Monday, November 29, 2004

Backing off of VBAC...
The New York Times today has a story on the decreasing popularity of vaginal birth after a Caesarean section (VBAC): Trying to Avoid 2nd Caesarean, Many Find Choice Isn't Theirs. Now procedurally this is really not my cup of tea but I find the definition of "choice" put forth in the article to be largely in the eye of the beholder.

The notice, posted in her obstetrician's office in Lancaster, Calif., came as a shock to Danell Freeman: the local hospital would no longer allow doctors to deliver babies vaginally for women who, like her, had previously had a Caesarean section. Unless she changed doctors and hospitals, Ms. Freeman would have to have another Caesarean - something she had hoped to avoid.

Ms. Freeman is 29, pregnant with her fifth child. The first three were born normally, the fourth by Caesarean. "I don't like the idea of being cut open again," she said.

Women around the country are finding that more and more hospitals that once allowed vaginal birth after Caesarean, or VBAC (commonly pronounced VEE-back), are now banning it and insisting on repeat Caesareans. About 300,000 women a year have repeat Caesareans. The rate of vaginal births in women who have had Caesareans has fallen by more than half, from 28.3 percent in 1996 to 10.6 percent in 2003

VBAC was very much en vogue when I was a medical student and women were encouraged strongly to give labor a try. The risk of uterine ruptured was thought to be acceptable.
Obstetricians estimate that there is a 1 percent chance that the old Caesarean scar will cause the uterus to rupture during a subsequent labor, which can cause dangerous blood loss in the mother and brain damage or death in the baby. A decade ago, the risk of rupture was thought to be 0.5 percent or less. The percentage of babies injured after a rupture is not known but is thought to be low
But not everyone is happy with the pendulum swinging the other way.
Many women are willing to take the risk, and the hospitals' stance has become a charged issue, part of a larger battle over who controls childbirth. Some women say their freedom of choice is being steamrolled by obstetricians who find Caesareans more lucrative and convenient than waiting out the normal course of labor. Doctors say their position is based on concern for patients' safety.
Read carefully how "freedom of choice is being steamrolled". The story compares the apples of the "more lucrative and convenient" primary c-section to the oranges of the more safety oriented VBAC. Research has shown many variables contribute to the decision-making process of when to perform a c-section: "convenience" (how evil), labor expectations of the mother (and her mother), and recent experience of the OB/GYN (read:litigation).
Some doctors and hospitals freely acknowledge that fear of being sued has driven their decisions. Hospitals say they cannot comply with guidelines issued in 1999 by the American College of Obstetricians and Gynecologists, which call for a doctor to be available "immediately" throughout active labor during such a birth, to perform an emergency Caesarean if needed. Previous guidelines had called for them to be "readily" available.

Half the hospitals in New Hampshire and Vermont have stopped allowing women who have had Caesareans to try normal deliveries, according to Dr. Peter Cherouny, an associate professor of obstetrics and gynecology at the University of Vermont. A telephone survey by an advocacy group, the International Cesarean Awareness Network, found 300 hospitals around the country that had quit offering the deliveries.
The change in the ACOG guidelines has proven to be unworkable in many situations:
Dr. Charles Lockwood, chairman of the department of obstetrics, gynecology and reproductive sciences at Yale and an author of VBAC guidelines issued by the American College of Obstetrics and Gynecology, said alarms began to sound in the late 1990's.

"What precipitated this were reports in the literature and reports that came to the college itself about women who had ruptured their uterus, particularly in rural settings, with no doctor and no anesthesiologist around," Dr. Lockwood said. "Babies died, and women lost the uterus in some cases."

That prompted the obstetrics college to change its formal recommendations for vaginal births after Caesareans in 1999, saying a doctor should be immediately available during labor to perform an emergency Caesarean.

"That had a chilling effect," Dr. Lockwood said, particularly on hospitals in rural areas that did not have anesthesiologists available around the clock, and on doctors in solo practices who could not stay with a patient throughout her labor......Dr. George F. Lee, a former obstetrician who is an administrator at California Pacific Medical Center and a spokesman for the American Hospital Association, said that while VBAC had proved safe in carefully controlled studies, the risks were higher in the real world of everyday medical practice.

"We went from seeing a ruptured uterus once every several years to seeing half a dozen a year at our medical center," Dr. Lee said.

So results that play out well in the academic setting don't have the same effect in the private practice world, surprise, surprise. The fear that some in the medical profession have is that women who insist on VBAC will make another choice:
Some doctors worry that banning the procedure may lead women who have had Caesareans to try giving birth at home or in birthing centers that are not equipped to perform an emergency Caesarean if it becomes necessary. Doctors also say some women, determined to avoid a repeat Caesarean, have endangered themselves and their babies by staying at home in labor - or even staying in the hospital parking lot - until the last minute.

"The real issue going across American right now is, what do we do?" Dr. Flamm said. "Hundreds of thousands of women a year now are coming to hospitals with a previous Caesarean, some in communities where every hospital has shut down its VBAC program. That's the issue. Some will go to a lay midwife and have a VBAC in their bedroom. A good number will do fine, but some will have horrendous outcomes."
Aren't these choices made by the women? And now for the advocates view:
Some women see a Caesarean as having an operation instead of giving birth, and feel it means missing out on life's most joyful rite of passage.

"I'm an earthy person," said Barbara Stratton of Baltimore, who had her first baby by Caesarean in 1999. "This is a womanly thing to me. I wanted to birth my baby. You have that taken away if you're lying in a room full of strangers and they cut your baby out of your abdomen.

"For some of us who really care about birth, it can completely crush you."

Ms. Stratton said that she hoped to have another child, and that if she does, "I'm going to VBAC and I'm doing it at home."
Ms. Stratton has made her choice, it seems. What these patients want, it seems to me, is to have their choice trump everyone else's. What is the goal here? I thought it was for the safe birth of a healthy baby with a healthy mom to take care of it. How this goal was achieved should be secondary.
I admit my bias since I am: #1 a man, and #2 both of my children were Caesarean births. Mrs. Parker attempted labor with our first child but there was "failure to progress" and a c-section was required. Mrs. Parker and I discussed VBAC and she and I fell into this category:
As for his own patients, Dr. Schipper said: "I can't think of any who had major issues. By and large, the feeling was, 'Great, I don't have to make a decision, go ahead and do the C-section, I was agonizing about it anyway and who am I as a lay person to go against what you think?' "

Why shouldn't the choice of the physician or hospital carry some weight? There is always a risk/benefit calculus with such things. The physicians have found that the risk of VBAC (uterine rupture and the complications thereof) outweigh the benefit (patient satisfaction with natural childbirth). The VBAC advocates believe the benefits of a trial of labor and the "birth experience" outweigh the risks of VBAC. So much so that some, like Ms. Stratton, are willing to undergo delivery out of the hospital. Yet the choice of the provider is given short shrift. Patients change physicians all the time, such as when they do not get the prescriptions they want, and no one raises a fuss. But when a non-emergent procedure is not offered, much hue and cry ensues.
Speaking from personal experience, the decision to restrict one's practice (which is what is happening here) is influenced by many factors. You cannot become tunnel-visioned and forget that there are other patients than the one in front of you. The OB/GYN is faced with denying VBAC to the few patients that want it, or agreeing with it and if something goes awry, facing the consequences. What if they can't get liability coverage and have to move? Who will take care of their patients? What if there are no other OB/GYN's in town? Is it worth it for the satisfaction of a minority given the access problems associated with OB/GYN? Tough choices, but ones that are treated poorly by some in the article.
What about high-minded ideals of "service to the community"? Unfortunately nowadays it is a question of survival for many physicians.
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