Don't forget to thank the dems and the trial lawyers, they're so smart.
Posted on 11/28/2004 10:23:16 PM PST by neverdem
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.
Major medical centers still perform such deliveries, but many smaller ones have banned the practice, saying that it is riskier than once thought and that they do not have the staff to handle emergencies that may arise. 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.
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.
On a practical level, many women prefer vaginal birth because they recover more quickly and with less pain than they do from a Caesarean. In addition, each Caesarean increases the risk of complications in the next pregnancy, so women who want more than two or three children often hope to avoid the operation.
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.
"My intuitive feeling is, it's going to be harder and harder to find places that offer it, because of the known risk and the medical legal climate we live in," said Dr. Gerrit Schipper, chief of obstetrics at Frederick Memorial Hospital in Frederick, Md., which banned the procedure recently. The decision provoked a protest outside the hospital on Nov. 9 by about 50 mothers with their children.
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.
"There are very irate people in various parts of the country," said Dr. Bruce Flamm, an obstetrician with Kaiser Permanente and a clinical professor at the University of California, Irvine, who has written a book and many articles about vaginal births after Caesarean sections. A recent study by Dr. Flamm, published this month, concluded that such deliveries should be handled in hospitals, not birthing centers, because of the increased risk of complications.
"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."
As a solution, he suggested, hospitals that do not allow normal birth after a Caesarean should refer women to hospitals that do. Or, he said, "you don't have a whole crew in 24/7, but how about just a few nights a year when you have a VBAC patient in labor, you say, 'We will sleep in the hospital or sit in the lounge'?"
Having a Caesarean or not, Dr. Flamm said, "should be the woman's choice."
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."
But some doctors report that women themselves seem to have lost interest in trying labor after a Caesarean.
"I'm a huge advocate," said Dr. Laura Riley, an obstetrician and maternal-fetal medicine specialist at Massachusetts General Hospital in Boston. "But our rates have dropped. Patients aren't interested. When there's any risk, they don't want to hear about it. A lot of people are into total convenience. If I tell them we can schedule a Caesarean on X day at X time, they go for it."
A study published in an obstetrical journal in 1997 found that when women with a previous Caesarean were offered a natural delivery, 30 to 50 percent wanted it.
In the past, the medical rule was "once a Caesarean, always a Caesarean." The thinking changed in the 1980's, when studies at big medical centers suggested that 60 to 80 percent of women could safely go through labor and a normal delivery after a Caesarean. The risk of rupture appeared to be about 1 in 200.
A burst of enthusiasm followed. The proportion of mothers who had had a Caesarean and then a normal birth rose from 19.9 percent in 1990 to 28.3 percent in 1996. In Europe, the rate was about 50 percent in 1997.
Government health experts in the United States endorsed the procedure as a way to help control climbing Caesarean rates, since repeat Caesareans account for a third of the one million done each year. A government health report published in 2000 said one of the nation's goals for the year 2010 should be a VBAC rate of 37 percent. Instead, the trend reversed.
In 2002, more and more women with a previous Caesarean began calling the International Cesarean Awareness Network, saying they could not find a nearby hospital that would allow a normal delivery, said the group's director, Tonya Jamois. Now, she said, she receives such calls every day.
"Women are not being allowed to have a choice even if they have had several VBAC's before," Ms. Jamois said.
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.
"I think the real death knell to VBAC's was the malpractice crisis," Dr. Lockwood said.
About 2,000 babies a year are born at Frederick Memorial Hospital, including about 60 last year delivered vaginally after a previous Caesarean. Dr. Schipper said he had been a proponent of VBAC, but felt differently after three women at Frederick had major complications within the past three years. Two had severe blood loss, and one needed a hysterectomy. The hospital banned the procedure.
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?' "
If a woman still wants a vaginal birth, he added, he will refer her to a larger hospital in Baltimore, 50 or 60 miles away.
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.
Dr. Cherouny of the University of Vermont said that not all women who had had Caesareans faced the same amount of risk from trying to deliver vaginally. Women who have had more than one Caesarean, for instance, have a considerably higher risk of rupture and other complications, and many doctors say they should not try a vaginal birth. Women whose first labors were very sluggish are also unlikely to succeed, as are those who pass their due date and do not go into labor spontaneously. Drugs commonly used to induce labor also markedly increase the risk of rupture, studies have found.
Dr. Cherouny said some women were so determined to avoid a Caesarean that they delayed coming into the hospital until they were in advanced labor, leaving doctors little choice but to deliver the baby.
"I'm not going to chain them down and do a C-section," he said, adding that courts rarely force women to have Caesareans.
For that reason, he said, he and his colleagues tell hospitals: "You must be ready. Even if you don't want to do VBAC's, you will. The patients will make you."
Don't forget to thank the dems and the trial lawyers, they're so smart.
Put in a zipper.
I personally don't like the turbo-litigious nature of our present society, but I think the chumps behind this anti-freedom measure need to get their asses sued off. (And I say that only because pounding their dumb asses flat wouldn't change their minds.)
my caesarian was the worst@!@! try being paralyzed from the neck down!
In an irony maybe Planned Parenthood centers would be willing to do VBACs with all their risk, after all it's only "a lump of tissue" to them prior to the birth.
Such an attitude will have even less docs practicing obstetrics.
FReepmail me if you want on or off my health and science ping list.
I had a vaginal delivery after having a C-section. I was given a choice. Kaiser.
As for 3 weeks, yikes. I couldn't imagine waiting that long. Both of my sons were born 3-4 days after their due date. That was wait enough for me. :)
My first Cesearean was in 1993, had a VBAC in 1995, (15 days overdue) and had another Cesearean in 1997. Doubly glad not to have to worry about this crap anymore!
One can also schedule a vaginal delivery, since labor can be induced with drugs.
Ahhh....the PERFECT example of the impact of legal issues and financial issues on medicine.
Believe me, this issue has NOTHING to do with a repeat C/S being more "lucrative" to Physicians, and EVERYTHING to do with safety.
In the modern era, with the almost universal use of regional anesthesia (Spinal or Epidural anesthesia) for C/S that are non-emergent, the true incidence of major morbidity and/or mortality from elective C/S has become negligent or non-existent. With attempted VBAC, there is a CERTAIN risk that approaches 1% by most estimates of a potential CATASTROPHIC outcome for either the mother, fetus or both.
In the current medicolegal environment, as a physician, which route would you choose?
The primary problem with VBAC is COVERAGE IN HOUSE when women are in labor...the ONLY way I would let my wife labor as a VBAC is if BOTH the obstetrician AND Anesthesia provider (preferably and Anesthesiologist) were IMMEDIATELY AVAILABLE... and that means IN HOUSE, and NOT OTHERWISE OCCUPIED.
No one in medicine presently gets reimbursed by insurance carriers for "being available", or staying "in house"...if it's 0200, and your wife comes in to the facility as a VBAC in labor, am I expected to come in to the facility and stay there FOR NOTHING so you can have the choice to attempt VBAC to ensure it's safe? If it's in the middle of the day, am I supposed to cancel elective OR cases to make an anesthesia provider IMMEDIATELY available to respond to the mother attempting VBAC who has an emergency? Who pays for that? Who pays for the immediately available scrub tech and circulating RN?
Legally, as a physician if I know that elective C/S is inherently safer (regardless of the patients feelings) than VBAC, and if I am legally liable for a potential lawsuit in the multiple millions of dollars for a bad outcome secondary to a catastrophic UNANTICIPATED, and UNPREVENTABLE event such as uterine rupture, am I obligated to acquiesce to the patients wishes?
Listen folks...anyone that is anticipating VBAC that is reading this thread, I encourage you to ask the following questions:
1. Will the obstetrician be IN HOUSE and immediately available?
2. Will there be an anesthesia provider IN HOUSE and immediately available?
3. Does the hospital make provisions to have immediate OR availablity with proper staffing 24/7/365?
If the answer to any of these questions is no, then you are rolling the dice.
The big issue here -- and its an issue in a number of other legal liability areas as well -- is that our legal system has no provision whatsoever for waiver of liability concerning injury to children. You can make the parents sign a waiver so that THEY can't sue if a baby is harmed during delivery, or a child is seriously injured participating in an organized sport. But these waivers do not prevent the child, or some other entity purporting to act on behalf of the child, from suing and winning multimillion dollar judgements.
IMO we need a federal law giving full legal weight to liability waivers signed by parents on behalf of their children. More children are being harmed by the lack of such waivers, than would be harm by parents who sign them thoughtlessly. Not only are many babies being born in cars on the way to distant hospitals, with no medical help at all in the event of a problem, because all the nearby obstetricians have been put out of business. But children across the country are being prevented from being physically active by liability-conscious schools and play facilities that have eliminated a huge range of activities and equipment on the grounds that someone might get hurt and sue. Workplace based daycare centers, where parents could actually keep an eye on how their children are being cared for, and informal home daycare opportunities, where children can be cared for by a trusted friend or neighbor, are very rare, because of the massive liability issues that can't be contracted out of.
Your experience sounds like mine:). Both mine were C section, the first after 24 hours labor, pre-eclampsia, high blood pressure....The second, extremely easy. Altho not having a normal birth to compare too, I didn't think the C section was all that painful, or hard to recover from. It wasn't any worse then the labor anyway.
Becky
Liability waivers have not, to my knowledge, ever protected anyone in the medical community/profession from being sued....adult OR child.
People want to make "their" choice, and then hold others accountable when things go wrong...and it doesn't help that they are egged on in this endeavor by a bevy of lawyers.
bttt
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