A mom's struggle to find a care provider and have a VBAC
Pretty amazing story - but not unusual to have such roadblocks placed for a woman to have a VBAC. What is unusual in her situation is the fact that her OB went so far as to have her evicted from the practice.
It's a long story, but well worth the read.
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Informative. Never knew that was an issue.
Something smells fishy about that story.
A patient can't be dropped without a 30 day emergency care letter (and labor would be an emergency) by any physician. There is a process that we have to go through to fire a patient. If that part of the story is true, she can sue for abandonment.
Resident clinics don't turn people away. That's why it's a clinic (disclosure - I'm director of OB/Gyn at a Medicaid clinic in a rural area). My patients get quality care and free care, but they do NOT get fast care. Unfortunately, due to need, we have a ton of patients per day. And we add in new patients all the time. I love doing a first OB visit on a 39-weeker. ;)
Sad story - ER's Mom is correct. We cannot 'fire' a patient without giving 30 days notice so to speak. We take patients at term but I think I know why others may not - liability issues. I once got a patient requesting to transfer to our practice at 41 weeks because her OB was telling her she couldn't VBAC and wanted her to have a section. That one we had to turn down unfortunately. That was an invitation to step into the middle of a mess. This is why it is so important that women try to do some research when choosing a provider.
ER's Mom may be correct, but it doesn't change the fact that this happened to this mom. Not only that, but she was the perfect candidate for VBAC--not that "not" being a perfect candidate precludes a woman from the right of choosing how she gives birth. Here's a link to the news segment on this story, which shows a copy of the letter this moms received: http://ican-online.org/community/users/ican-blog/blog/chicago-mom-ob-who-dumped-her-no-cesarean-necessary
Could a case be made that the mother had effectively "abandoned" the practice, since she was going AMA?
-Kathy
Excellent point by Kathy. Can she sue if she had gone AMA? And could the insurance company refuse to pay her medical bills if she goes AMA? I have heard rumors that insurance agents can refuse the bill if you go AMA. ANd yes, in my State the OB must give 30 days notice.
women have a right to chose where to birth. However, I have a right to refuse to engage in a risky activity if I think it medically negligent. I cannot be forced to provide care that I think is puting a patient at risk. Granted, I have no problems with VBACs, but I get rather annoyed when the public thinks I have to provide services, any service they deemed necessary. That does not sound fair does it? If I don't need to help out with a medical opinion on safety? Then why did I go to 4 years of school to become a BSN nurse then go to more classes after graduation? If I just needed to do what ever someone wants me to do according to how they interpret safety, then why do I need an education? And why do I need a license? I thought they gave me a license because I passed a test that gave the board of nursing the impression I was safe to practice. If I make decisons to practice in a manner the BORN decide are unsafe, they have every right to take my license away.
So unforunately in the past many many women have wanted a VBAC and have ruptured their uteruses. This has left Obstetricians uncomfortable providing this service. Also the women who signed a waiver saying they understood the risk of the proceedure, then took the Doctor who did the stat c-section on the ruptured uterus and was not able to safe the baby, to court. In court they said, "I did not understand I could lose my baby." And the court room full of "peers" aka people who might not have any idea WTF anatomy and physiology are about, award money to the injured Mother. Can you see why we will have plenty of gynocologist in the future but no Ob/gyns?
I agree with pinky. OB malprac is already high enough as it is, they shouldn't be forced to provide services theyre not comfortable with and may put the woman in danger.
Anyways, here's a pretty good article that kind of examines this whole issue from an medical ethics standpoint: http://www.nature.com/jp/journal/v29/n11/abs/jp2009123a.html
Just because a doctor suggests somethng as "medical advice" does not mean it is what is best for the patient as we saw in the case of this woman. VBAC is becoming harder and harder to come by when it is SAFER than repeat elective cesareans. That is a fact.
What happened to this mother is a disgusting example of what the maternity care system in this country is becoming and one of the biggest way that it is failing. I hope that doctor, who never even saw the patient to begin with loses their license.
If they are so easy to drop patients when they are "concerned" about the healthy and well being of the mother AND baby, they are not practicing "do no harm" by leaving them with no provider at term.
Lastly, these providers should look into providing evidence based care, because clearly they are not, they are practicing nothing short of defensive medicine.
"by when it is SAFER than repeat elective cesareans."
Simple logic dictates if it were safer, obs would prefer to do them via vbacs. Your information may be faulty. Facts must be backed up just saying it is a fact does not prove anything. I could assert I am the king of spain..or that monkeys fly out of my a$$ on a regular basis. Nether of which is true.
What they did wrong was to tell this woman that they would provide a VBAC if they were not comfortable with it.
lastly, I think any smart provider would be looking into providing medical assistance in another country. One like Sweden or England. Cause being an Ob here (in the United States) is like stabbing yourself in the eye repeatedly.
It is not rocket science that VBAC is safer, and any HONEST provider will tell you.
In low risk pregnant women, with no pregnancy complications, or pre-existing medical conditions, VBAC is safer.
If we started practicing the Maternity care systems that those same countries had, being an OB/GYN in the US wouldn't be like stabbing yourself in the eye.
First of all, those stories of VBACs gone wrong and doctors sued for millions aren't a VBAC issue. They are an issue of informed consent, pure and simple. Of mothers never being told that yes, VBAC carries this particular risk, which is not reduced to zero by scheduling an elective repeat cesarean. As much as I'm against OBs telling women of the risks of VBAC and the benefits of ERCS, I'm also against OBs telling women of the benefits of VBAC without mentioning the risks. Women HAVE to know. If they don't, and something goes wrong, they sue. I would, too. Unless they're informed and later find out that the OB's misuse of Pitocin or even Cytotec during their TOL (yes, it's happened and yes, they've been sued and won) was malpractice.
Secondly, to say that doctors and hospitals ban VBACs because they are unsafe is uninformed. The true reason is that VBACs are more of a financial and legal risk than a medical risk. As a participant of the VBAC ban survey by ICAN (http://ican-online.org/vbac-ban-info), I know first hand that doctors/hospitals who don't do VBACs do so because it's too expensive. Many times, women will find doctors willing to attend their VBACs but their hands are tied because of "hospital policy" that is looking out for the bottom line.
Finally, a VBAC is NOT a procedure. It is the natural conclusion of pregnancy in a woman who has had a previous cesarean. You don't have to "do" anything or "perform" any procedure on a woman who is pushing her baby out. A doctor doesn't "deliver" the baby -- her or she "catches" it... and is there in case emergency intervention is needed. The mother is the one who does all the work. For the woman who does not feel comfortable pushing out her baby at home, she should have the option of doing so in the hospital.
As a midwife working in a practice where we do many, many VBACs and sometimes even VBA2Cs, informed consent is very important. We have a handout that we utilize that discusses the risks or VBAC and the risk of repeat c/s. I am also aware that being sued even with appropriate consent does happen....and sometimes the litigant wins if they have a particularly sad story. It happens. It really does Lily.
Lily, your statements regarding the hospitals are absolutely true as are your statements in the last paragraph - well put.
Pinky says, "Your information may be faulty. Facts must be backed up just saying it is a fact does not prove anything."
Then later, "many many women have wanted a VBAC and have ruptured their uteruses." After a comment like that, I have to ask: Has anyone come across a legitimate, factual percentage of catastrophic outcomes between ERCS and VBAC? Since VBAC vs. ERCS studies (Landon is just one, there are more) show than over 99.5% of women who chose VBAC do NOT rupture (particularly when pitocin is not used), it is an extremely safe option. Therefore, I’m just not sure exactly what "many many" means in this context of the whole VBACing population. I could share the many many horrific outcomes I've witnessed or heard of from women who've chosen ERCS just because their doctor said it was safest (with evidence to the contrary). But that's limited to my experience, not to factual data. I agree with Pinky, just saying it does not prove anything. And I think it's a good thing for us all to be reminded of while we read some highly opinionated comments that lack any substantial evidence whatsoever. Rather, they reflect only hearsay or rumors.
Back to the article: When I was regularly on a couple birthing discussion lists, women would come on saying they were dropped in the last week or two of their pregnancy for refusing ERCS or refusing to be induced at 38 weeks after a previous c-section. I also have a personal friend who, just this fall, was dropped at 37/38 weeks because she refused a ERCS IN A PREVIOUS pregnancy because it was AMA (they knew this all along, and were fine with her VBACing this time, so why wait until her last couple weeks to drop her?). I'm only limited to a certain percentage of the countries population and I have no idea if anyone's keeping count of how many moms are dropped like this. But it does happen and though I'm tempted to say it happens to "many many" women, I'll just leave at "it happens" which I'm sure you all already knew. :)
Danielle my assessment of your conversation is thus:
A) you are a zealot
B) you have a small education, perhaps in theater arts?
C) You don't have clue number 1 what you are talking about but clearly think you do. Thus conversation with you it futile and exhausting.
My suggestion: You want to change it so bad, sign up for med school and work it out!
Let's keep it nice ladies. Pinky, I really like you, but what you said to Danielle wasn't playing fair.
It's ok, AtYourCervix, because frankly, that is the type of bad bed-side manner that "many" mothers, including myself, are used to from "many" OB's (I'm assuming from her statements, she is an OB.) But what does Pinky have to say to anonymous, when the "facts" are presented, ie. Landon, etc?
I think it's laughable as well that she mentions going to Sweden...one of the leading countries in the world for birth: lowest maternal mortality rates, lowest infant mortality rates, lowest epidural and pitocin/induction use, highest number of homebirths, highest number of midwives attending births (at home and at hospital), lowest cesarean rates....no, let the American OB's stay here, and all the mothers go there if they want SAFE BIRTH.
I am one of the mothers who had a uterus rupture and lost a child. For me...I was on my third pregnancy, after two cesareans I'd been duped into. OH sure you say,... well whatever, I won't go into it in a comments section of a blog, but... ruptures happen after cesareans, period. It's not about VBAC. The national C/section rate is over 31 % (as of 2007 CDC rates, i'm sure it's higher by now) and the maternal mortality rate, that was already too high (higher than some more third world type countries) is RISING! You can NOT honestly defend that by throwing litigation fears in our face. Grow a pair (ovaries or balls, doesn't matter) or yes, get out of Obstetrics. You went to medical school to help ppl hopefully, not get rich. You went to medical school to "First do no harm", if not, get out. You went to medical school for the crazy "odd hours" schedule, get out if you can't handle that and want to schedule every damn birth between 9-5. because it's killing mothers (I had to be revived)...maternal mortality risk is higher w/ cesareans. period. Abruption risk, previa risk, hysterectomy risk, blood loss (and all manner of morbidity), rupture risk, etc all go up after that first cut. The evidence, the "Facts" are there. And yes, I do believe that in this case, w/ VBACs etc and women's bodies, doctors SHOULD "have" to do it... it's not like prescribing narcotics to an addict just because you're a doctor and they ask for it..... "letting" them birth the way they want, is not about YOUR comfort level. sorry. again, get out if you can't take it...there are midwives in line, waiting to serve women and their wishes for safer births who can't legally practice in many states...ie, we're no Sweden here..you got that right!
-a mother fighting for safe birth, even though she'll never "birth"...fighting for her daughters and their future
Pinky, I know exactly what I am talking about, unfortunately you just do not like what I have to say. But any further discussion with you will not be worth my time considering your mentality and "debating skills" or lack there of.
Good day.
Pinky, you are quite wrong.
The relevant figure is not the percentage of VBAC resulting in uterine rupture (scary as that is for both woman and caregivers) but the percentage of VBAC resulting in uterine rupture with a mortality or permanent morbidity.
Smith et al. 2004. look at the Scottish data to help address this question. They found an overall perinatal mortality rate of 1:2000 for VBAC, but this was strongly associated with the size of the unit that women gave birth in. They speculate that "Hospitals with greater throughput are more likely to have resident obstetric, anaesthetic, and neonatal services as well as a dedicated obstetric operating theatre. "
"The risk of perinatal death was about one in 1300 in hospitals with < 3000 births a year and one in 4700 in hospitals with 3000 births a year. "
It's a good study, you should read it,
http://www.bmj.com/cgi/content/full/329/7462/375
This is the study I would discuss with a woman considering HBAC (since one can extrapolate from their findings that the outcomes in the event of uterine rupture will be much worse at home than in a hospital) but more to the point - it actually shows a low rate of perinatal mortality in hospitals with > 3000 births a year.
yehudit: That is what I love about you! You slap me with a real study. I will look it up. Again, I am comfortable with Vbacs. I am just uncomfortable when it is being forced and not mutually agreed upon.
Anonymous: I am heartfully sorry for your loss. I cannot imagine the pain associated with such a loss.
I am sorry Cervix. I will try to behave.
As someone else has stated up thread, VBAC is not a procedure, but rather just the natural conclusion of pregnancy in a woman with previous CS. Since it is not ethical to coerce someone into having surgery, I don't think "VBAC bans" are ethical.
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