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More VBACs will take communication, compromise, better training, and tort reform

Screenshot 2014-05-21 19.49.20The NY Times has reported on a woman who wanted to deliver vaginally and claims she was forced to have a repeat c-section (her third c-section) against her will. I can’t comment on the veracity of her claims, however a forced c-section is never, ever acceptable. It doesn’t mater if the fetus has an agonal rhythm (is visibly dying on the monitor), as an OB your role is to try to make your case for the intervention you feel is the most medically acceptable, but never, ever with force or threats. You make sure all your discussions are witnessed and you spend a lot of time documenting, but choice is choice.

Specifics of the case aside, it is a great launching point for a rational discussion on vaginal birth after cesarean section (VBAC). Failure to get an in-hospital VBAC has left some women to VBAC at home, which medically is less than desirable.

Why the medical fuss about VBAC? About 0.7% of the time the laboring uterus rips open as the scar from the previous c-section fails from the force of the contractions. When the uterus ruptures there is a 5% chance the fetus will die (although some people report higher stats the 5% is from the Swedish Birth Registry data). The biggest risk to the fetus is if the placenta was implanted over the previous scar, so when the wound separates the placenta literally blows out into the abdominal cavity. An unattached placenta is catastrophic for the baby. A c-section within 10 minutes would be unlikely to salvage that situation. Uterine rupture can also result in catastrophic hemorrhage for the mom, although the maternal death rate with an attempted VBAC is about the same as an elective repeat c-section. The risks with uterine rupture (massive hemorrhage) are offset by the baseline increased risk of a c-section.

So you say 0.7%, well, that’s not too bad? In medicine a potentially catastrophic outcome of 0.7% is high. Would you get on an airplane if you knew ahead of time the risk of a crash was 0.7%, after all most crashes are survivable? A uterine rupture is like an airplane crash. Some are fender benders on the tarmac and have no or minimal  consequences, but some result in loss of life.

98-99% of women who attempt a VBAC at home will not have a catastrophic outcome. Midwives who deliver at home and claim to have never had a rupture have not done enough deliveries and have the lowest risk clientele (healthy young women will generally have the lowest VBAC failure rate). They also may not read the surgical report of the c-section that happened after the patient was transferred in. However, when you do a 5-year residency in a hospital that delivers 6,000 babies a year with a welcoming VBAC policy you see a few ruptures and the feeling of free-floating fetal parts in the abdomen is simply sickening.

Given that 99% of VBAC won’t have a catastrophically bad outcome why won’t more hospitals and doctors do them? Lawyers. VBAC is the love child of medical malpractice lawyers. Many malpractice insurance carriers require specific VBAC consent forms and many hospital have given up altogether out of lawsuit phobia (never mind the fact that they couldn’t pay to keep anesthesia in-house 24/7). A staggering 26% of OBs indicate that they stopped offering VBACs due to malpractice concerns.

The height of the VBAC success rate was 1996/1997 and it has plummeted since. I finished training in 1995 and we aggressively pushed VBACs. Go to a doctor who finished training after 2000 and the odds that they look on VBAC favorable are likely much lower, and now those doctors who trained since 2000 are training the new doctors.

VBAC and c-sections, from Wiliiams Obstetrics, 23rd Edition.

VBAC and c-sections, from Wiliiams Obstetrics, 23rd Edition.

So what can we do?

Doctors and labor room nurses need to realize that most VBACs will be successful. Some are riskier than others, but on’t paint all VBACs with the same brush. Training and education might help to create a more supportive environment. Doctors should be honest upfront about chances of success based on real data and also about their VBAC training and experience. You don’t have to do VBACs just like you don’t have to do abortions, but it should be in the welcome-to-my-practice letter.

Women need to be realistic about their VBAC prospects and the risk of rupture, because it could be higher than 0.7% depending on a variety of factors. For example, if a pregnancy within 6 months of a prior c-section increases the risk of rupture three-fold with VBAC. Scars need time to heal. Many factors also affect VBAC success rates and there is even a calculator that can help predict the odds of a successful VBAC (it’s in Williams Obstetrics). Maybe if the chance of a successful VBAC were 75% versus 15% it might affect the decision. It might not, but that is of course the crux of informed consent.

Patients (and the few midwives who disparage hospitals) need to realize that  safety measures like an IV and fetal heart rate monitoring are really not evil paternalistic medicine. An IV is like a seat belt on a plane. Most times you don’t need it, but if your plane drops 600 feet in a few seconds it could potentially save your life or save you from injury. If you are in that 1% or so who has a rupture the seconds getting to the OR count. Even with drills and training the average time from calling a true crash c-section to cutting the belly is 14 minutes. Putting an IV in takes at least another minute, but sometimes longer. The monitor cam help detect fetal heart rate changes that could be a signal of impending rupture. Would you want your pilot to fly without instrumentation?

VBAC specific tort reform is desperately needed. VBACs are a huge source of lawsuits. If they were not they would not have fallen out of favor obstetrically. Most midwives who deliver a VBAC at home and have a complication will never get sued because they don’t carry enough (if any) malpractice insurance for a lawyer to consider it worth the while. I have heard of doctors who received a patient who labored at home with a VBAC, there was a rupture, they did the emergency c-section within minutes of the ambulance arriving and got sued because they were the ones with the insurance.

Without tort reform more delivery rooms are not going to adopt a can-do VBAC attitude, so tort reform will have to happen before training picks up (and it’s going to have to happen before everyone who finished training before 1998 retires).

 

Would you ever drive with your newborn on your lap in the car? Most of us would be aghast at the thought of such a thing. The thing is the chance of a car accident on any given day is far less than a uterine rupture with a VBAC. Is is technically safer to drive with an unrestrained infant than VBAC at home. These stats don’t mean don’t have a VBAC anymore than they mean don’t take your baby for a drive, just do those things in the safest manner possible.

There is no reason why all good candidates shouldn’t have the opportunity for an in-hopital VBAC if they want, but it will take…

Communication.

Compromise.

Tort reform.

Better training.

 

 

 

All the data is from Williams Obstetrics.

 

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Discussion

6 thoughts on “More VBACs will take communication, compromise, better training, and tort reform

  1. Thanks for this… Very interesting to see the numbers

    Posted by crankygiraffe | May 22, 2014, 7:11 am
  2. I’m a bit too far away from a copy of Williams’ Obstetrics at the moment, so can’t check the source of their data, but would like to comment that the figures we were taught (in Australia) are 0.5% risk of rupture, and also a local study in the BJOG (2010) in an Australian cohort that had a rupture risk of 0.19%. The article also helpfully outlined the effects of various induction and augmentation procedures on the OR of rupture.

    Posted by araikwao | May 22, 2014, 3:29 pm
  3. The risk of uterine rupture that you quote is for a VBAC after one C-section. The risk more than doubles after two C-sections, according to this study (1.59% vs. 0.72%):

    http://www.ncbi.nlm.nih.gov/pubmed/19781046

    Posted by Daleth | May 23, 2014, 10:12 am
  4. Responding late because I just found this. My daughter born by VBAC is twenty-seven this year. I had had a complicated first pregnancy (more complicated than just the cesarean) so of course my approach to VBAC had to be cautious.

    The best thing for me was that I did find a doctor who proceeded on the basis of the available science and observing events in front of him rather than just doing what “seemed right.” He and I were able to discuss with clear eyes and frank language exactly what we knew about my situation and what conditions would mean that we would no longer be willing to proceed with the VBAC plan. Even though I naturally had strong emotions about the emergency cesarian I’d had before, I was able to be willing to ditch the VBAC if necessary, and not wait till the last minute either!

    In the event it was an uneventful birth though it did take a while. Even if we had gone to a cesarean at some point, though, I would have felt completely grateful for Dr, Salvay and his thoughtful, scientific approach to my daughter’s birth.

    My point is that you are right: doctors need to be knowledgeable and observant for childbirth generally, and VBAC specifically. It’s stupid that lack of training gives doctors the choice of putting women through surgeries they may not need because the doctors don’t know how to manage these births and when the women really do need surgery. And it’s even stupider that women end up having to choose to put themselves at risk, either by accepting a possibly unnecessary surgery or by giving birth away from medical backup.

    Posted by Lucy Kemnitzer | June 16, 2014, 2:16 pm

Trackbacks/Pingbacks

  1. Pingback: Roundup: What Top Pelvic Health Bloggers are Talking About - Pelvic Health and Rehabilitation Center - July 11, 2014

  2. Pingback: Forced c-sections. Unethical outliers or a disturbing trend? | Dr. Jen Gunter - July 28, 2014

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