variable in their outcome. Some will turn out fine and some will not. Regarding VBAC at home, I think that uterine rupture has the potential to be a very time sensitive event, where the time required to detect the rupture and transport the patient for delivery could lead to a fetal death or injury that would have been prevented in the in hospital setting. Case history has shown that a mother who has an infant injured in a VBAC attempt, even with proper informed consent, many be able to win a massive settlement. Doctors are appropriately concerned about this, and will continue to be until there is appropriate reform in tort law to prevent these types of settlements.
I think that if we are going to support out of hospital birth, it should really be for known low risk pregnancies. If we have known polyhydramnios, probably one should deliver in the hospital due to the known risk of cord prolapse with rupture of membranes (artificial or otherwise), as well as the possibility of previously undiagnosed diabetes. The argument against homebirth is that while bad events tend to be more common in high risk pregnancies, as most pregnancies are low risk ultimately the majority of pregnancies will occur in low risk mothers, and as such a risk stratification system will not prevent us from having bad things happen at home. While I think homebirth is a reasonable option, I do think it adds some quantifiable amount of risk to the overall birth process, and in general would try to reduce that risk by encouraging women with any identifiable high risk factors to deliver in the hospital.
LikeLike
What are your feelings on VBA2C? Do you support a TOLAC for a mother who has had two prior cesarean section (first for breech presentation, second for twins) both with low transverse uterine incisions? Does your current practice/hospital support VBA2C?
Thank you.
LikeLike
ACOG now supports VBAC after two low transverse cesareans in hospitals that are appropriately equipped to handle VBACs. The clinical situation you describe would be a reasonable case, barring some other reason against it.
I am not aware of any hard policy on VBAC after two cesareans here at Emory. As a tertiary center I suspect we’re OK with it.
LikeLike