Opinions, please, Hospital's "reason" for a No-VBAC POlICY

[3boys3girls]

Hi, I am 9 weeks pregnant with #6. First, a brief history on my births.

DS 1) 13 years ago, Water broke, no labor, baby not dropped, had an epidural, felt absolutely NO pain EVER, birthed 8.3lb baby nearly 24 hours after water broke. Dr. was so close to calling for a CS.

DS2) 9.5 years ago, 14 days overdue, had a MW for a hosp. birth. He was an all day labor, I had "intra-thecal" (<sp?) MORPHIN with which I felt NO pain, but threw up the whole time. He was almost 10lbs, VAG birth.

DD1) 7 years ago, Induced on my due-date, PITOCIN, no pain-meds, ALL DAY Labor, birthed my 8.9lb baby.

DD2) almost 4 years ago, tried to induce twice, worked the second time, she was 14 days overdue. Heavy on the Pitocin, all day labor. No Pain meds. Birthed 8lb baby.

DD3) This was my CS baby. One month before she was born dr. discovered a 10cm abdominal mass in baby. I developed polyhydramnios (excessive amniotic fluid) b/c of baby's mass. I assume that's the reason, after the research I did. The baby would not AT ALL engage even the slightest in my pelvis. She was continually going from head-up to head-down positions. We tried to induce with pitocin one morning when she was head-down but in about 20mins she had flipped again. My dr. was concerned that the cord would drop, or an arm/leg, so she highly recommended a CS at 38 weeks. I live about 45mins from Hospital. I agreed. We tried "draining" the fluid, when baby was head down, but fluid rapidly replenished itself. I was somewhat concerned also about pushing a baby OUT with a 10cm fluid filled abdominal mass. Anyway, as it turned out the mass was an Ovarian Cyst on my daughter, due to an overload of circulating maternal hormones. Praise God my daughter was not in any pain whatsoever!!! The mass decreased to 8cm by birth, and after 1.5 years of "life" detached from mom's hormones, the cyst fully disappeared! Yes, they wanted to operate (at children's in the twin cities) but I said No way, God is in the process of healing her. And He did. Anyway:

Now, I'm expecting my next baby. Possibly my last & I would like to have the BIrth Experience that I love so much....! However, Safety is my ultimate priority of course. So, this hospital that I've had my 3 dd's at (awesome, DR. with a "midwife" approach. She trained midwives at Baylor U, in Houston, I believe, for many years) no longer "allows" VBACS, they did up until approx. 4 years ago, but something has changed. my dr. is disgusted by it, she mentioned something that "some other dr. did" that caused the change. She says I'm a perf. cand. for a VBAC. HERE'S THE REASON THE DIRECTOR OF THE OB DEPT GAVE ME YESTERDAY WHEN I SPOKE TO HER: "WE DO NOT HAVE AN ANESTHESIOLOGIST (<sp?) OR A SURG. TEAM ON STAFF 24/7, SO WE CANNOT ALLOW VBACs"......

PLEASE tell me, does that make any sense? i asked her, what about cases of Emergency CS's? She replied that the ACOG's rule is that it can take no longer than 20 minutes for the birth of the child FROm the time a CS is called for..... so, if the ENTIRE staff ON CALL can get there within 10minutes they are okay. DOES THAT MAKE ANY SENSE?! PLEASE GIVE ME YOUR OPINIONS.

They other nearest hosp that allows VBACs is in Duluth, an hour south.

sorry for this long post, i am really reading this forum to get some advice on what I should do, what my risks are, ect.

Thanks so much!

[MicheleVet]

ACOG recently (sorta) updated their Practice Bulletin outlining the "guidelines" for VBACs....and the general interpretation is that when a VBAC woman is laboring, the staff needed for a C-section have to be in the hospital....so for large hospitals with doctors who stay the night at the hospital when they are on-call, it's not much of a problem....but for hospitals that allow the on-call docs to stay at home until needed....this messes up that plan. So these hospitals ban VBACs.

This (VBAC) is different from a non-VBAC laboring woman who needs an emergency C-section. IMO, it really was a rather crappy update to the Practice Bulletin and has been interpretted at the "benefit" of the hospital rather than in the best interest of the patient.

[aylaanne]

get a midwife and stay home.

[Right of Passage]

JMO I know it's ACOG's guidlines for VBAC, but I hate their reason. If they want to use that reason I don't see it being a far leap to ban ALL laboring because you NEVER know when an emergency can happen. It's crap, most VBAC labors are safe. You do sounds like a perfect VBAC candidate. If you really desire a hospital birth I would go to the other one, otherwise I'd stay home and birth there.

[mommato5]

I would go to the other hospital. With my next I will be going to the hospital about 30/40 minutes from here because they have CNM's on staff there.

[Mrsboyko]

Just do not concent. All their policies can take a flying leap if your doc is on board and you are adimantly against a c-section. Just do not let them induce and stay home as long as possible. You know your other 4 were ALL DAY long labors, so keep that in mind when labor hits. As a way to side step the inevitable scheduled c-section at 39 weeks, try to push for just coming in when labor starts. Tell them "I want to let baby choose his/her birth day", and that should be it. Add on that 3 of the other 4 were nearly 2 weeks over the typical due date, thus 39 weeks would be like taking a baby 3 weeks early, making for very real possibility of breathing issues.

[kltroy]

As OPs have said, the hospital is, unfortunatly, simply conforming to the non-VBAC-friendly ACOG guidelines, which call for operating facilities to be "immediately available". I suggest you contact your local ICAN chapter and see if you can get suggestions on either (a) legal advice on challenging VBAC bans (our chapter is working on this, so yours may be too) or (b) suggestions for an alternate hospital to give birth.

Best of luck to you!

[3boys3girls]

Hi, Could it be as simple as refusing to give consent.... for surgery. ?? I think I forgot to mention that I've always-always been induced..... scheduled inductions. Why? I guess b/c my second was 14 days passed & nearly 10lbs. I've always assumed I stay pregnant forever if I wasn't induced. My 3rd was induced on her dd, my 4th we attempted induction on the dd but instead it worked 14 days later. I have to admit that I have a fear ( I despise that word!) of staying pregnant passed the dd. I want the baby out & safe in my arms ASAP. Additionally, I know this sounds CRAY-ZEE, but I don't want a homebirth. I sound like a nut but a couple days VACATION in a hospital sounds okay to me. However, I don't want to be so far away from my family: kids & hubby. Duluth is too far. The other location is 45mins max. I just wish they'd "allow" VBAC!! I'm going to see what I can do. It would be so nice if I'd just go into labor at 39 or 40 weeks,,,, naturally on my own, and then show up there ready to birth the baby..... i'd be saying, "whatcha gonna do now?"

[Mrsboyko]

Well, with a c-section now, they will not want to induce you the way they always have, at least not if they like practicing medicine. When you were induced the prior times, were you dialated at all? They can do a foley cathater induction (basically is it like a manual dialation over an extended period) as long as they can get it in. Also, stripping membranes starting at 39 weeks is possible too. If you get to 42 weeks again they can try breaking the bag of water first. None are GOOD options, but everyone has the possibility of keeping you out of the OR. You just need to get your doc on board.

A doc can not legaly "fire" you after 36 weeks w/o providing adequate transfer of services. It is considered patient abandonment. In your shoes I would drop a few hints that you are not keen on the section, but I wouldn't go into full blown VBAC mode till after 36 weeks.

Good luck, think positive, early baby vibes. Look into hypnobabies and their "come out baby" CD. Keep us updated too.......

[TCA2008]

Here is something I posted on another thread, but much of it is applicable here - you are a perfect candidate for a VBAC, and you should not have to be bullied into surgery against your will, please make SURE you write a letter to ACOG:

******
no woman should ever been forced into surgery against her will, but it has happened. I also encourage you to show up with a doula and as many support people (witnesses) as possible so that when you refuse the section there are a number of people to repeat "She said no." But I wouldn't wait until labor to refuse. When you are over 36 weeks, write a detailed letter to the hospital stating that you are birthing there in (month) and you are refusing a repeat c-section, and you want to make sure that all potential staff that could be caring for you are aware in advance that you are refusing a repeat section.
Most doctors would not drop a woman after 36 weeks, but even if your doctor threatened to drop you, the hospital cannot deny you care if you show up in labor - they must take you.

Suggested information to include:

I
am planning a vaginal birth at (hospital) sometime in (month). I have had two previous c-sections, and
have decided, after reviewing all of the medical literature, that a VBAC
birth is safer for me than scheduling a cesarean section. I have received
excellent prenatal care during my pregnancy, and I have been looking very
forward to my VBAC birth at (hospital). I sincerely hope that you will
support and assist me in having the best vaginal birth possible. I am
writing to request a meeting to review the following things:

1. I want to ensure that the VBAC policy at (hospital) is supportive
of VBAC births and the rights of pregnant women to make their own birth
choices.

2. I want to request that (hospital) draft a formal policy statement
that under no circumstances would staff pressure or coerce a woman to
undergo a cesarean if she has made an informed refusal for surgery - in
other words, it is important that there is no policy stating that women with
more than one c-section are "restricted" from having a vaginal birth.

3. I want my medical record at (hospital) to be clearly marked that
I have already made a fully informed choice to refuse a cesarean, and that I
do not intend to argue or fight with staff about a cesarean when I arrive in
labor to vaginally deliver my baby.

4. I want the enclosed medical literature showing that a VBAC birth
after multiple cesarean sections is safe (my risk of uterine rupture is less
than 1% if I am not induced), and that my risks from a third cesarean are
high, making a cesarean risky and dangerous for me to be placed in my chart
so that all hospital personnel assisting with my VBAC know that I have been
fully informed of my risks. I am truly scared of the risks of a third
cesarean, my risk of death is much higher with a cesarean than with a
vaginal birth, and I cannot undertake this risk for me or for my other
children unless some emergency warrants it (cord prolapsed, placental
abruption, etc.). It is my hope that if the staff understands my concerns,
everyone will work with me to ensure I have the best vaginal birth possible.

I thank you very much for your time in reviewing the enclosed literature and
for considering my concerns.
I hope that once we meet, I can rest assured that policies are in place
that support a woman's right to VBAC, and that no woman will have to face
pressure to have a cesarean after they have made an informed refusal for
surgery. After knowing that (hospital) will be supportive of my VBAC, I
will be able to just focus on having a healthy pregnancy and preparing for
my upcoming vaginal birth at (hospital). I appreciate you
making time in your busy schedule to discuss my concerns, and working with
me to ensure I have the best birth possible at (hospital).

Sincerely,



Here is the suggested literature to include:

http://medicalcenter.osu.edu/patient...press/?ID=2835

http://www.greenjournal.org/cgi/cont...tract/108/1/21


Please also send a copy of your letter to ACOG, asking them to take action to put an end to unethical VBAC "bans." ACOG is reading letters being sent. Please make sure they hear from you:

Douglas H. Kirkpatrick, MD, President

The American College of Obstetricians and Gynecologists
PO Box 96920
Washington, DC 20090-2188

[alegna]

Originally Posted by aylaanne

get a midwife and stay home.

:

My ds was 43 weeks 5 days.

Some babies/moms cook longer.

-Angela

[OceansEve]

My understanding of it - for the hospital to have insurance that covers VBAC malpractice they have to have everyone needed for an emergency c/s 24/7. Sounds like you'll have to find another hospital if you want to VBAC even if it is further away. That's what I had to do with DD2. This time I am hoping to just skip all that fighting with the med staff and stay home. Good Luck.

[funkymamajoy]

Originally Posted by Nursingmama05

JMO I know it's ACOG's guidlines for VBAC, but I hate their reason. If they want to use that reason I don't see it being a far leap to ban ALL laboring because you NEVER know when an emergency can happen. It's crap, most VBAC labors are safe. You do sounds like a perfect VBAC candidate. If you really desire a hospital birth I would go to the other one, otherwise I'd stay home and birth there.

:

[rixafreeze]

An excerpt from my dissertation explaining ACOG's 1999 VBAC guideline that essentially has led to hundreds of hospitals banning VBACS:

Vaginal birth after cesarean, for example, is increasingly difficult to arrange in the United States. Hundreds of hospitals have banned VBACs since 1999, when the American College of Obstetricians and Gynecologists (ACOG) revised its recommendations on VBAC. The 1999 recommendation stated that VBAC “should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.” In practice, this translated into round-the-clock in-house anesthesia and OB coverage, a requirement that many smaller community hospitals could not meet. Dr. Marsden Wagner has noted that the ACOG “has no data to support it, no studies showing improvements in maternal mortality or perinatal mortality related to the characteristics of institutions or availability of physicians.” In fact, the studies that do exist show no elevated mortality rates among VBACs in smaller hospitals compared to large tertiary hospitals.

In contrast, the American Association of Family Practitioners (AAFP) has recommended that VBACs “should not be restricted only to facilities with available surgical teams present throughout labor since there is no evidence that these additional resources result in improved outcomes.” The AAFP noted that the ACOG policy does not require immediate access to OB and anesthesia coverage for other rare obstetrical emergencies (such as shoulder dystocia, placental abruption, or cord prolapse) that may be more common than VBAC. The AAFP concluded that “current risk management policies across the United States restricting a TOL [trial of labor] after previous cesarean section appear to be based on malpractice concerns rather than on available statistical and scientific evidence.”

Although the ACOG’s 1999 recommendation was not evidence-based, obstetricians and hospital administrators are now under pressure to comply with the recommendations. As a result of the ACOG’s new position on VBAC, hundreds of smaller hospitals have instituted a no-VBAC policy, requiring women to have mandatory repeat cesareans or to travel elsewhere—sometimes very long distances—to give birth. In addition, some states such as Arizona do not allow home birth midwives to attend VBACs. If a woman desires a home birth or even a vaginal birth in such states, she often faces no choice but to give birth unassisted.

[wombatclay]

So like pp mentioned, this hospital is following the ACOG party line. My local hospital does not have 24/7 ER coverage but they bring in a complete team when a vbac mama arrives. It's expensive for them and as they've recently changed financial management teams this service may not be maintained.

So, EMTALA does require a hospital to attend a mother in labor. And you are of course allowed to refuse surgery. However, for EMTALA to apply you need to be in active labor (5cm or more). And the hospital is most likely going to be unsuportive and arguementative. A women in my area recently showed up at the hospital in active labor with a notorized signed statement from her lawyer explaining that she did not consent to XYZ and any attempt to perform such without written consent from mom would be met with legal action. She got her intervention free VBAC but the hospital staff was not amused and her birth was not the respectful experience she and her babe deserved.

In the past some hospitals have gotten court orders to force a woman to undergo a c/s. Because of a few recent cases, these court orders are much less appealing to hospitals today (big settlements against hospitals for wrongful surgery/assault), but they'll still try to pressure you. If you do intend to have a vaginal birth in a VBAC-ban hospital please consider bringing a doula, a very well informed and supportive partner, and perhaps a friend who is equally informed about your legal rights as a birthing woman.

ICAN can help you locate information, provide help in confronting a VBAC ban, and offer support during your pregnancy. But the women I know who have VBAC'd at a "ban" hospital all had to work for it. And I don't know if I'd have the strength (while in labor) to stand my ground that way. And the hospital would certainly be within their rights to refuse an induction or augmentation...

If homebirth is out I'd probably try to use the other hospital... or see if the ban can be reversed in a similar manner to how my small rural hospital does it.

[3boys3girls]

Thank you to everyone who has replied! I really appreciate all the information! Please keep the responses coming! I plan on talking to my doc at my next appt. on 12/29. I am fairly certain that she is in support of VBACs, but I'm not entirely to sure how willing she'd be to go up against the hospital. That's one thing I'll be asking. I def. don't want to cause trouble for her. And if my first choice hosp. is out of the question I'll just go to the other one. I suppose I need to check with my ins. to see if they do cover VBACs. Do some insurances NOT cover them? I think I'll go make that call right now. Okay, & there's the chance that the docs in the hosp. that does not have a No VBAC policy will not induce me for a VBAC. Oh that reminds me, I am scheduled today to call the other hosp for some info.... i called earlier this week and they asked me to call back on Fri. to give them time to collect the info: what i asked is "how many VBAC attempts actually result in a successful VBAC?" I believe that was one of the things my doc said about VBACs at this other hosp. They say they're okay with VBACs but do they really follow through & allow the mom to have one.... I'm trying to find out as much as I can.

[alegna]

Insurance can't refuse to cover a VBAC

-Angela

[Turquesa]

Originally Posted by rixafreeze

An excerpt from my dissertation explaining ACOG's 1999 VBAC guideline that essentially has led to hundreds of hospitals banning VBACS:

Great snippet of info!

Let's try on an analogy for size. Imagine a black diamond ski run that has resulted in serious injuries and even deaths. Rather than doing the sensible thing and closing it down, the ski resort decides to park an ambulance with paramedics at the bottom.

The reason that VBAC's are considered "dangerous" and ACOG wants hospitals to have the anesthesiologist on hand is because of uterine rupture. But uterine rupture is caused almost invariably by artificial induction of a VBAC labor, something that is unique to OB's and hospitals. Rather than discourage such inductions, ACOG declared "Keep it up, boys. We'll just hire more specialists to stand by."

This sums up hospital anti-VBAC policies to a T.

ETA for the OP: Whatever your hospital and doc decides, for your own safety, be really leery about suggestions for induction!

[3boys3girls]

I found out today that my insurance does cover VBACs. I wasn't sure, as I've heard of some people who've had to "battle" ins. companies.

I kind of "cross posted" this with Turquesa, above..... I am learning so much about the dangers of inducing a VBAC. Thanks to everyone here...... .... i wrote the following, submitted it, then read the above response....

Also, I have learned > and this I'm sure doesn't surprise anyone on this board < that the docs in this VBAC "friendly" hospital will not induce with a VBAC. I def. plan on asking my doc about that (her philosophy) when I see her later this month. I would be totally shocked if I went into labor on my own with this baby! It hasn't happened yet, after 5 pregnancies!! At some point I'm going to be looking for info on "naturally bringing on labor"....!! I've never even dialated much before my inductions. So, I guess that's all for now. Oh yeah, The VBAC-friendly hospital could not give me any stats on "VBAC attempts" vs. "successful VBACs". I asked how many women (not expecting exact #'s) attempt VBACs & how many end up with CS's anyway. Actually, I posed that question to the OB clinic in the area (with the docs who work at this hosp) & the person (one who deals with patient relations, not just an OB nurse) told me "we don't track that". What kind of an answer is that?! So then, later, I called the hosp just to find out if they could find out the # of VBACs, say, in 07. I guess, in reality, what this all comes down to is WHETHER I'M ABLE TO ACHIEVE LABOR ON MY OWN. If so, I cannot imagine that, upon arrival at my hospital, they would whisk me into surgery!!! yes, I'd def. wait as long as possible to go to the hosp. Imagine! Me, totally unfamiliar with spontaneous labor, birthing my baby in the van en route to the hosp. 40-45 mins. away! Yikes. My husband would freak & pass out!!!!!

[OceansEve]

How far along were you when induced w/ prev preg? Some women go to 42+ weeks, its just the way their body works. You might do some looking into what is reasonable term birth. I would not even think about induction till I hit 42 weeks personally (and I probably would have to convince my OB to do it). Your body will go when its good and ready, even if your OB or even you may feel its been long enough Not a fun option, but true.

You definately will have trouble finding a hospital to induce you if that is what you really want. They are too scared of the malpractice ramifications (sp?). They didn't give me pitocin till after I'd been in labor for 24+ hours, which I wouldn't have needed if I'd managed to deal w/ the pain w/o epi but that's another story.