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Friday
May062011

VBAC in a Military Hospital

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by Emjaybee

 

One of the women on my ICAN list posted this, and Jill and I thought it was fascinating.

First, the ICAN post (posted here with permission):

Let me start by saying that so long as things go as we’ve been told (which, does it ever in the Army?) I know which hospital I’d be at for delivery.

Last night the base had a townhall meeting on facebook. Prior to the meeting there was an opportunity to email in your question that pertains to “Medical”. I took advantage of this, and emailed in asking what their VBAC policy was. I wasn’t sure they’d get to my question, as they hadn’t last month with the housing townhall meeting. So, I also called L&D. I spoke to a nurse, who said they allow VBACS, I just had to sign forms and take a class when I get pregnant. I was so excited to just hear it can happen! She even asked about my prior cesarean, and she said my complications were rare but that the hospital on post has both midwives and ob’s, and at my first appointment they’d be able to say if I could see a midwife, or if I’d have to see an OB. Still, it was nice hearing it!

During the townhall meeting, my question was answered, and they said they follow the VBAC policy established by the headquarters of the US ARMY Medical Command. So I found that information online.. and now I’m not on my happy high anymore :(

 

Below is what she found, she says, by Googling “MEDCOM” and “VBAC”; however it appears to be out of date, and no new protocols seem to be available online at the U.S. Army Medical Department site. If there are any military women out there with better links, please provide in the comments and we’ll update. 

 

Here is the full text:

*MEDCOM Cir 40-18
DEPARTMENT OF THE ARMY
HEADQUARTERS, UNITED STATES ARMY MEDICAL COMMAND
2050 Worth Road
Fort Sam Houston, Texas 78234-6000
MEDCOM Circular
No. 40-18 5 January 2005
Expires 5 January 2007

Medical Services

TRIAL OF LABOR FOR PATIENTS ATTEMPTING VAGINAL BIRTH AFTER PREVIOUS CESAREAN DELIVERY

1. HISTORY. This issue revises paragraphs 4, 8a(2), and 8b(1) and updates publication/expiration dates and authentications.

 

2. PURPOSE. This circular provides standardized guidance to promote maximum effectiveness and safety to the maternal-fetal unit during trial of labor (TOL) for vaginal birth after cesarean (VBAC) section delivery and to provide an optimal environment and psychosocial support to the patient.

 

3. APPLICABILITY. This policy applies to all health care professionals in those U.S. Army Medical Command (MEDCOM) facilities that are eligible (by virtue of having qualified personnel, adequate staffing, and appropriate equipment/anesthesia/facilities) to provide VBACs.

 

4. REFERENCES. American College of Obstetricians and Gynecologists Practice Bulletin Number 54 July 2004, Clinical Management Guidelines for Obstetrician- Gynecologists Vaginal Birth After Previous Cesarean Delivery.

 

5. EXPLANATION OF ABBREVIATIONS.

BTL……………………………………………………………………………bilateral tubal ligation
C/S…………………………………………………………………………………..cesarean section
MEDCOM………………………………………………………..U.S. Army Medical Command
OB/GYN……………………………………………………………………..obstetrics/gynecology
TOL………………………………………………………………………………………….trial of labor
VBAC………………………………………………………………….vaginal birth after cesarean

6. RATIONALE.

a. Recent data show that 60-80 percent of TOL patients deliver vaginally. TOL is a reasonable alternative to repeat cesarean sections (C/Ss) in those patients who meet criteria and elect to undergo a TOL.
b. Advantages for those who have a successful VBAC include fewer blood transfusions, fewer postpartum infections, shorter hospital stays, and more rapid healing.

 

7. RISKS. The two most common risks associated with TOL for patients attempting VBAC are listed below. Patients will be informed of these risks when MEDCOM Form 746-R (TEST) (Medical Record Consent Form for Patients with Previous Cesarean Birth) is signed (see appendix A).

a. Uterine rupture or dehiscence.
b. Necessity for C/S.

 

8. PATIENT SELECTION.

a. Selection criteria. The patient has–
(1) A desire for TOL.
(2) One prior C/S or two prior C/Ss with a prior vaginal delivery.
(3) A clinically adequate pelvis.
(4) No evidence of classical uterine incision or extension of vertical uterine
incision into the contractile portion of the uterine corpus.
(5) No other uterine scars.
(6) No previous uterine rupture.
(7) No maternal or fetal contraindications to labor.
(8) Available functioning fetal/uterine monitors in the treatment facility.

b. Potential contraindications include–
(1) More than one prior C/S (except as noted in 8a(2) above).
(2) Unknown uterine scar.
(3) Breech presentation.
(4) Multifetal gestation.
(5) Suspected macrosomia.
(6) Post dates pregnancy.

c. Contraindications include–
(1) Patient does not desire TOL or requests C/S.
(2) Any contraindication to labor—medical or obstetric.
(3) Inability to perform emergency C/S due to surgeon, anesthesia, staffing, or
facility constraints.
(4) Prior classical or t-shaped incision or other transfundal uterine surgery.
(5) Contracted pelvis.

 

9. OTHER PATIENT CONSIDERATIONS.
a. Patients are strongly encouraged to participate in childbirth preparation classes.
b. Pitocin augmentation or induction is not contraindicated.
c. Patients who desire a BTL should be allowed a TOL if desired.

 

10. STANDARD PROCEDURES.

a. Appropriate personnel (anesthesia and obstetrical) will be notified that a TOL is in
progress and remain in the hospital throughout the active phase of labor until delivery is
accomplished.

(1) A physician who is independently privileged to monitor and evaluate labor
and perform an emergency C/S delivery shall be immediately available in the hospital
throughout active spontaneous/augmented labor or at the initiation of labor induction.
(2) Anesthesia and personnel for emergency cesarean delivery shall be
available in the hospital throughout active spontaneous/augmented labor or at the
initiation of labor induction.


b. Routine admission procedures will be followed, including type and screen for two
units packed red blood cells.
c. A patient whose antepartum care has been provided by a family practice
department or by a certified nurse midwife service, may continue to be managed by this
service during labor. However, if the patient’s intrapartum course is managed by a
provider who is not independently privileged to perform cesarean delivery, then the
obstetrician/gynecologist on call must be notified of the patient’s admission and plan for
VBAC attempt and this physician must remain in house throughout the active phase of
labor until delivery is accomplished.
d. If non-obstetrics/gynecology (OB/GYN) providers (irrespective of their privileging
status) managing a TOL patient, observe or consider any of the following procedures or
conditions prior to or following admission, patient management should be reassessed in
consultation with the OB/GYN provider on call:


(1) Induction of labor.
(2) Oxytocin augmentation of labor.
(3) Chorioamnionitis.
(4) Labor dystocia (abnormal labor course).
(5) Nonreassuring fetal heart tracing (especially repetitive variable decelerations
which are often the initial sign of uterine scar separation).
(6) Meconium-stained amniotic fluid.


NOTE: This list is not all inclusive. While some circumstances may necessitate a
repeat consultation with an OB/GYN physician, others may require a transfer of patient
management to the OB/GYN service.


e. The patient will receive counseling and obtain consent using the VBAC consent
form, MEDCOM Form 746-R (TEST).
f. Guidelines for routine labor care and/or care of patients with pitocin augmentation
or induction will be followed.
g. Use of prostaglandin cervical ripening agents for induction of labor are not
generally recommended and should not be considered unless in consultation with an
obstetrician/gynecologist.
h. Continuous assessment of maternal/fetal status by a professional nurse and a
privileged provider is mandatory.
i. The patient will be monitored with continuous electronic fetal monitoring during
labor.
j. The patient’s oral intake may be restricted.
k. Analgesics are offered as requested by the patient and epidural anesthesia is
encouraged.
l. Vaginal bleeding should be checked carefully to distinguish normal bloody show
from excessive bleeding.
m. The suprapubic area should be observed pre- and post-voiding for evidence of
asymmetrical or abnormal contours indicating hematoma formation or fetal parts
extruding from the uterus.
n. Routine recovery care will be provided with particular attention paid to signs of
uterine rupture including postpartum hemorrhage, hypotension, tachycardia, and
abdominal pain.
o. Should the patient require a C/S, care will be provided in accordance with the
locally developed standard operating procedure addressing C/S care.


Appendix A
Appendix A contains the following “-R” form (authorized for local reproduction).
MEDCOM Form 746-R (Medical Record - Consent Form for
Patients with Previous Cesarean Birth)


The proponent of this publication is the Office of the Assistant Chief
of Staff for Health Policy and Services. Users are invited to send
comments and suggested improvements on DA Form 2028
(Recommended Changes to Publications and Blank Forms) to
Commander, U.S. Army Medical Command, ATTN: MCHO-CL-Q,
2050 Worth Road, Fort Sam Houston, TX 78234-6010.
FOR THE COMMANDER:
CHARLES C. HUME
Colonel, MS
Assistant Chief of Staff for
Information Management
DISTRIBUTION:
This publication is available in electronic media only and is intended for MEDCOM
distribution As (14) 4 ea, (16) 1 ea, (25) 1 ea, (26) 10 ea; Cs (1 thru 8) 5 ea, (10) 5 ea;
and Ds (1 thru 6) 10 ea, (7 thru 39) 5 ea.
SPECIAL DISTRIBUTION:
MCHC (Stockroom) (1 cy)
MCHS-AS (Forms Mgr) (1 cy)
MCHS-AS (Editor) (2 cy)
JOSEPH G. WEBB, JR.
Major General, DC
Chief of Staff

____________________
* This circular supersedes MEDCOM Circular 40-18, 1 May 2003.

 

 

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Reader Comments (6)

I am no longer in the military, but when I was they offered VBAC at the couple of different locations I was stationed in (Army). It will probably depend on the set up where you are- military providers in military hospital, military providers in a civilian hospital, or all civilian. The good thing to keep in mind is that military practices tend to be more evidence-based than their civilian counterparts because they are not worried about lawsuits. You also have the option to switch to Tricare standard (this is assuming you are a dependent, not active duty yourself) and use a civilian provider without having to get a referral. Also. military or not you have the right to refuse anything and even if someone "orders" you to a repeat c/s it is not a lawful order. An acquantance recently delivered a vaginal breech in the military hospital because in the providers own words "I cannot make you do anything." So be encouraged, you have a lot of options:)

May 6, 2011 | Unregistered CommenterCourtney

As with any hospital, specific provider plays a huge role too. My HBAC transfer resulted in a vacuum assist by a wonderful OB. The night nurse told me that I was lucky I came in that day & not the next. She said the on-call on Sunday was knife happy & from what she knew of the situation she was pretty sure he wouldn't have been patient or understanding & would have cut me.

May 6, 2011 | Unregistered CommenterRacheal

I can also confirm that a woman can decline to follow her doctor's recommendation. I was told by my Army doctor that I could not refuse induction because I am active duty. I went through with it out of fear of legal consequences. After the fact, I filed a complaint that was found in my favor. The response was that any decision that goes against the recommendation of the ob/gyn college requires the woman to have an ob consult, but she has every right to decline the recommendation.

May 6, 2011 | Unregistered CommenterAmber

Amber, that is awful that you were unlawfully ordered and manipulated into a procedure that you did not want. It's great that you filed a complaint.

May 7, 2011 | Registered CommenterJill

I had a military CRNA say that,"Walking into the hospital IS consent."
I said,"That is not the legal definition of informed consent.:
She said,"The doctor can do whatever they want and give you whatever medication they want,"

I am going to file a complaint so that she is counseled on informed consent.

There was a vaginal breech birth at this hospital last year. It was one of the military docs who gave birth and was attended by a civilian midwife who was employed by the military hospital at that time.

May 7, 2011 | Unregistered Commentermamaseoul

I think, much like in the civilian world, it depends on the hospital and provider. I do know that the one place where military hospitals/providers can cause more issues is with authority. Obviously, there are issues with patients being comfortable enough to speak up to doctors as civilians. However, with the addition of actual rank, it's much easier for there to be abuses, both with active duty service members (generally of a lower rank than their provider) and to spouses of active duty service members (who may want to avoid conflict with their partner's superior).

I am glad to hear, though, stories of patients who advocated for themselves. :D

May 7, 2011 | Registered CommenterANaturalAdvocate
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