Want to Help Review a VBAC Consent Form?
Wednesday, April 28, 2010 at 12:45AM
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]
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."
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!
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."
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
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."
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.
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"?
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
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.
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...
Add to #8, I believe, or make a subsequent number. I understand that Nipple stimulation through the use of a breast pump, or other personally selected method may be as effective and medically administered pitocin and should be considered a first option.
THhs way we can get over the uncomfortable bullshit.... Personally, over an hour on a "double milker" kept me in the drivers seat which was great for my determination and esteem and resulted in a baby after an additional two hours (45 min of pushing). After pumpoing I had a sandwich so I would aslo add
" I understand that there is minimal medical concerns regarding consumption of food during labor and That I may go against Dr.s concerns and consum food if my insticts dictate that it will progress my labor"
The nurse grab a puke bag... and waited and waited... I happily scarfed down a fried chicken sandwich and started pushing 20 min later.... total labor time 18 hrs.... epidural strarted at 7cm, about 6 hrs into labor.
Between #13 and #14.
I understand that although a physician covering for my ["ob"] may not agree with an attempted VBAC, all of the options will be discussed with me in order for me to make my decision. I still have every right to refuse interventions.
I just think the lack of competing information on these kind of VBAC Consents make it sound as though one is taking unnessasary risks opting for VBAC, and leads one to believe that ERC is better.
How about a statistic on fetal harm in the case of a rupture? Most ruptures are a) not noticed, and b) not catastrophic. So a percentage of 1% might be helpful for women to think about.
"A Pitocin induction is contraindicated in previous VBACs and this drug will not be used in this manner."
I don't like this part and would prefer it said that pitocin induction increases or doubles the chance of uterine rupture. I certainly don't WANT to be induced but definitely prefer that option to a RCS if a medical need for imminent delivery occurs, as the risk of rupture is still pretty low with pitocin induction. There are a number of women in a VBAC support board where I participate who have faced induction and had it result in a successful VBAC. It could also be mentioned that pitocin augmentation has not been associated with an increased risk of rupture.
I agree that the risk of catastrophic rupture should be specified (1 in 2000 - 1 in 3500 depending on source) because most ruptures are not catastrophic.
one thing i always found interesting, is all this concern for "uterine rupture". perhaps i am confused but isn't a c/s (whether planned or elective) no more then a (theoretically) controlled uterine rupture? all the things that can go wrong during a rupture can also happen during a "normal" c/s, correct? i mean, it really is and when the mom is explained all the risks, she is likely to see it that way as well.
also, how common are these consent forms? i only ask because when i had my vbac, i didn't sign any consent forms from anything. before or at the hospital. i mean, i signed generic consent of care forms, but nothing specific for the vbac.... perhaps i was lucky?
i guess i don't really have any additional feed back besides what others have already mentioned.
Without reading what everyone has written first, I would say I would like an accurate statistic on there, and not "around 1%", especially since it is lower. I would also like to see more that discusses the risk of elective repeat cesarean. Why don't women have to sign a risk waiver for that???
Definitely needs to be a separate column for ERC risks, especially describing risks to future pregnancies. This form looks like all the risk is on VBAC, and very little on cesarean. I also agree that I would be uncomfortable giving a blanket consent for pitocin. And there definitely needs to be clarification that even though this ob can't guarantee that other physicians will LIKE to allow VBAC, I would still have the right to refuse a cesarean regardless, and VBAC even without the covering physician's direct assistance. I think I'm just echoing a lot here, but certainly make a distinction between uterine rupture and catastrophic uterine rupture. Finally, I would like something ensuring that any medical decisions will be discussed with me (or my husband, if I'm unconscious) BEFORE the decision is made final, AND that I have the final word. Something about the NIH panel determining that VBAC is a relatively safe option for most people would be nice too.
I signed one of these on my last birth. I also had a VERY SUCCESSFUL VBAC!!!
I second many of the comments, including
- the 1% statistic is not accurate and needs to be revised to reflect the true underlying rate of UR during a non-induced, non-augmented TOL. Immediately following the consent form should mention how many of those UR are actually emergent vs asymptomatic dehiscense, and the rate of major fetal morbidity and/or death due to UR, compared with the overall rate of major morbidity/death in giving birth in general (which are nearly equivalent, in my understanding.) It's important to set the numbers in context of the overall "risk picture" of giving birth in general. It's not like a VBAC = risk while "birth in general" or "ERCS" = no risk, but rather a balancing of one risk over the other.
- the form definitely is biased in favor of ERCS in its wording. It seems you patients have other consent forms to sign when choosing ERCS, etc, but still...I think the VBAC consent form still needs to include an accurate portrait of the risks of ERCS to set the risks of VBAC in context
- I'd like to see the research about the decreased risks with multiple VBACs, versus the increased risks of multiple repeat CS, as well.
- Should mention something about how VBAC can be an especially good choice for women wishing to be able to have more than 2 children, since the risks of ERCS multiply exponentially with each subsequent surgery, especially getting into the 3rd/4th/5th surgeries