Birthing Beautiful Ideas

One of my previous doula clients recently mailed me a copy of a “patient safety update” that she received from her current OB/GYN practice.*

The topic of this particular patient safety update was vaginal birth after cesarean, or VBAC.**  And it was…”interesting.”

In fact, it was so “interesting” that I’ve transcribed the entire document below, for your reading “pleasure.”  (And just so I don’t color anyone’s opinion of the safety update before you read it, I’ve left my editorializing for the end.)

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Patient Safety Update: Vaginal Birth After Cesarean (VBAC)

On a monthly basis the staff of **** meets to discuss current practice protocols and to review various patient safety issues raised by our staff.  We jointly discuss challenging cases from the preceding month as well as those due to deliver in the near future.  Our goal has always been to provide the safest medical care possible to our patients.  The topic for our recent meeting was a review of the safety implications of Vaginal Birth After Cesarean Section, more commonly known as VBAC.

Trends:

Fewer women are attempting a Trial of Labor after a Cesarean.  There are several potential reasons for this: medical and legal pressure; changes in patient and provider preference; changes in obstetrical practice; and publication of complications related to vaginal delivery and failed trial of labor.

The most serious concerns are increased risks of uterine rupture and perinatal death.  A recent study of 33,000 patients showed that the risks of uterine rupture, hysterectomy, thromboembolic disease (blood clots), transfusion, severe infection, and death are 56% greater in women attempting VBAC vs. Repeat Cesarean Section.***  Overall you would need to do 588 elective Cesareans to prevent one poor perinatal outcome.

Summary

588 Cesareans to prevent one poor perinatal outcome is acceptable to some but not to others.  Our group is evenly divided.  Some of our physicians do participate in VBACs and some do not.  As a result the following key points need to be understood by our patients.

If you definitely want to have a trial of labor and attempt a VBAC, you should consider transferring to a practice that supports VBACs completely.

If you want a VBAC and stay with the practice it must be understood that you will not be guaranteed the opportunity to have a VBAC attempt.  On certain days there might not be a physician who will participate in a VBAC trial of labor.

A trial of labor is definitely more risky for the baby than an elective Cesarean Section (much in the same way that labor is more risky than an elective cesarean section).  You must be willing to accept that risk in order to proceed with a trial of labor.

We regret any inconvenience this may cause to our patients planning to attempt vaginal birth after cesarean section.  We urge our patients to stop and contemplate the statistics listed above.  We plan to meet individually with the patients affected by this decision and address their individual concerns.

Thank you.

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Oh, where to begin.

How about with this: I think that framing this issue as a “patient safety update” is problematic, to say the least.  For if I were to receive a letter from my care provider (OB/GYN or not) alerting me to a patient safety update, I would automatically think that the information contained therein would be primarily concerned with protecting me from harm.  With keeping me safe.

Thus, it seems reasonable to assume that many women who received this “patient safety update” have approached this document with the belief that the OB/GYNs at this practice had a safety concern about vaginal birth after cesarean.

And it seems quite obvious that the safety concern here places an extraordinary emphasis on the risks of VBAC (and labor, for that matter) without giving even a mere mention of the risks associated with repeat cesarean section.

It makes no mention of the current research concluding that babies born after VBAC have significantly lower rates of respiratory morbidity and NICU admission than babies born after elective repeat cesarean.

It makes no mention of the recent report concluding that elective repeat cesarean is associated with a threefold increase in maternal mortality when compared with vaginal birth after cesarean.

It doesn’t even mention any of the risks associated with repeat cesarean sections, including abnormal placentation in future pregnancies (which can lead to life-threatening problems), bowel obstruction, and blood clots.

I’m sorry (and I’m angry), but highlighting the risks of VBAC (and LABOR!) in a “patient safety update” on VBAC without even mentioning the risks of elective repeat cesarean does not offer transparent information to the women in this practice.  In fact, I’m not even sure that it best keeps patient safety in mind. 

How can a woman make a major decision such as this one without knowing the risks (and benefits) of both options?

How can she even go on to rationally weigh those risks and benefits when she has received a letter putting the fear of God into her about VBAC?

It should be stated that I wholeheartedly support a woman’s right to choose a repeat cesarean delivery over a VBAC.  Wholeheartedly.

But failing to present a woman with the risks and benefits of VBAC and repeat cesarean in a letter such as this one undermines her ability give informed consent to either option.

So at best–and despite the fact that the practice recommends that women seeking VBAC should switch to a more VBAC-supportive care provider–this letter is disingenuous.

And at worst, it strikes a major blow to women’s ability to give informed consent to what they do with their bodies in order to birth their babies.

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*I want to extend a hearty thanks to my doula client for thinking of me after reading this “safety update.”  Quite simply, she rocks!

** I think it is no coincidence that this letter was sent out mere days after the NIH Consensus Panel released their statement on VBAC.

***It’s worth noting that a recent Agency for Healthcare Research and Quality Report determined that “the rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between TOL [trial of labor, or VBAC attempt] and ERCD [elective repeat cesarean delivery].”    Even the 2004 Landon study, which this practice may have been referring to when they mentioned that “recent study of 33,000 patients,” concluded that while the rates of endometritis and blood transfusions were higher in women attempting VBAC than in women undergoing repeat cesarean, “the frequency of hysterectomy and of maternal death did not differ significantly between groups.”

Anyone who has read my VBAC story might remember that my VBAC itself occurred after I switched care providers at nearly 37 weeks into my pregnancy.

Obviously, this is not something that one does “on a whim.”

It’s hard to do anything on a whim when you have an eight-pound person tucked inside your midsection!

And so my decision to seek a new care provider in the last four weeks of my pregnancy was not a “whim” decision but was instead a decision informed by my own careful (yet harried) reflection and research.

And it was a decision I made in reponse to the blatant misinformation about VBAC and repeat cesarean that my original OB/GYN had given me in an attempt to “talk me into” an (unnecessary) repeat cesarean.

So in the the spirit of my request for your stories about the lies, misinformation, and/or miscommunication you’ve experienced when it comes to VBAC, I’m going to share my own story of “Very Bad At Communication” here:

It all started when my obstetrician informed me that he “needed” to do an ultrasound at my 36 week appointment so that he could measure my lower uterine segment.  As he told me, if my lower uterine segment (LUS) was “too thin,” we would need to schedule a repeat cesarean.  If it was not “too thin,” then I could “attempt a trial of labor.”

(For what it’s worth, I’ve found that care providers who use phrases like “attempting a trial of labor” tend not to demonstrate much confidence in vaginal birth after cesarean.)

The warning bells started blaring in my head when he told me that, “You know, just last week, a mom came in here, and we measured her LUS, and it was too thin for a VBAC.  She’s gonna have to do a c-section.”

Why did he share that information with me?

I’m guessing it was his own way of telling me not to get my hopes up (because he was going to shatter them no matter what the ultrasound showed?).

And then I had the ultrasound.

The sonographer determined that my LUS was measuring approximately 3.7 mm thick.

And I, I who had done myVBAC research–I who had scoured PubMed for articles on VBAC, including the then-published articles on using LUS measurements to predict uterine rupture–celebrated for a brief moment, because most studies on this topic recommended anywhere from 1.5 mm – 3.5 mm as a “safe cut off point” for attempting a VBAC.

Even if those studies were flawed in some ways, 3.7 mm still made me safe in their eyes!

Except then my OB/GYN told me that my LUS needed to be 5 mm thick in order to safely attempt a vaginal birth.

The devastation started creeping in.  Those “warning bells” were trying to tell me something after all.  (And they had probably been ringing all throughout my pregnancy, but that’s another issue entirely.)

The sonographer noted the immediate change in my expression and attempted once more to measure my LUS, just to see if there was any one point that was 5 mm thick.

And there wasn’t.

I immediately tried to ask about the other studies I had read, but my OB/GYN interrupted me mid-question and said, “Kristen, I’m sorry, we need to schedule a repeat cesarean.”

I tried again.  “Well, what is the risk of uterine rupture with a LUS measuring less than 5 mm?”

His response?  “The risk of uterine rupture during all VBACs is 2%.”  (By the way, that’s not true.  And it didn’t answer my question.)

I tried again.  “Hmm, that seems pretty high!  And doesn’t pitocin…”

He interrupted me.  “The risk of uterine rupture during all VBACs is 2%.  Period.  And anyway, you never know if you’ll need pitocin!”

(I was trying to ask him about how pitocin affects the risk of uterine rupture.  For what it’s worth, pitocin augmentation and induction have been shown to increase the uterine rupture rate from approximately .4% to .9% and 1.1%, respectively.)

I tried again.  “Well, what are the risks of repeat cesarean as compared to VBAC?  Will having this c-section have any negative effect on my future pregnancies or births?”

His response?  “No, repeat c-sections are no big deal!  You can have as many of them as you want!  And hey!  Now you don’t have to worry about incontinence issues in the future!”

(Note: just six months prior, he had informed me about how he only recommends VBACs to women who want more than two children since third, fourth, etc. cesareans can carry so many extra risks and complications.)

I tried again, people! “But didn’t you say…”

And here’s where he threw down the gauntlet.

Well, first he turned to my husband and chuckled, “I’m really making her angry, aren’t I?”

And then he said, “Look, Kristen, we need to schedule your repeat.  Period.  There’s no more discussion.  Now, let’s see, you’re due on May 27th, I’m going to Italy at the beginning of May…how does May 20th look?”

I was stunned.  (And pisssssed!  Seriously, that patronizing crap he pulled with my husband was totally uncalled for.  And it’s what infuriated Tim the most throughout the entire “conversation.”)

But I was also searing with the hormonal rush that is the last few weeks of pregnancy.  I was on the absolute precipice of tears.  And I held myself together just long enough to mutter, “Well, we’ve got a two-year-old, so we’re gonna have to find a babysitter before we schedule anything.”

And Tim and I left that office so fast that we forgot our jackets in the waiting room.

The rest is history.

With the help of our doula, we found a new care provider.

I went on to have not only a successful VBAC but also my hospital’s first waterbirth.

And I was eternally grateful that I had made the terrifying yet empowering decision to switch to a more supportive care provider at such a late stage in my pregnancy.

(And, to his partial credit, my original OB/GYN even called me at home–and my husband on his personal cell phone–to tell me that he had “gone and done his research” and “discovered” that my LUS measurements were “alright for a trial of labor afterall.”)

But what if I hadn’t done all that research?

What if I had allowed myself to fall prey to my original OB/GYN’s non-evidence-based claims about VBAC and uterine rupture?

Should I have even been expected to have read those relatively obscure studies on LUS measurements anyway?

Thinking about the potential answers to those questions make me realize just how exceedingly important the issue of VBAC-related patient counseling is.

We can call it “poor communication skills.”

We can refer to things like “misinformation” and “misrepresentation” and “misguided intentions.”

We can even call out some of ‘em for what they really are: “lies.”

Yes, when some women discuss vaginal birth after cesarean (or VBAC) with their health care providers, the information they receive can be mangled by everything from poor communication to outright falsehoods.

You can take a look at my own VBAC Scare Tactics series, where each post has been “inspired” by actual misguided scare tactics that women have encountered in their quest to find a health care provider to attend their child’s birth.

You can scour My OB Said WHAT?!? to find some (outrageous) instances of this misinformation.

You can search any number of VBAC-relevant message or support boards to find women reporting the false or exaggerated or misguided claims that their OB/GYNs or midwives have made about VBAC.

You can also ask nearly any woman who has ever attempted to find a VBAC-supportive care provider, and most of them will probably have some VBAC-related whoppers to share.

Want some examples?

There are loads of women (and their friends, relatives, and other loved ones) who think that or who have been told that “VBAC only has a 70% success rate, so why would you want to risk your baby’s health like that?”

The truth is that the “70% success rate” means that (approximately) 70% of VBAC attempts will end in vaginal birth and 30% will end in a cesarean section.  This does not mean that 30% will end in uterine rupture–only .7% of women attempting VBAC experience uterine rupture, and the majority of those ruptures are not catastrophic.  Making an informed decision regarding VBAC and repeat cesarean involves receiving accurate, non-misleading information about the difference between VBAC success rates and uterine rupture rates.

There are women who have been told (or who have engaged in conversations that have implied) that VBAC carries an exhorbitantly large risk and that repeat cesarean carries little to no risk.  VBAC consent forms are generally good at “mis-communicating” this information.

The truth is that neither VBAC nor repeat cesarean is without risk.  The main risk associated with VBAC is uterine rupture, which occurs in approximately .7% of VBACs.  Repeat cesarean, however, is associated with a number of risks, including incision-site infection, hemorrhage, bowel obstruction, and an increased risk of placenta previa, accreta, and percreta in future pregnancies for the mother; and iatrogenic prematurity, respiratory problems, and lacerations for the baby.  Preserving patient autonomy regarding VBAC and repeat cesarean involves ensuring that women know the risks associated with both VBAC and repeat cesarean before they enter the hospital, regardless of their birthing choice.

Women have been told that VBAC is very unsafe for babies and that VBAC is downright silly since it is only about a woman seeking out a certain “experience” at the expense of her baby’s health and safety.

The truth is that current research concludes that babies born after a VBAC have lower NICU admission rates and fewer respiratory problems than babies born via elective repeat cesarean. And the truth is that VBAC is never just about a woman seeking a certain “birthing experience” at the expense of her baby’s health and safety–there are many other reasons that women choose VBAC over repeat cesarean.  VBAC is a safe and healthy option for many women, and actively discouraging VBAC might very well compromise maternal and neonatal health and safety when one takes into consideration the benefits of vaginal birth for moms and babies and the risks that repeat cesarean(s) pose to a woman’s future reproductive health.

My thoughts in a nutshell?

I think that care provider-initiated misinformation about VBAC eats away at informed consent and patient autonomy and maternal and neonatal health.

And I think that in many cases, health care providers need to be counseled on their counseling when it comes to VBAC.

This why I’d like to take these thoughts to the NIH Consensus Development Conference on VBAC in March.  And I’d like YOUR stories to help me do so!

Have you been lied to about vaginal birth after cesarean?

Did you face “VBAC scare tactics” during your pregnancy (or pregnancies)?

Were you misinformed about the relative risks (and benefits) of VBAC and repeat cesarean?

PLEASE SHARE YOUR STORY HERE SO THAT YOUR VOICE CAN BE HEARD AT THE NIH CONFERENCE!!!

Because advocating for women’s birthing choices isn’t just about making sure that health care providers are doing the right things–it’s also about making sure that health care providers learn and say the right things.

After months and months of a persistent cough, my son, M, has finally been diagnosed with bronchial asthma.  And while I’m sad that he has to deal with this condition for the next few years (or at least I hope for only a few more years), I’m also happy that he at least has options for treating his cough.

What’s more, I’m also thrilled with the way his new pediatrician handled his treatment options.  In fact, my interaction with her had me day-dreaming about what her approach to informed consent would look like if it were mapped onto the ways that OB/GYNs (and even midwifes) tend to approach the option between VBAC and repeat cesarean.

But before I recount my day-dream, I should give you a picture of what my interaction with M’s pediatrician looked like:

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Dr. S: Based on what you’re telling me, it sounds like your son probably has bronchial asthma, or what some people call “cough asthma.”  *Explains a bit about what it is.*

Me: What sorts of treatments do you recommend?

Dr. S: There are generally two options: Singulair, a medication traditionally used to treat the symptoms of asthma, or Boswellia, an herbal medication that I have also recommended to many of my patients.  From my experience, both seem to treat bronchial asthma equally well.  That being said, there have been many parents who have told me that they have preferred Boswellia since it doesn’t seem to have the same sorts of negative side effects that Singulair does.

Me: What are some of those negative side effects?

Dr. S: Mainly, some parents report that their children experience significant mood changes while taking Singulair.  And this is one of the side effects associated with the drug.

Me: Oh, okay.

Dr. S: *Explains the dosage and administration of each drug, the risks/benefits of each drug, also addresses where we could safely purchase Boswellia.*  Do you have an idea about which treatment you would like to use?

Me: My gut reaction tells me Boswellia, but would it be alright if I went home and researched it first?

Dr. S: Of course!  I actually encourage that.  Why don’t you call me in a couple of days when you make your decision, and then we can talk about how we will proceed from there.

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And then I started dreaming of what a prenatal appointment would look like if a doctor or midwife were to take the same empowering, informed-consent-supporting attitude that my son’s pediatrician took to his asthma treatment.

Dr. OB/GYN: Congratulations on your pregnancy!  Since you had a cesarean for your last birth, have you thought about what you would like for this birth?

Pregnant mama: Do you mean VBAC or a repeat cesarean?

Dr. OB/GYN: Yes!  Both are relatively safe options, although each one carries particular risks and benefits.

Pregnant mama: Can you tell me a little more about that?

Dr. OB/GYN: Of course.  The main risk associated with VBAC is that the uterine scar will begin to separate during labor.  This risk of “uterine rupture” is very small–only .7% for all VBACs, and only .4% if your labor begins on its own. 

Pregnant mama: Uterine rupture sounds very serious.  What about repeat cesarean?

Dr. OB/GYN: You’re right, uterine rupture is serious, but it is only “catastrophic” in approximately .05% of all VBACs.  So the risk itself is very, very small.  We may monitor you a bit more carefully in the hospital, but we can also take steps to make sure that you can still be upright and mobile during your labor.  And repeat cesareans, although relatively safe, also have serious risks.  For instance, each subsequent cesarean increases your risk of serious placental complications, such as placenta previa and accreta.  In addition, a recent study has shown that babies born after VBAC have lower NICU admission rates and fewer respiratory problems than babies born via elective repeat cesarean.

Now, this isn’t meant to scare you!  But it’s always good to know that there are risks associated with both options.

Pregnant mama: Do I have to decide right now?

Dr. OB/GYN: Of course not!  I encourage you to take the next few weeks to do some research on VBAC and repeat cesarean, and then we can discuss your plans during your next appointment.  (Editorial note: In a super-ideal world, the OB/GYN would also give the mom a couple of pamphlets on cesarean section and VBAC from ICAN.  A girl can dream, can’t she?)

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But I know from experience that these sorts of prenatal appoinments often look a little bit more like this.

Dr. OB/GYN: Congratulations on your pregnancy!  So, when are we going to schedule your repeat cesarean?

Pregnant mama: Well, what about VBAC?

Dr. OB/GYN: VBAC?!?!?!  Why would you ever want to do a thing like that?!?!?!  I.  DON’T.  DO.  VBACs.