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Sunday
Jun212009

Hospitals Can't Handle VBACs? Then What Can They Handle?

Two comments that got me thinking…

 

Iris427 on this Bump.com thread said this:

If a hospital is not equipped to handle a VBAC, it’s not equipped to handle any emergency in childbirth, period. If they can’t do an emergency c/s for a VBAC attempt, what do they do if a baby’s cord prolapses? What if a baby goes into sudden distress? You can either do emergency cesareans or you can’t. It doesn’t matter if the mom is trying a VBAC.

That is exactly what Dr. Lisa Masterson said on the episode of The Doctors featuring Ricki Lake and Abby Epstein. It was a gaffe for anti-home birth Dr. Masterson, whose exact quote was “You cannot necessarily get there [from a home birth quickly enough] because even in a hospital sometimes you can’t transfer quickly.”

 

A comment with a similar sentiment was left by Lori on the latest birth story submitted.

“small hospitals are not staffed or equipped to handle emergency cesareans on a regular basis.” This is nuts! The poor women and babies who actually have a true emergency during the poorly staffed times! In my mind that completely eliminates the assurance a parent would feel by choosing to birth in a hospital. You’re right. This is a human rights issue. Or at least a truth in advertising issue. If small hospitals are not continually prepared for emergencies, then they shouldn’t communicate that they are the “safest” place for a birth!

 

Unrelated to the comments above but something that made me extra joyful on a Sunday night…

This story (and a picture) were posted on The Unnecesarean Facebook Fan Page. Did my eyes well up just a little? Yes, they did.

I had an “unnecesarean” 22 months ago. Was induced for being 1 week “overdue”, got epidural, labored for 16 hours, pushed for 3, never felt the urge to push though, they turned off the epidural so I could feel the urge to push, was out of my mind with the contraction pain (since I hadn’t felt it up until then), and agreed to a section asap (wasn’t educated about the dangers of cesarean at that time!). Aidan was 9 lbs. 9 oz. and they said I needed the section due to failure to progress and that his head was too big. Here’s the happy ending: had a beautiful baby girl 2 months ago, home birth with a midwife, VBAC, Clare weighed 10 lbs. 6 oz.!

 

 

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Reader Comments (14)

I loved the last story. Congrats to her!

I have so many things to say about the stuff about hospitals not being able to do stat c sections. I was at the birth of a 27 1/2 week baby without an ob/gyn present. Was it at home? No, it was at a hospital. We had two midwives, me (a midwife student), and a NICU team. (Actually, my son Z was an infant at the time and I had him in a sling. Amazing what they will let you get away with in an emergency).

The patient was a midwife student who went into premature labor. We called the hospital (which was five minutes away) on our way in, and waiting 45 minutes in the delivery room with the poor patient screaming and writhing in pain. She had been complete for a while, apparently most of the labor was painless, although it was hard to see that at this point. It is also hard to talk someone into a peaceful place whose baby has come months early and the damn doctor won't show up.

Finally, the midwives and NICU team decided the baby needed to come out, and she pushed him out. He was 2 1/2 pounds. He is doing great now, but the doctor didn't show up for almost another hour, and then proceeded to tell off the poor mother.

Whenever someone says "I would feel so much more comfortable with a doctor there" or "what if an emergency happens?" when speaking about out of hospital birth, I always think of this story. This was a hospital in a major city, by the way, not some rural outpost.

What does that say for VBACs? Well, from what I have read and seen, and I have attended at least a dozen successful VBACs and been on transfers of one or two unsuccessful ones, they are not as urgent as some of these other obstetric emergencies. If a hospital is supposed to be able to handle a very low birth weight baby (and this one was), they should be able to handle a VBAC or a VBAC transfer.

June 22, 2009 | Unregistered CommenterMomTFH

I wish someone, ANYONE, would do a survey of the "when OBs/Hospitals weren't available, women died in childbirth" thing. I wonder if there are any statistics other than anecdotes. Midwives will say that most of the women who died did so because of lack of hygiene. OBs will say it was other reasons.

I have had two C-sections. The first was scheduled because the baby was breech, and my doc didn't deliver breech babies. There is only ONE OB in our major metropolitan area who will deliver a breech baby. I could have switched to him, but whatever. Anyway, my first would probably have ended up an emergency C if I had labored (barring the knowlege that the baby was breech ahead of time) because he was a transverse/footling. I had an attempted VBAC with my second that ended in another C. 25 hours of labor, mostly at home and unmedicated. Water broke at hour one. Failed to progress beyond 4 cm, though my doula thought I was complete. Doc said the kid's head was a bit tilted and "caught" on my pelvis and he wasn't descending.

Asked my doula what would have happened to me 100 years ago and she said that I would have labored for a couple of days. Maybe the baby would have moved enough to descend, maybe not. He was VERY mobile during labor, trying desperately to get where he was supposed to go.

Anyway. I am glad I have/had the option of Csections, but I am cranky as all hell that I didn't really believe that I had the option of a vaginal birth with No. 1. I do seem to be one of the very minority who truly NEED a C, but still. Makes me cranky that I had two abdominal surgeries. Phooey.

June 22, 2009 | Unregistered CommenterKimberly

I have actually been thinking about this a lot lately. And the points in this explain it perfectly! If a hospital isn't able to prep in an emergency in a regular labor, they won't be able to for a VBAC. But most hospitals say that it takes about 10 to 30 minutes from decision to incision, and that seems like a long time to me. If something is truly wrong, won't it go bad faster than in 10 minutes time?

I have read tons of birth stories where the woman is fully dilated and pushing, and the doctor is nowhere around to catch, and then gets mad and yells at the mom for not holding on until he got there in case 'something had gone wrong'. But if that was truly the case, why don't they try to speed up their times for emergencies?

(I hope that made sense... it made sense in my head haha).

June 22, 2009 | Unregistered CommenterKayce

I love it when folks point that out. I know Pamela Udy from ICAN did a fantastic inteview with a local Public Radio station and was quick to point out this exact same thing. I try to remind folks that this is especially concerning for an unscarred uterus - they can rupture too and from my understanding are more likely to be catastrophic ruptures than those w/a scarred uterus. It usually turns out to be one of those "I never thought of that/knew that" moments.

June 22, 2009 | Unregistered Commenterpampered_mom

Jill,
My house is a mess today because I have been reading your Facebook site, and the comments were fascinating and sad to me. They were sad to me as a health care worker because so many women feel let down and abused by hospitals. So many of them seemed terrified of having to have a C-section (as my currently pregnant SIL is) and frustrated that they can not find anyone to perform a VBAC. The majority of women in this country want and choose a hospital birth. Therefore it is our jobs as health care workers to respects women's rights and wishes during their hospital birth. Hearing stories of doctors yelling at their patients like MTFH said, makes me sick.
Some of the comments on the Facebook site made me a little nervous. I am not a big fan of unassisted births, and some of the posts encouraging unassisted births at home for previous C-section moms was scary. I hope that women's bad hospital experiences are not pushing them into potential dangerous scenarios at home, with little or no one their to help them.

Reply from Jill (6:39 pm PST June 22)

I'm just going to stick this in with your comment, okay? Easier.

For the sake of this blog, I avoid telling anyone what to do or what to choose. Know what I mean? I picked my words very carefully in the thread you’re talking about. When one commenter asked “You can do that?” I pointed out that it is ones right to give birth unassisted. I posted links to a more or less pro-unassisted birth blog and a more or less anti-unassisted birth blog.

For some women, UC is their ideal and they would plan for it independent of any prior experiences. For others, like you speculate, it has everything to do with needing a totally hands-off birth after a previous traumatic hospital birth, being unable to find anyone who will attend their VBAC and/or because they are in one of the 24 states that doesn’t have recognition of licensure of CPMs. So if a hospital birth is out of the question and a home birth with an experienced midwife is basically illegal, what’s left? That baby is coming out one way or another. I’m sure there are plenty of other motivators for UC. I’m also open to correction if this sounds wrong or doesn’t address enough of the nuances in decision making. I’m just going by what women have told me and am not trying to pathologize the decision at all.

Once I learned (long before the Facebook thread) that women that otherwise would prefer NOT to give birth without assistance either had to choose an elective repeat cesarean for no reason or unassisted birth (if there were no “underground” midwives available to them), I decided to step up my efforts to fighting VBAC bans. I have yet to physically get out and rally, but I’m getting things in gear.

June 22, 2009 | Unregistered CommenterReality Rounds

I think you could go two ways on this one - either realize that the home birth option is similar to access to care in an emergency, or investigate hospitals thoroughly and pick one with a below-average decision-to-incision time. The problem is that most hospitals, even big ones, (as MomTFH pointed out) don't have that and if you're in any kind of even vaguely rural area you have no options to pick from anyway.

I also can't see how, in a practical sense, that would ever change. You'd either have to close the community hospital L&D units and shuttle all women to centralized units hours away from home, or you'd have to somehow come up with the money to staff all these little hospitals 24/7. It's interesting that the hospital administrators and OB staff in those hospitals have apparently accepted that level of risk as inevitable and acceptable (even if they do not advertise it), yet few would probably agree that homebirth delays in reaching care are similarly acceptable.

June 22, 2009 | Unregistered CommenterRebecca

I've mentioned this problem before, and I still stand by it. If you can't perform emergency sections (even if only at certain times), then how do you have an L&D floor open (during those times)? Particularly with the vast number of inductions that are being performed these days, and the high section rate from them, how are these hospitals working?

June 22, 2009 | Unregistered CommenterTara

Reality Rounds: I would submit that for a large percentage of women, it isn't a previous hospital experience, but a lack of options that drives women to UC. In many, many areas around the country, there are NO doctors who will support a VBAC. In half the states, midwives are illegal, and in the states in which midwives are legal, I would bet that a good number of those midwives are prohibited by their licensing from attending a VBAC, or at least a VBAMC.

For many women in our country today, really their only choices are repeat c-section in a hospital, or home birth with an illegal midwife or none at all.

June 22, 2009 | Unregistered CommenterEmily Jones

Oh good. Emily responded. Emily, how did I do in my attempt to spell out UC?

June 22, 2009 | Registered CommenterJill

Emily,
I think that is exactly my point. We should be supporting women's choices and options in and out of the hospital. I am spoiled to have only worked in hospitals that have supported VBACS. But I do realize that there are hospitals and whole states out there that have essentially banned VBACS. For me, I choose to fight the good fight of promoting more choice in hospital births. I actually had an insane argument with the head of anesthesia the other day about not starting a saline lock for a woman who wanted a natural childbirth. Trust me, it can be exhausting fighting this fight.
But I do not think the answer is having women going "underground" to give birth unassisted. I truly believe women should have someone experienced in assisting birth with them during birth, either at home or in the hospital. This includes VBACs.
BTW, it may not just be the doctors who are not supporting VBACS. Every hospital who accepts public aid (which is every hospital) has insurance carriers who have a say in how MD's practice. They can cut the insurance to the hospital if the hospital does not comply with their recommendations (like not performing VBACS if you do not have 24/7 in house anesthesia). If they cut the insurance, the hospital essentially closes. So it is hospitals, doctors, lawyers, and insurance carriers that dictate some of these rules. Patient demand can change these rules, just like the 24 hour discharge from the hospital after a vaginal delivery was changed due to patient outrage.

June 22, 2009 | Unregistered CommenterReality Rounds
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