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Yes, This (from the NIH VBAC Conference)

March 11, 2010
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From the draft Panel Statement:

We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL [trial of labor]. Given the level of evidence for the requirement for “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement relative to other obstetrical complications of comparable risk, risk stratification, and in light of limited physician and nursing resources. Healthcare organizations, physicians, and other clinicians should consider making public their TOL policy and VBAC rates, as well as their plans for responding to obstetric emergencies. We recommend that hospitals, maternity care providers, healthcare and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to TOL.

I know, the language itself doesn’t sound that exciting, but there is a lot of hope that it will have an effect in encouraging hospitals and providers with official VBAC bans and unofficial anti-VBAC stances to reconsider.

If you’re like me and had other work and life things in the way of catching the whole conference, video from days 1 and 2 and other materials are available from http://consensus.nih.gov/2010/vbac.htm. You can also poke through eleventy-billion tweets on the topic by searching for the hashtag #nihvbac. I’ll try to include some good blog posts on the topic in next Sunday’s round-up, as well.

I’m reserving judgment on the “women don’t have a settled right to refuse surgery” business until I actually get a chance to hear what was said in the day 3 video (which is not yet available) and telebriefing for myself, but Courtroom Mama has written about it for The Unnecesaran. Suffice it to say that I believe a woman has an absolute right to refuse any surgery, any time, for any reason – pregnant or not.

16 Comments leave one →
  1. Greg permalink
    March 12, 2010 11:11 am

    When you write “I believe a woman has an absolute right to refuse any surgery, any time, for any reason – pregnant or not,” you’re setting up a straw man argument. Of course any woman (or man or transgendered individual or emancipated minor) has the right to refuse any surgery. But the right to refuse surgery itself isn’t the issue at the heart of this VBAC dilemma.

    What is the issue, is that after that right is exercised, if something bad happens to the baby or mom, does the patient have the right to sue the doctor for NOT doing the surgery that they themselves had refused? The answer, shockingly, is yes. That’s what frightens doctors.

    If you are delivering, and the doctor thinks a C-section is necessary but you don’t, you CAN legally refuse a C-section. That is every woman’s right. But in a number of states women have then successfully sued their doctors when their babies have died or have brain damage, after they refused the C-section. They cite not having been in a position to give informed consent as the reason that the doctor is still at fault. It’s not surprising that these stories give doctors cold sweats. To defend against this outcome, doctors then recommend C-sections even if VBAC is medically possible. Do something about the fear of being sued, and VBAC rates will go back up to match the level that scientific consensus deems is reasonable.

    • March 12, 2010 11:26 am

      “But the right to refuse surgery itself isn’t the issue at the heart of this VBAC dilemma.” – it is certainly one important issue when women are being threatened with court-ordered cesareans and women don’t have access to labor support from care providers willing to “allow” a trial of labor (see one example at http://www.cnn.com/2009/HEALTH/10/15/hospitals.ban.vbacs/index.html).

  2. March 12, 2010 2:53 pm

    I have to concur with Greg; as a feminist, mother and obstetric nurse I think this is an issue that comes down, fundamentally, to keeping mothers and babies safe. VBAC resulting in uterine rupture (<1% of all VBACs… a number quoted ad nauseam in this debate)and a failed TOL (i.e. resulting in an emergency C/S) are very distinct categories. In the medical literature rates of failed TOLACs are as high as 17%. In fact, a Swiss retrospective study of 29,046 deliveries reported complications significantly more frequent in the VBACs compared to elective repeat cesarean section including maternal febrile episodes, thromboembolic events, bleeding due to placenta previa during pregnancy, uterine rupture (92 cases) and perinatal mortality (118 cases!!! including 6 associated with uterine rupture); 81 cases of peripartum hysterectomy, and 1 maternal death.

    Another study reports an overall risk of uterine rupture for VBAC at 4.5 per 1000; rupture associated with spontaneous labor was 5.2 per 1000; uterine rupture with non-prostaglandin induction was 7.7 in 1000 and with prostaglandin induction was 24.5 in 1000 7. In the same study, the rate of perinatal death was 5.8 per 1000 with TOL with NO augmentation of labor.

    I am not sure how to get around the evidence that the absolute risk of VBAC is a REAL issue. While women are entitled to a TOL option, for sure, VBAC *absolutely* necessitates surgeons and anesthesiologists be immediately, readily available in the event of fetal distress or maternal complication. As a labor and delivery nurse, I would demand it – no matter my political penchant.

    • IndianaFran permalink
      March 12, 2010 4:24 pm

      CircusNurse,
      I don’t know what studies you are quoting findings from, but they surely don’t match with the results reported by the NIH committee.
      You can review their entire evidence report here
      http://www.ahrq.gov/downloads/pub/evidence/pdf/vbacup/vbacup.pdf
      The numbers you have quoted are simply, plainly, not representative of what the entirety of the evidence on this matter shows.

      There is a small but measurable increase in risk to the baby with TOL. There is a small but measurable increase in risk to the mother with repeat CS. In addition, repeat CS incurs additional risk to both the mother and baby in any subsequent pregancies.

      On the whole, the balancing of these risks is a decision that is up to the mother.

  3. Kate Tuttle permalink
    March 12, 2010 4:52 pm

    I agree that writing “I believe a woman has an absolute right to refuse any surgery, any time, for any reason – pregnant or not” is creating a straw man argument, but not for the same reason the above commenters cite. The right to refuse surgery, under any circumstances, even when safety is at issue isn’t the key point to me — the key thing here is that in the majority of cases, according to all published studies, VBAC IS the safe option. Repeat C-sections aren’t on the rise for safety reasons but for liability reasons.

    If doctors and insurance companies were open to allowing a trial of labor for women who want to go VBAC, they’d have better outcomes for both women and their babies, and then in the cases where safety truly does indicate a repeat C-section, women would be more likely to trust that it was truly necessary. But the situation we live in now has nothing to do with safety, everything to do with legal exposure. To put it another way, VBACs aren’t riskier for women, they’re riskier for doctors.

    • March 12, 2010 5:00 pm

      Kate, thanks for your comment. I think perhaps I wasn’t clear to those who might not have followed the conference closely. There was apparently some discussion on day three about women’s right to refuse surgery not being a settled or absolute or uncontroversial matter. And, again, I want to get a chance to hear that discussion for myself, but the link to the Unnecesarean provides a bit of context for my statement.

  4. MomTFH permalink
    March 13, 2010 7:54 pm

    I agree, Rachel. Great quote.

    I am planning on writing a synopsis of the new evidence report, soon.

    However, in the meantime, let me just say I strongly disagree with the commenters that the risk of a doctor being sued outweighs the right of a woman to refuse a non medically indicated and non evidenced based surgery.

  5. Shannon Mitchell permalink
    March 14, 2010 12:11 pm

    • March 14, 2010 12:59 pm

      Shannon, thank you for sharing this, and for making your comment to the panel in the first place.

    • MomTFH permalink
      March 14, 2010 6:04 pm

      Thank you Shannon!

  6. Circusnurse permalink
    March 14, 2010 8:36 pm

    (1)American College of Obstetricians and Gynecologists. (2004). Vaginal birth after previous cesarean delivery. ACOG Practice Bulletin No.54. Obstetrics and Gynecology, 104, 203-12.
    (2) Martin, J. A., et al. (2009). Births: Final data for 2006. National Vital Statistics Reports. Volume 57, Number 7,1-104.
    (3) Greene, M. F. (2002). Uterine Rupture among Women with a Prior Cesarean Delivery. NEJM 346: 134-137
    (4) Rageth JC. et al., (1999). Delivery after previous cesarean: a risk evaluation. Obstet Gynecol, 3:332-337.
    (5) Heffner, L. J.., et al., (2002). Uterine Rupture among Women with a Prior Cesarean Delivery. NEJM 346: 134-137
    (6) Hook, B. et al., (2009)Neonatal morbidity after elective repeat cesarean section and trial of labor. Am Acad Pediatrics,100(3):348-353
    (7) Lydon-Rochelle, M. et al., (2001) Risk of uterine rupture duringlabor among women with a prior cesarean delivery. NEJM 345:3-8.

    Among many, many others. It’s worth taking the time to do the research rather than depending upon those, with vested interests, to do it for us. I think the NIH conference is another example of what we should consider when looking closely at the issue of the safety of TOL and VBAC, but it is certainly not the whole picture.

    A commitment to a cause needs to take this into some serious consideration: how to critically examine what it put before us. If one is dedicated enough to that cause, it will be worth looking into deeply and drawing our own conclusions from the information before us.

    As I said in my initial previous post, it’s about the health and safety of mothers and babies. I’m not sure how, as those committed to women’s health, we can be opposed to that simple principle.

    • MomTFH permalink
      March 15, 2010 6:53 am

      I am a little confused as to whom this comment is directed. Who is “we”, who is ignoring what research, and who is not committed to the safety of mothers and babies? And, what issues do you specifically have with the literature review and analysis performed by the OHSU team commissioned by AHRQ, and released immediately after the conference? Did the reviewing team at OHSU have a different set of “vested interests” than the sample of studies you posted above?

      The main significant difference in literal health and safety outcomes in the review of 192 studies done by OHSU for this NIH conference was a large increase in maternal mortality for elective repeat cesarean section, compared to TOL for VBAC. Other health outcomes were similar, with many arguably favoring TOL, especially if there is going to be more than one ERCD following.

  7. Shannon Mitchell permalink
    March 15, 2010 12:58 pm

    It is not ignoring research or favoring bias to state that women deserve the right to say no. OBs have been ignoring the research for thirty years and affecting the outcomes of VBAC through practice and policy the entire time. Uterine rupture risk is real, women should know that it is real. This does not change that long-term, cesareans are misapplied and add more and more lifetime risk, most of which is ignored because of immediacy. Many OBs never see women through their bowel obstructions, early hysterectomy, stillbirths in later pregnancies, the uterine rupture after the SECOND cesarean due to the first one being done, this is an exponential risk and every time we balk at vbac, we are adding on the exponents. I deal just as much with women who have lost their babies due to that first, unnecessary cesarean after failed induction as I do with women trying to make educated choices. My view is that OBs need to provide informed consent and stop pretending that a cesarean is a preventative method of avoiding harm.

  8. Circusnurse permalink
    March 15, 2010 8:30 pm

    @MomTFH –
    You address the very point I was making: that research of all sorts, whether it is that I have cited or that presented at NIH conference, has some degree of vested interest and so must be looked at critically. (And, to answer, I was addressing the reply to my original post, above.)

    I do not argue your point that maternal mortality rates may be lower for low risk women who have a successful VBAC. However, the point I was trying to address was that of attempting a TOLAC without anesthesiologists or surgeons immediately available. Fetal demise is not on the the decline for failed TOL or VBACS and my main concern, which is well documented in both the literature I provided and that presented at the NIH conference, is that it is an unnecessary risk that endangers lives.

    @Shannon –
    I have never implied or intimated that women do not have the right to refuse ERCS. I totally believe that women have that right, AMA. As for the rest of your post, I simply disagree based on my own clinical experience. With that experience, I hope to take a sympathetic position — one that considers both the rights of a woman and her/ her baby’s on-going safety.

  9. August 25, 2010 3:59 pm

    I completely feel women have the right to decide but their decisions need to be based on the risks and with the intentions of keeping themselves safe and keeping their baby safe.

    I also understand the doctor’s concerns as well. A woman looks to her doctor for advice, if s(he) gives it to her and she does something else that leads to medical problems or death, she can sue. A lot of these issues lie with our legal system, but we won’t get into that.

    Uterine rupture during vbac is rare but the fact of the matter is, it can happen. I would just say that if a woman wants a vbac or even a vbac after multiple c-sections, plan it so that you are in a facility that can perform immediate surgery if needed. In most cases it may never be needed but I say be safe by being prepared.

  10. Hannah permalink
    October 21, 2010 7:25 pm

    this is very encouraging for me to read. At 20 years old and pregnant with my second child i was told this morning that i cannot have a trial of labor. I have had one c-section with my son 3 years ago and the only reason is that he would not “engage” into the pelvic area. This seems like a ridiculous reason for my doctor to deny me a TOL. He simply told me, “Hannah, I like you but you are 224 pounds and if i let you have a TOL then that would mean that I have to be at your bedside the whole time and i am not willing to do that.”

    First of all, why would he have to stay by my bedside?

    Second, Just because i weigh 224 pounds does not mean that i cannot deliver vaginally. I know women twice my size that have delivered naturally.

    Third, High blood pressure is not a problem and hasnt been so far.

    Fourth, just because my first child didnt come down to my pelvic area, how does that mean that my second wont?

    I am very upset about all of this and anyone with information on what i can do to contest this, please email me at jhlacy@mailsky.com

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