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Wednesday
Apr282010

Want to Help Review a VBAC Consent Form?

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By Jill—Unnecesarean

 

 

Those of you who read the comments are probably aware of the obstetrician who calls himself “Ob” and believes that VBAC should be the norm, thinks midwives are great and, after all those years attending births, still seems pretty soft on the whole process of baby people emerging from other people. He leaves comments like this:

Reading this blog has not changed my practice, c/section rate, or had any impact on my labor management (or lack thereof) but it has damn sure changed the way I talk with my patients. I now make as sure as possible that my patient fully understands the reasons for her labor progress/c/section indication/induction/whatever. I thought I did before. Now I believe I do better. Is this supposed to be a self help blog?

 

Ob is looking for helpful feedback on the malpractice carrier mandated VBAC permit that all patients with a previous cesarean must read and sign. Nothing can be deleted, but text can be added.

What would your thoughts and feelings be as a patient (or birth attendant) when reading this form? What specific additions would you make?

 

 

Consent for Vaginal Birth After Cesarean Section

 

Name of Patient: _________________________         Chart # ________________

 

Initials

 

_____ 1. I understand that I have had one or more previous cesarean section(s).

 

_____ 2. I understand that I have the option of undergoing an elective repeat cesarean section or attempting a vaginal birth after a cesarean (VBAC).

 

_____ 3. I understand that approximately 70% of women who undergo a VBAC will successfully deliver vaginally.

 

_____ 4. I understand that the risk of a uterine rupture during a VBAC in someone such as myself, who has had a prior incision in the noncontracting part of my uterus, is around 1%.

 

_____ 5. I understand that VBAC is associated with a higher risk of harm to my baby than to me if there is a complication of labor.

 

_____ 6. I understand that VBAC carries a lower risk to me than does a cesarean delivery if there is no complication of labor.

 

_____ 7. I understand that if I deliver vaginally, I most likely will have fewer problems after delivery and a shorter hospital stay than if I have a cesarean delivery.

 

_____ 8. I understand that during my VBAC, the use of oxytocin (Pitocin) hormone to make my uterus contract may be necessary to assist me in my vaginal delivery, and the risks of this drug have been thoroughly explained to me. A Pitocin induction is contraindicated in previous VBACs and this drug will not be used in this manner.

 

_____ 9. I understand that the decision to have a VBAC is entirely my own, and the option of an elective repeat cesarean has been discussed with me.

 

_____ 10. I understand that if I choose a VBAC and end up having a cesarean during labor, I have a greater risk of problems than if I had had an elective repeat cesarean.

 

_____ 11.  I understand that if my uterus ruptures during my VBAC, there may not be sufficient time to operate and to prevent the death of or permanent brain injury to my baby or myself.

 

_____12. I understand that if my uterus ruptures during my VBAC, a hysterectomy (removal of the uterus) may become necessary.

 

_____ 13. I understand that [“Ob”] cannot guarantee that other physicians who may be covering for him will allow me to attempt a VBAC.

 

_____ 14. I understand the complications of VBAC may include but are not limited to uterine rupture and may also include any complication of a non-VBAC vaginal delivery.

 

I understand the above information. I have been given an opportunity to ask questions and have had them answered to my satisfaction.

 

_____ I want to attempt a VBAC.                                 _____ I want a repeat cesarean.

 

[Patient and physician signatures]

 

 

 

 

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Reader Comments (49)

There is so much to say... but for a start, how about:

"I understand that uterine rupture is a possibility whether I choose an elective repeat cesarean surgery or a VBAC."

And a clarification/expansion of #9:

"I understand that the decision to have a VBAC is entirely my own, and the option of an elective repeat cesarean has been discussed with me, along with a clear explanation of all of the risks and benefits of this surgery for this and any subsequent pregnancies."

April 28, 2010 | Unregistered CommenterJennifer

What about rephrasing? I'd like to see #5 read: I understand that there is a higher risk of harm to my baby than to me if there is a complication of labor during VBAC. Also, could #4 go nearer #11, #12, #14 (all uterine rupture items together).

PS to Ob - thanks for hanging out 'round these parts!

April 28, 2010 | Unregistered CommenterJMT

Not bad. Very similar to the one we had where I trained as a midwife.

I would add "I have been told that the American College of Obstetrics and Gynecology currently recommends that all good candidates for VBAC should be offered a trial of labor."

April 28, 2010 | Unregistered CommenterMomTFH

I love this cesarean consent form http://www.motherfriendly.org/pdf/TheRisksofCesareanSectionFebruary2010.pdf it gives lots of ideas on the risks of cesareans you may find helpful. Also #10 confused me. I've always thought even a little labor was better for baby than just a scheduled section

April 28, 2010 | Unregistered CommenterKristen

Sorry for the double post here, but my comment made me think. I just read over the ACOG practice bulletin on VBAC last night (after getting into an annoying "devil's advocate" conversation with a fellow medical student who was studying for his women's health final) and the recommendation I posted above is a highest level (level A) recommendation.

There are two interesting points. One, the suggestion that a physician be immediately available is a level C. I think ACOG is clear in saying this should be offered, and that is more important than the immediately available issue. Language about physicians being available for emergency cesarean also appear in their bulletin on inductions, but that is rarely mentioned. Finally, under "Intrapartum Management", it says:

"Once labor has begun, a patient attempting VBAC should be evaluated promptly. Most authorities recommend continuous electronic monitoring. However, no data suggest monitoring with intrauterine pressure catheters is superior to external monitoring. Personnel who are familiar with the potential complications of VBAC should be present to watch for nonreassuring fetal heart rate patterns and inadequate progress in labor." I

I think this is a much lower standard than many people say this bulletin warrants.

Also, under delivery: (emphasis mine)

"There is nothing unique about the delivery of the fetus during a trial of labor. The need to explore the uterus after a successful vaginal delivery is controversial. Most asymptomatic scar dehiscences heal well, and there are no data to suggest that future pregnancy outcome is better if the dehiscence is surgically repaired. Excessive vaginal bleeding or signs of hypovolemia at delivery require prompt and complete assessment of the previous scar and the entire genital tract."

April 28, 2010 | Unregistered CommenterMomTFH

Add to #4 a brief note saying that the risk of uterine rupture may be less if induction and augmentation drugs are not used, and perhaps a figure indicating how many ruptures are catastrophic? Uterine rupture sounds pretty horrifying and final to the uninitiated.

April 28, 2010 | Unregistered CommenterJulie

I'm very confused by point #8:

" 8. I understand that during my VBAC, the use of oxytocin (Pitocin) hormone to make my uterus contract may be necessary to assist me in my vaginal delivery, and the risks of this drug have been thoroughly explained to me. A Pitocin induction is contraindicated in previous VBACs and this drug will not be used in this manner."

I *think* it's saying that pitocin will NOT be used to start labor, but may be used (despite risk) to increase the strength of contractions in an established labor. Right? If so, it needs to be re-worded to be clearer about the distinction between induction and augmentation.

And what does the word "previous" mean in "...is contraindicated in previous VBACs"?

April 28, 2010 | Unregistered CommenterLiz Chalmers

This document needs a matching category for the ERC. For example:
1.I understand I am at risk of hemmoraging during a repeat cesarean, and this hospital may not be able to get it to stop on a timely manner.
2. I understand an ERC will increase the risk of placental problems in future pregnancies, and may result in loss of mother or baby
3. I understand I may react unfavorably to anesthesia, this can lead to anaphalactic shock or death
ETC....and so forth
and end with
: Both of these options carry risk and you, as the patient, are the primary decision-maker. Please discuss your questions and indicate your choice below.

_______ TOLBAC/VBAC ____________ERC

April 28, 2010 | Unregistered CommenterJoy Szabo

You need to give the actual risks of a repeat cesarean along with the risks for a vbac... I asked to see both forms while planning my last vbac and they were very misleading. There was a shocking lack of risk information for the repeat c-section consent form. The c-section risks info should include the risks to future pregnancys.

April 28, 2010 | Unregistered Commenteranna

I would not want to give broad consent to Pit (#8). My understanding is its use can raise the risk of uterine rupture. If there were circumstances in which pit needed to be used, I would want to discuss those at the time and give informed consent, not simply agree that it could be used at any time. Not sure how that could be incorporated...

April 28, 2010 | Unregistered CommenterSara Kay
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