A Strange Juxtaposition of Articles on VBAC
Wednesday, July 21, 2010 at 4:10PM
By Jill—Unnecesarean
I read two articles about VBAC today. I’ll give you the first paragraph of one and the last paragraph of the other.
From the Health section of the New York Times today comes the article “New Guidelines Seek to Cut Rate of Repeat C-Sections.” The article is pretty neutral and covers some interesting points about twin VBACs and VBA2C. (via ANaturalAdvocate)
Most women who have had Caesarean sections can safely give birth the normal way later, studies have shown, but in recent years more and more hospitals, doctors and insurers have been refusing to let them even try, insisting on repeat Caesareans instead.
This doozy of an editorial is found on OBGManagement. (via Dr. Poppy)
It’s up to us to determine whether VBAC should stay or go
I estimate that we have a window of opportunity of 5 to 10 years to resolve whether VBAC remains part of practice. If we don’t take that opportunity, we’ll be left with a generation of physicians who have little or no experience performing the procedure. VBAC will disappear, in a self-fulfilling prophecy—which, when you think about what happened with vaginal breech delivery, may not be a bad thing.
Reader Comments (16)
huh? Surely by definition VBAC is not a procedure a doctor performs.... ugh.
Doozy is right! Where to start? It's so equivocal and unclear that I can't tell wtf it is saying. Not to mention that it does nothing to dispel the whole "doctors have a god complex" myth.
As for the Times piece - hello Debbie Downer! And here I was feeling full of optimism!
Here, CM. You probably heard this after you read those articles.
Yeah, I read the whole article by Dr. Poppy. WHERE THE CRAP IS HE GETTING HIS INFO!!??
Here are some of the highlights that I did not like from his article, some shociking:
1. Now, we’ve moved to the other end of the spectrum: It seems we offer VBAC to anyone who wants it, regardless of comorbidities.
Me: What a bunch of crap! Women all around me are having to go underground or unassist to avoid life threatening major surgery and he says we have swung to the under end of the spectrum. Even with this recommendation we have a long haul ahead of us.
2. And I considered VBAC finished when I compared the target VBAC rate established in the US Department of Health and Human Services’s Healthy People 2010 report against the astounding data that we see reported today:
Me: He goes onto quote the high numbers of c-sections. Well, obviously VBAC isn't dead.
3. The true risks of VBAC are unknown. However, we do know—all the data are in agreement—that elective repeat cesarean delivery, performed at the appropriate gestational age, is safer for fetus and newborn than a trial of labor.
Me: He is quoting another doc at this point. But EVERYTHING I Have EVER read has said the exact opposite. Is ACOG getting different data than us or have they lost their mind. I need to find this data cuz I will happily put my food in my mouth if that is the case
4. It amazes me when the quoted VBAC success rate at a given hospital exceeds the likelihood there of successful vaginal delivery of a nullipara. I see such data reported often.
Be certain that your patients know the hospital-specific cesarean delivery rate and VBAC success rate—and if you don’t have those data, then tell the patient that you don’t. It doesn’t make sense to quote an 85% VBAC success rate if your institution’s primary cesarean delivery rate is 25%.
Me: This is idiotic. Do I really even need to comment on this. This should say something to the doc already.
5. Furthermore, the expense of settling malpractice claims of “VBACs gone awry” is never included in estimates of the cost of care.
Me: VBACs gone awry... that one got me. I would love to see the definition of VBACs gone awry cuz I have heard countless stories of sections gone awry. Never a VBAC.
6. The current structure of reimbursement for health care doesn’t favor VBAC. In most regions of the country, 1) physicians’ reimbursement for performing a VBAC is either the same as, or lower than, it is for cesarean delivery and 2) most hospitals enjoy a greater margin on the hospital stay postcesarean than after a vaginal delivery.
Given the increased time involved in managing a VBAC, a change in reimbursement to recognize the greater effort and exposure to liability would be a reasonable step for payers—if there is true interest in reversing the trend away from VBAC that we’re seeing.
Me: Just early in the article it talks about medical need should be taken into consideration over the cost in favour of c-sections. Dude just contradicted himself.
7. In every data set that I have reviewed, perinatal morbidity and mortality are clearly higher in the VBAC group than in the repeat cesarean group. In essence, the central issue with VBAC is uterine rupture and all the complications that can flow from that event.
Me: Looking for THAT data now cuz once again, everything Ihave read thus far says the opposite.
Now this one floored me.
8. How well do patients accept VBAC?
It’s tough to sell a product that people don’t want. My anecdotal experience (meaning that my conclusions are unencumbered by data) is that informed health care personnel who themselves have had a cesarean delivery almost uniformly select cesarean delivery subsequently. They know the data and they’re aware of the risks. Often, they aren’t planning on having more than two children, so the problem of placenta accreta in the future doesn’t apply.
These observations suggest, to me, that maybe 1) we need to do a better job counseling patients or 2) our society’s value system overwhelmingly favors predictability of delivery and safety of the newborn at the expense of even a slight increase in risk to the mother.
Me: While yes, I have met numerous women who would rather keep the calendar than the health of their baby, a majoirty of them were not fully informed of the risks. Also, I have met just as man women that can't find a provider that will catch VBAC or feel their options are limited. I have met many women that wish they hadn't had the surgery to begin with. The ones that want vaginal birth far outweigh the ones that want sections yet they simply can find someone that isn't cut happy or that gives them options. In my area alone you have to drive over an hour for a provider that will actually catch for VBAC or go underground and most women don't know about those options. VBAC isn't hard to sell, it isnt being sold to begin with!
Me again: He did say something spot on, "we need to do a better job counseling patients." YA THINK!? 1 in 3 women are now having sections. 1 in 4 are having problems with secondary sterility believed to be from the sections. Are women informed of this? Are they told this surgery might affect being able to have future children? EVERY women in my area that I have spoken with that has had a section has NOT been told of this. Why?
Please tell me these people really aren't that out of touch with reality.
the references mentioned are now on my ever expanding reading list
God Bless,
Nirvana "Harley" (A Mamas Nirvana Birth Services)
on facebook
"A woman meets herself in childbirth."
I'm quite sure that a VBAC is actually a NON-procedure. If doctors are considering it a procedure, therein lies the root of the problem.
Obviously all those studies and breech births they're doing in Canada have totally gone over his radar. What a doof.
Oh. My. I'm appalled that there are doctors such as John T. Repke who are paid to give out medical advice despite the fact they obviously haven't investigated what they're advising. I'm also sick of reading doctor columns that claim studies show this or that while ignoring the entire body of research (um, Landon anyone???). WHY wouldn't he read all of the studies unless he's cherry picking one that will solely support his position (I see he picked the Guise study to back his "ERCS is safer" argument)?!
Some of our hospitals DO have better VBAC rates than primary cesarean rates. Duh. Why is that so difficult to understand? If a woman carefully chooses VBAC, that means she's been through a c/s before...she's choosing otherwise...she doesn't want the surgical recovery again...and because of her determination, she's usually far more prepared going into it again.
I wish I had more time to vent. Or maybe I'm glad that I don't. Either way, this entire article was so sad to me. 'God complex' is right! And it's terribly sad that VBAC is being considered a procedure needing to be managed. Just leave these women alone to labor, already.
"VBAC will disappear, in a self-fulfilling prophecy—which, when you think about what happened with vaginal breech delivery, may not be a bad thing."
What the....??? I have to go put my eyeballs back in my head now.
It's official. Dr. Poppy is living in a strange alternate universe.
Oops - I mean Dr. Repke is in the alternate universe. Dr. Poppy was just pointing it out.
Oy. There are just no words for Dr. Poppy.
Oh wait, I always have something to say! :-) First, in response to Harley, point #3...I have read several studies that found evidence that a scheduled cesarean was safer for the baby than a VBAC. Before anyone jumps down my throat, let me say two things. 1-the flipside is that a VBAC is safer for the mother (I don't know about you, but since I have two kids I think mother's safety trumps baby's in my case). 2-Saying cesarean is safer for baby or VBAC is safer for mother is like saying you'd be safer driving in a Honda Accord than driving in a Toyota Sienna. It's mincing numbers because the mortality rates for baby and mother are so small. Doctors need to quit using the dead baby card, because honestly birth is safe, c-section or vaginal or VBAC. And if I remember correctly, morbidity is way better for VBAC.
Second thing I wanted to say. I completely echo that I resent the implication that VBAC is a procedure! Excuse me, mister Bigshot Doctor, but a VBAC (in my case, VBA2C) would be the natural physiological conclusion to the pregnancy of a woman who has had a previous c-section. Does it have risks? Sure. Does that make it a medical procedure? No way. Performing abdominal surgery (however safe) is a procedure. VBAC is nature taking its course on a woman who's had a procedure done to her previously.
Third thing I wanted to say, and then I have to get back to writing a research paper! Regarding Dr. Poppy's comment "It doesn’t make sense to quote an 85% VBAC success rate if your institution’s primary cesarean delivery rate is 25%." Well, it doesn't seem likely...but it's not contradictory. They are two separate statistics, mister Bigshot Doctor. So it COULD happen. Let me illustrate, in case any Bigshot Doctors read this: If a hospital has a 25% primary c-section rate, that means that 75 out of every 100 women who have their first baby at that hospital will have a vaginal birth. And, if a hospital has an 85% VBAC success rate, that means 85 out of every 100 women who attempt a VBAC at that hospital will have a vaginal birth. Two different groups of women, two different statistics. Still with me? So while it seems improbable that a hospital would have a higher VBAC success rate than primary vaginal rate, it is possible and therefore does make sense. Perhaps the c-section rate includes scheduled cesareans or high risk women that would never end up VBACing. Perhaps VBACing moms there are untouchables and the docs want nothing to do with them, so their success rate is higher than a nullipara? Lots of possibilities, mister Bigshot Doctor.
VBAC IS NOT A PROCEDURE. IT'S JUST. GIVING. BIRTH. If you can't do a VBAC then you shouldn't be doing ANY deliveries because the risks are the SAME. Lord 'a mercy.
And herein lies the crux of the problem with hospital birth: they see it as a "procedure" they have to "perform." Hate to break it to ya, doc, but most of the time, you could sit on your hands in the corner and that baby will still come out. Now, a Cesarean is indeed a procedure, because a knife won't fly up off of a table of its own accord and cut a woman's uterus. But a birth? No.
Sorry, I'm going to put this in all caps and bold so no one misses it:
DR. POPPY DID NOT WRITE THE ARTICLE! She posted it to her Facebook page.
Sorry for shouting. :)
Does anyone understand why all the press on this issue refers to the American COLLEGE of Obstetricians and Gynecologists? What happened to the name change to Congress?
@Nora - I noticed both names (Congress/College) on the press release page and wondered about that:
http://www.acog.org/from_home/publications/press_releases/nr07-21-10-1.cfm