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Friday
Apr292011

Comparison of Verbiage in ACOG's Position Statements on VBAC

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A timeline of the verbiage in ACOG’s opinions and practice bulletins pertaining to VBAC over the decades. 

 

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Reader Comments (28)

So?

Is this supposed to mean something? Is there a conclusion we are supposed to draw?

April 29, 2011 | Unregistered CommenterAmy Tuteur, MD

I don't see one. I thought it was interesting to watch the shift in language. What did you take away from it?

April 29, 2011 | Registered CommenterJill

I'm not sure what you mean by shift in language. ACOG changed its position and has explained why it has changed its position. You may not agree, but there is nothing sinister about it.

As we've discussed many times, the only way to have an impact on access to VBACs is for American women and American society to determine what is an acceptable risk of preventable neonatal. Considering the VBAC lawsuits that have been filed, it seems like the acceptable risk is zero.

April 29, 2011 | Unregistered CommenterAmy Tuteur, MD

"I'm not sure what you mean by shift in language."

and

"ACOG changed its position"

Yes. You addressed your own confusion. Shift = change and that is interesting to some. It is of historic interest to watch positions change based on the the best evidence available. Of course, now I find myself terribly self-conscious for posting something that you found uninteresting.

The other element that I thought was noteworthy is how the language shifted ultimately to encouraging patient autonomy in making decisions with their care provider based on data that are personally relevant to the patient. A far cry from encouraging TOLAC.

Looks like you're just in the mood for a good old Friday morning VBAC debate. I'm sure if you keep going, you'll find some takers.

April 29, 2011 | Registered CommenterJill

Perhaps the change in opinion from ACOG is a reflection of the environment that obstetricians face on a daily basis. The following is a trial lawyer’s version of the NIH findings.

Below is an excerpt from http://www.syracusemedicalmalpracticelawyerblog.com/2010/04/study-will-make-vbacs-availabl.html

Study Will Make Central New York VBACs More Available Despite Risk Of Uterine Rupture and Baby Brain Damage

While encouraging more VBACs, the NIH panel conceded there was "moderate evidence" of a "clear increased risk of uterine rupture in trial of labor compared to an elective repeat cesarean delivery" and noted that uterine rupture "can be catastrophic and remains the most dreaded short-term complication of a trial of labor."

In terms of risks to an unborn baby, the NIH panel found "moderate evidence" of "increased perinatal mortality and low-grade evidence of increased fetal mortality." It concluded that there was "insufficient data on the incidence of hypoxic ischemic encephalopathy in cases of VBAC versus repeat cesarean sections." Hypoxia and ischemia can lead to cerebral palsy.

The trial lawyers at Bottar Leone, PLLC, have decades of experience investigating, prosecuting and trying to verdict all types of medical malpractice and birth injury cases, including those involving uterine rupture during VBAC. If you or your baby have been injured due to medical malpractice, you, your child and your family may be entitled to compensation for lifelong health care, medical expenses, special education, medical bills, loss of income, and pain and suffering.

April 29, 2011 | Unregistered CommenterGustavo San Roman, MD

I didn't draw any conclusions, and definitely didn't imply that anything was sinister.

Some of the language change is not well explained, and some is. I actually think the new ACOG VBAC guidelines are quite favorable toward offering a TOLAC (trial of labor after cesarean). I wish they were applied more in practice.

We've had this discussion before. There are a lot of successful VBACs, when a TOLAC is actually allowed. These VBAC attempts, when the candidates are well selected, should not carry any higher risk of poor neonatal outcomes, less risk to the mother, and about the same malpractice risk to the physician as primary vaginal delivery Considering how many more primary vaginal delivery attempts there are than TOLAC, and how rare the absolute numbers are of actual adverse events and subsequent lawsuits, I think hyperfocusing on this one aspect of the debate is further pushing the discussion in the wrong directions. I think it is pretty clear ACOG thought so, too, and that is why they came up with this most recent incarnation of their position statement.

PS Jill, thanks for linking to my Prezi!

April 29, 2011 | Unregistered CommenterMomTFH

Unfortunately, from the viewpoint of hospitals and obstetricians LIABILITY is the ONLY aspect of the debate.

The math is simple, 1 in 300 rupture rate equals one lawsuit for every 300 TOLAC. Payment of 8-10 million dollars from the obstetricians and hospital is required to obtain a settlement that will avoid a potentially larger jury verdict. We had a jury verdict in New York of 213 million dollars which was reduced to a mere 65 million on appeal. A 9 million dollar settlement divided by 300 TOLAC = $30,000.00 per TOLAC. Who can afford this liability?

The difference between the liability for a primary vaginal delivery and a TOLAC is that a trial lawyer has a much more difficult time making the case to the jury that a cesarean delivery would have been safer than attempting the primary vaginal delivery. The NIH study has actually given the trial lawyers more ammunition as noted in the blog referenced in my previous post. The trial attorney will merely tell the jury that the findings of the NIH revealed that; “the NIH panel conceded there was "moderate evidence" of a "clear increased risk of uterine rupture in trial of labor compared to an elective repeat cesarean delivery" and noted that uterine rupture "can be catastrophic and remains the most dreaded short-term complication of a trial of labor." and that if the doctor had heeded this warning and advised the patient to have an elective cesarean delivery little Johnny wouldn’t be in that wheel chair today.

If you want to increase TOLAC we need to come up with a solution for liability. Here is mine: Starting tomorrow I will change from my malpractice insurance carrier that charges me $200,000.00/year for the ability to practice OB/GYN to a new malpractice carrier. That new malpractice carrier is called the United States of America and they will provide me with free malpractice insurance as long as I agree to be bound by the rules that they set for providing care to my patients. When I get sued, the Office of Professional Medical Conduct (OPMC) will review my care and if I am deficient in any way they will have the power to sanction me, fine me, advise me to change the way I practice, pull my license or drop my coverage. A similar program would be offered to hospitals and overseen by The Joint Commission. The cost of a government run malpractice carrier would be very small compared to the savings of no longer paying for all of that defensive medicine (i.e. scheduled repeat cesarean delivery).

Patients would still have exactly the same rights to sue that they have now and trial lawyers will continue to fight for the rights of those who are harmed. However, doctors who aren’t doing such a hot job will be found out by the OPMC and doctors who are doing a good job will not have to worry if today is the day that they go to work and lose their house because something happened at work that was not within their control.

April 29, 2011 | Unregistered CommenterGustavo San Roman, MD

I'm pretty sure that not EVERY woman who experienced a rupture would sue the hospital, so the math isn't quite right. Also, most ruptures are not catastrophic, so that number would probably be even lower. A VBAC that is monitored correctly and not augmented has a very low risk of ending in a catestrophic rutpure that might, not WILL, but might result in a lawsuit.

The liability issue is based on the FEAR of lawsuit, not the actual risk of a lawsuit.

April 30, 2011 | Unregistered Commentersara

Unfortunately Sara, every rupture at my hospital that caused a fetal injury has resulted in a lawsuit. As for the math, I purposely used a 1 in 300 rupture rate to reflect the correctly monitored, not augmented, not induced low risk TOLAC. I appreciate the hopeful way that you are wishing that a catastrophic rupture won’t result in a lawsuit but unfortunately the facts don’t support your statement.

I have never had a FEAR of a lawsuit because the REALITY is that I have been named in several lawsuits including two from women who had a catastrophic injury from a uterine rupture during a TOLAC. One from a woman whose life I saved after she had an amniotic fluid embolus during her fourth labor and another one for failing to remove a woman’s third ovary. Despite these lawsuits I continue to offer my patients a TOLAC but I am a dying breed. Many obstetricians and many hospitals no longer offer a TOLAC not out of FEAR but out of the actual reality that they have written checks for millions of dollars as a result of offering TOLAC.

TOLAC unfortunately seems to be going the way of the local roller skating rink. I loved going to the rink when I was growing up but as kids got hurt they sued the rink and eventually the cost of the lawsuits put them out of business. I think that you would have a hard time getting a roller skating rink owner who went bankrupt to open another rink unless you could provide him with a solution to his liability problem.

Since I will probably not be around for the solution to our liability problem I believe that the safest way to have a successful TOLAC is to not have the primary cesarean delivery in the first place. To this end, I have developed software that can help decrease the number of primary cesarean deliveries that are being performed and I challenge all obstetrical care providers (obstetricians, family practitioners and nurse midwives) to use my free software to measure, compare and adjust (if needed) the way that they manage their pregnant patients.

April 30, 2011 | Unregistered CommenterGustavo San Roman, MD

Where can this software be found?

Pregnant patients. I love that.

May 1, 2011 | Unregistered Commenterreally?
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