Friday, February 17, 2012

More Business of Being Born VBAC Segment

I was so excited to watch this. I thought that I would enjoy lending it to clients of mine, and had even prematurely asked if my Professor friend over at the college would help me set up another campus screening with a followup Q&A about VBAC.

Boy was I wrong. So, so wrong.

The VBAC segment was not only mostly one-sided, the risks were over inflated and misrepresented. The title of the segment is a load of crap, because it really DOESN'T talk much about what a woman's options are. It shows the incredible amount of unbalanced information that is out there, especially from OBs.  A sound resembling a dying cat escaped my throat every time I heard the words, "attempt a VBAC", "try to have a VBAC", and "trial of labor". Yes, this is OB lingo. And while I will agree that in the hospital it really IS "attempting" a VBAC, because hospital VBAC "attempts" are rarely successful...and even less so if we look at the big picture and include women that start out interested in having a VBAC, and then are dissuaded by the is hurtful language. I believe in the power of words. What if we told each mom who wanted a natural birth that she was, "attempting a natural birth", or that she could, "try for a natural birth"? What does this imply? This, to me (and many other women) implies great room for FAILURE. Never mind that most natural birth "attempts" are hindered by the hospital staff, or by lack of support, or by lack of knowledge.

What if I told my clients that I would be happy to help them "attempt" a home birth? Holy cow, that would be scary! That would leave their minds open to the idea that they are likely to end up in the hospital, and not with the home birth that they planned for.

One thing that they did portray accurately - though I'm sure wasn't the intention - is the fact that the Obstetric system is NOT set up to support VBACs. The doctors interviewed spoke openly about issues with hospital protocol, and mainly, liability insurance. And that's what it comes down to. Not risk. Not a woman's ability to have a VBAC. Politics.

One of the most common things I have heard from women and OBs is that a VBAC isn't allowed at a certain hospital because they are not equipped to handle emergency surgery. Let's think about this for a moment. A uterine rupture is HARDLY the only emergency that can come up during childbirth, necessitating immediate surgical delivery. Cord prolapse, placental abruption (both of which occur more often with intervention, for the record) both would fall in this category. If a hospital isn't equipped to handle a VBAC, it isn't equipped to handle ANY birth. Period.

I screamed outright at the screen when a woman was interviewed who had found a supportive OB, and planned for a VBAC. She labored at home before going in. Once in the hospital, her OB discussed the need for her to progress consistently and timely (?!?!?!?!) in order for her to have her VBAC. He discussed breaking her water to speed things up if need be. (!?!?!?!?!?!?!)  She was a good girl and progressed from 7cm to 8cm in an hour. Then an on-call OB came in 2 hours later and checked her AGAIN, and found her to "still" be at 8cm. Started talking cesarean immediately. She mentioned breaking her water (!!!!!!) and asking for her OB to be called in. The doctor was upset that she was refusing medical advice. Her baby was fine. She was fine. But she had not progressed in 2 hours - or so the new OB said. Her OB was called back in, and in this Mama's words was, "So gracious to allow me more time". OMG! So gracious to ALLOW you and your perfectly healthy baby more time in labor?!?! Let's give her OB of the year award, shall we? The OB said she MUST progress to 10cm quickly, and baby must be descending.

She got to 10cm. But baby was not descending. What did she do?

She said that she had already put her OB in a difficult situation, and she knew it wouldn't BE FAIR to her OB to expect more. She agreed to a cesarean.


This is what happens to a HUGE chunk of women who think they are going to have a hospital VBAC. They get HUGELY manipulated into thinking that they should be FAIR to the person they *hired*. At the expense of their body, and their baby. They agree to surgery that is NOT medically warranted...because they love their doctor.

One OB who was interviewed said that the risks of VBAC may *seem* low, but that those low risks can come with catastrophic results. can induction of labor. How many women has he ordered induction for, in his years as a doctor? How many amniocentesis has he performed? An amnio comes with a higher risk of death to the baby than a VBAC does. (1 in 200-400 vs 1 in 2000)Yet, many women wouldn't blink an eye at having an amnio done if their doctor said it was best.

I recently read a study that said that women are more likely to go along with whatever their doctor says is the right course of action, regarding a VBAC or a ERCS. Regardless of empirical research that shows that a cesarean comes with a 2-4x greater risk of death for both mom and baby, if a doctor says it's best to do - most moms will go with it.

The study was a survey provided to women upon admission for their elective repeat cesarean section (ERCS) or trial of labor after cesarean section (TOLAC).  I am really shocked at the level of knowledge most of the women had. 73% of the women admitted for a ERCS did not know the chances of a successful VBAC and 64% did not know the risk of uterine rupture.  54% of women choosing a TOLAC did not know the chances of a successful VBAC and 45% did not know the risk of rupture.

So then I question - are WOMEN really making the choice if they are presented with inaccurate information? If they are willing to agree to major abdominal surgery on the suggestion of their OB? This is NOT informed consent. This is manipulation in the most base of forms. Women need to do their research. I've said it before - women research the type of car seat to buy, crib, diaper bag, more than they research their options in birth and weigh the risks/benefits of each. In our culture, however, we are pretty much brainwashed to view our doctor as our authority figure and not question. I have seen this with friends. Their OB lied to them or misrepresented risk, and they ended up with a cesarean. They go BACK to the same OB and talk to him/her about a VBAC. One of two things occurs most often:

1) OB says, "Well, you could TRY, but with your history of __________, the chance of needing an emergency cesarean - which is more dangerous for baby - is high. It's up to you though."  (yeah RIGHT)

2) OB says, "Sure, you can TRY for a VBAC. It doesn't LOOK like your issue should repeat." and then finds a reason at the end of pregnancy as to why a VBAC isn't going to happen. OB seems supportive, and then lovingly (HA!) finds a gentle way of telling mom that it doesn't look like a good idea after all.

Do you think she's going to switch care providers? For most women, no. It's this sick dependency thing we have going on, along with a very twisted romancing of complications and emergencies in birth and "needing" to be saved. Apparently this ranks higher than empowerment and an innate knowing that we are MADE to birth.

Anyway, back to the film. A doctor who was interviewed was asked to touch on the subject of HBAC - Home Birth After Cesarean. He inflated the risks. He talked about needing an OR available immediately - which is NOT GUARANTEED in the hospital!!! Nor is it evidence based. Studies show that you have 20-30 minutes to get to baby after a uterine rupture is suspected. Guess what? They can't have the OR prepped and ready in less than that in the hospital. But then he followed with, "Of course, a woman has to make this decision for herself."  HA! How many women do you think would choose this, or even do her own research if she was told that her baby is likely to die if she ruptures at home? (Let's go back to the fact that uterine rupture occurs in only 0.3-0.7% of VBACs, and those include the most common, asymptomatic uterine dehisciences, and that the risk of catastrophic rupture is a fraction of the 0.3-0.7%!)

Even Dr. Moritz admitted that in the hospital a VBAC has to go PERFECTLY. He called it a "Cinderella Birth." Which is realistic, how?? He also admitted that if there are ANY fluctuations in baby's heartrate, that it would be an immediate cesarean, without waiting any time at all to see if things were fine. Never mind that external consistent monitoring is highly inaccurate.

If I had been a mom watching the film for information on VBAC, I wouldn't be compelled to do my own research. I would walk away from the film with the idea that I should talk to my OB, and should act on his/her recommendation. I wouldn't look into my options, I would acquiesce to my doctor's advice and not think twice about it.

Ricky Lake and Abby Epstein had the opportunity to REALLY explore the problem with our current cesarean rates, and the extremely low rate of VBAC in our country - and they failed miserably. The only SLIGHTLY redeeming factor of this film is the birth story at the very end. Mom refused to bow to scare-based protocols of her local hospital, and planned a HBAC instead. Even in the face of the OB who refused her a "TOL" (trial of labor) calling her at 34 weeks to say that he would ALLOW her to TRY after all, she continued with her plan. It showed the very emotionally damaging effect that cervical exams can have, especially in a VBAC, when she was checked to be "only" 1cm, and wanted to give up and go in for a cesarean. Instead, her husband rallied by her side and helped her pick back up her resolve. She had a beautiful HBAC in the water - where she caught her baby herself.

But really, More Business of Being Born?? ONE positive, empowering story in all of an hour?? ONE? And the ONE woman you had talking about the risks of repeat cesareans - which are MANY - was not a "professional", but a mom. How does that look to people? The "professionals" are reiterating the risks and limitations of hospital VBAC, and a non-formally educated woman is citing the risks of surgery. Totally biased in presentation of risk/benefit. The risks of repeat cesareans were skimmed over, and the HUGE problem of care provider manipulation, hospital protocol, and misrepresentation of VBAC risks were barely touched on in the right way.

A study done on the morbidity rates of repeat cesareans:

Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999-2002).
There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively.
Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery.

And these are JUST the risks associated with repeat cesarean for MOM. This also doesn't take into account the rates of infection, the increased risk of DEATH, nor does it take into account the difficulty of healing from major abdominal surgery while having multiple children (and a newborn) to care for.

Once a woman has had a successful VBAC, her risks actually DECREASE for future pregnancies.

Among 13,532 women meeting eligibility criteria, VBAC success increased with increasing number of prior VBACs: 63.3%, 87.6%, 90.9%, 90.6%, and 91.6% for those with 0, 1, 2, 3, and 4 or more prior VBACs, respectively (P<.001). The rate of uterine rupture decreased after the first successful VBAC and did not increase thereafter: 0.87%, 0.45%, 0.38%, 0.54%, 0.52% (P=.03). The risk of uterine dehiscence and other peripartum complications also declined statistically after the first successful VBAC. No increase in neonatal morbidities was seen with increasing VBAC number thereafter.
Women with prior successful VBAC attempts are at low risk for maternal and neonatal complications during subsequent VBAC attempts. An increasing number of prior VBACs is associated with a greater probability of VBAC success, as well as a lower risk of uterine rupture and perinatal complications in the current pregnancy.
The problem is that when women are given the MISREPRESENTED information about VBAC, very few who are initially interested end up having one. So they end up in the category above - at higher risk for serious complications with each subsequent pregnancy. We have a HUGE issue on our hands here, and most days I feel hopeless for change. With women refusing to do research on their own, because it might mean choosing a different OB (or - :gasp: - a Midwife, increasing her chance of a successful VBAC!), or standing firm and choosing a VBAC against the advice of her care provider....we are going to continue to see a very high rate of uninformed women choosing repeat cesarean. We will also see higher rates of complications in pregnancy, and eventually, higher infant mortality.

And the root of the problem lies in the lack of ethics and evidence based protocols in Obstetrics, where it is commonplace to manipulate, scare, and even bully a woman into intervention that increases her risk of that primary cesarean. Women NEED to become better informed of what empirical evidence says about the common issues that arise in pregnancy, labor, and birth. Until women make a stand and demand better care, these risks will only continue to increase.


Jer said...

THANK YOU!!! Hear, hear!!! I haven't seen the film, but your description has me frothing at the mouth. The doctor-worship I see every day makes me ill. When will women start trusting their own brains, their own bodies, their own hearts??

Ashley and Daniel Tanner said...

I had a VBAC delivery with my son 6 months ago after my daughter was delivered as a c-section because I could not "push" her out and they kept telling me that I may be to small to delivery a baby and I ended up having a 9 lbs 3 0z baby who was posterior naturally...ha