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VBAC bans - x-posted in Birth Professionals Forum

post #1 of 44
Thread Starter 
I am so frustrated and angry today. Recently, my hospital has decided to stop providing VBACs. This was not provider driven. We are a small, rural community hospital and only do aroun 210 births a year. We are required to a have a perinatal agreement with a larger hospital with a NICU and other specialized services. This agreement includes all sorts of stipulations, like when we are required to consult a perinatologist and when we are required to transfer care. The powers that be in the bigger hospital don't want us to do VBACs because we don't have 24 hr in house anesthesia or OB. I have practiced here for 6 years and have attended around 20-25 VBACs, with over a 90% success rate. I am a family doc and don't do cesarean deliveries, so up until now, I would have all my VBAC clients meet my back up OB once in the third trimester. During labor, I would notify anesthesia and my OB back up that a VBAC client was laboring, and they would then keep themselves available, which in our hospital wouldn't necessarily mean sitting in house, but would mean staying ready. I stay in house during the entire labor. I've not had a problem, nor has my OB back up who has practiced here 30 years. Not every prior cesarean birth client I care for chooses to VBAC, but those that do, I've felt confident that we could assist them in making their own decision and then supporting them well. Since this policy is in effect, I'm not supposed to attend any VBACs at all. My OB back up has been making off the record exceptions for my repeat VBAC folks, but not for primary VBACs, and frankly, I'm worried that if this policy becomes more strictly enforced that I won't be able to do that even for my repeat clients. I'm supposed to tell them all they have to schedule a cesarean or deliver somewhere else.
Today, I had not 1, but 2 very excited women in my office in early pregnancy for new OB visits. Both were thrilled to be starting care with me because they had heard I'd help them VBAC. I had to tell both that I could no longer attend primary VBACs, even though they are both great candidates. After telling them where they could go to VBAC (hospitals an hour away or more, with less supportive labor environment, but no outright VBAC bans), one woman said to me "And what if I just continue my care with you and then refuse to have a c-section at the end?" I told her that was absolutely her right to make any decision she wanted to and we'd have to abide by it. To tell the truth, though, I think I'd probably lose my privileges pretty quickly if I had too many of those, and I'm not sure I wouldn't be required to turn the client in labor, even, since I don't do surgery to begin with and now have no back up to provide VBAC.

My question for both all the VBAC mamas and the birth attendants out there, is what can I do about this? Does anyone know if there is an active ICAN of IL chapter doing anything about VBAC bans? Do any birth attendants have experience with this type of situation? Where can I point these women so they get good counsel and information (besides myself)? Anyone else face a VBAC ban? I'm so upset about this I'm actually considering leaving the community over it (dh is not liking that one, we are settled and happy here) but I cannot participate in either forcing women to have a surgery they don't want, or guilting or persuading them into it by manipulation of facts. Any thoughts, ideas, or even just commiserations would be greatly appreciated!
post #2 of 44
Wow ... you have a fantastic vbac rate ... if every woman that wanted a vbac were so lucky to have you in her town or nearby.

Can I ask where you are at? There are four chapters - Chicago, Kane County, Central Illinois and Rockford. There is also St. Louis, Mo.
post #3 of 44
Quote:
Originally Posted by doctorjen View Post
My question for both all the VBAC mamas and the birth attendants out there, is what can I do about this? Does anyone know if there is an active ICAN of IL chapter doing anything about VBAC bans? Do any birth attendants have experience with this type of situation? Where can I point these women so they get good counsel and information (besides myself)? Anyone else face a VBAC ban? I'm so upset about this I'm actually considering leaving the community over it (dh is not liking that one, we are settled and happy here) but I cannot participate in either forcing women to have a surgery they don't want, or guilting or persuading them into it by manipulation of facts. Any thoughts, ideas, or even just commiserations would be greatly appreciated!
IMO...if a hospital is "banning" VBACs b/c of this reason that hospital shouldn't be having ANYONE labor/birth there. If the hospital isn't equipped to handle UR then how are they equipped to handle a prolapsed cord? Same rate of risk...

Hmm...that's probably not much help for you (and I'm probably preaching to the choir, but that really irks me!). It stinks that they have so completely overreacted and misappropriated the risk for UR that they're doing things like this. Absolutely ridiculous that they limit women's choices.

Anyways...publicity is certainly helpful. ICAN's got a good whitepaper on what to do (as a consumer) if you encounter a VBAC banning hospital

There's also an FAQ and some tips on a mom's right to refuse. I don't know how much leeway you would have in being able to pass out handouts like this, but at the very least you can direct women to ICAN's website and tell them to look at the whitepapers.

There's also a good section on ICAN's website about advocacy. Not sure if you will find it helpful, but I've linked it just in case.
post #4 of 44
Have you seen this?

http://www.midwiferytoday.com/articles/50ways_VBAC.asp

And..wow, thanks for being so supportive of VBAC, and all you're doing to support VBAC moms! We need more drs like you
post #5 of 44
Thread Starter 
This is a great article, but one of the early suggestions is to file a complaint about your doc - cripes, I hope no one will file a complaint about me!
Also, I understand writing to a newspaper with the info about not having 24 hr anesthesia, but small hospitals like mine just cannot afford 24 hr in house coverage. We have 24 hr coverage, but our main anesthesiologist provides this during the week all by himself at night, and does so from his home when able, 2 blocks from the hospital. In a true, life or death, seconds counting emergency, we would do a cesarean under local with IV sedation - which would absolutely suck for all involved, but is possible. My OB backup has a done a few cesareans this way over the years when it was life or death and he didn't feel he could wait even a few minutes to get things going. Our hospital could not afford enough anesthesia personel to be in house 24/7.

Quote:
Originally Posted by LiLStar View Post
Have you seen this?

http://www.midwiferytoday.com/articles/50ways_VBAC.asp

And..wow, thanks for being so supportive of VBAC, and all you're doing to support VBAC moms! We need more drs like you
post #6 of 44
I'm always inclined to take a statistical tack whenever I can. ;-) So, I wonder how feasible it would be to gather:

* Data on risk rates for VBAC UR under the conditions you have at your hospital
* Data on risks involved in VBACing with a hospital an hour or more away
* Data on risks involved with ERCS

...Which would combine to show that overall risk of mortality or morbidity is higher if your hospital may not perform VBACs?

Oooo! One thing you might be able to do is survey previous VBAC clients (anonymously), and find out how many would choose a homebirth or UC if this policy had been in place when they delivered. You can use a 1-10 type scale, so that you can gage how much more or less likely they would be to choose an out-of-hospital birth for their VBAC if they couldn't birth vaginally at your hospital. That might convince the right people that they're putting more lives at risk this way.

It might also be possible to contact the ACOG and ask them if their guidelines are intended to have this effect in this particular situation.

Do you know what's driving the other hospital's decisions? Did they change insurance carriers? Recently get audited or accredited? Get sued? Change managment?
post #7 of 44
I just want to say thank you, for supporting your patients right to choose a VBAC.

It seems like everyone has given you good advice. Perhaps you could also contact the author of that article (Barbara Stratton) to see if she has any more advice. She is really the ICAN expert at fighting VBAC bans. Does the article list an email address for her?
post #8 of 44
No advice, but thank you for doing all you can for VBAC mamas. We need all the support we can get.

One of the pp's brought up an excellent point about how many women would just stay home (possibly unassisted) if your hospital is no longer an option. Now, personally I don't have any problem with that, but it may open some eyes if the powers that be actually heard that. Unfortunately, in your case it's not like people are beating down the doors to birth there (VBAC or otherwise), so they're not losing a ton of money like some other hospitals might. They really shouldn't be doing any births if they cannot accommodate VBAC mamas. If it's good enough for a primip to have anesthesia 2 blocks away, then it should be fine for a VBAC'er to have the same.
post #9 of 44
what part of Illinois are you in? I know it's rural, but that's all I know.....


I wish you could come to St. Louis!! Sadly, the ob's have locked out fp docs (other than those in the fp residency program) from getting privileges at the local hospitals. It sucks. BUT, you can still homebirth. There is a hb doctor here who has done over 5,000 hb. We'd love to have you!!!
post #10 of 44
Quote:
Originally Posted by Ironica View Post
Oooo! One thing you might be able to do is survey previous VBAC clients (anonymously), and find out how many would choose a homebirth or UC if this policy had been in place when they delivered. You can use a 1-10 type scale, so that you can gage how much more or less likely they would be to choose an out-of-hospital birth for their VBAC if they couldn't birth vaginally at your hospital. That might convince the right people that they're putting more lives at risk this way.
Hmm....I'm not so sure I'm comfortable with this type of idea. I get that it would work with the medical types, but using this tactic is precisely the way to alienate would be supporters if one were to go the PR route.
post #11 of 44
In Houston, Tx the same thing is going on. One thing that is happening is getting a petition signed to give to the board in hopes they will change their mind.

http://www.thepetitionsite.com/1/sto...AC-ban-at-WHMC

Maybe someone in your community can start with this and organize letting media know womens right to make their own informed choice is being taken away.
post #12 of 44
Would you loose your privileges at the hospital if you attended births at home? I know that's more of what a midwife does, but it may be an option if you are able. In the meanwhile, collecting statistics that a previous poster mentioned and presenting an evidence based letter, etc. is also a good idea. I'm sorry that you've been put in this position. Thank you for being VBAC friendly.

Anna
post #13 of 44
Thread Starter 
I know gathering data and proving safety sound like a good idea - but frankly, this is not about data or evidence. It is about CYA and legal mumbo-jumbo. ACOG says you shouldn't VBAC in a hospital without 24 in house OB and anesthesia. We don't have that, and aren't going to get it. ACOG doesn't care if that means once a section always a section, that is perfectly okay with them. Our perinatal network feels the same way. No amount of evidence is going to change that.

Meanwhile, last wednesday I attended a lovely second VBAC for a client who I attended for her first VBAC 3 years ago. She was admitted in labor shortly after 7 in the morning, walked in our halls, sat in our tub, then labored on her side and in hands and knees on the bed with her sister holding her and talking to her and telling her she could do it. Eventually, she started to push, and her little boy was born over an intact perineum, passing quickly from my hands to hers, all before 10 in the morning. In less than an hour, she walked to the bathroom and then to her room. In the morning, she went home.
If this policy was in place 3 years ago she would instead have been scheduled for an unnecessary surgery instead!
post #14 of 44
Quote:
Originally Posted by doctorjen View Post
I know gathering data and proving safety sound like a good idea - but frankly, this is not about data or evidence. It is about CYA and legal mumbo-jumbo. ACOG says you shouldn't VBAC in a hospital without 24 in house OB and anesthesia. We don't have that, and aren't going to get it. ACOG doesn't care if that means once a section always a section, that is perfectly okay with them. Our perinatal network feels the same way. No amount of evidence is going to change that.
I think your answer lies in this here.

You see to have two choices.

One is to obtain 24/7 OB and anesthesia coverage.

Two is to work on ACOG changing their recommendations for VBAC.

Seems to me that trying to convince a hospital and/or doctor to deviate from ACOG recommentations would be a wasted effort, and for good reason. But ACOG can and does change their standing on issues as new information arises.

If it could be shown that the current recommendations are actually doing more harm than good, that would be information that ACOG should take into account.

As for what you can do in your daily practice, I cannot advocate going against hospital policy if you have any desire to keep your job. I can only imagine the outcome of a malpractice lawsuit should a woman under your care, or any of the OB's 'secretly' doing VBACs, actually rupture while in labor. I wonder if your malpractice carrier would even cover you if you were attending a VBAC in a hospital with a known ban on VBAC?
post #15 of 44
Thread Starter 
I frankly don't really give a crap what ACOG says. I'm a family doc. Their guidelines are frequently not evidenced-based, but based on "expert opinion." There is not adequate evidence that having in house anesthesia makes a significant difference. Catastrophic rupture is rare, and when it happens every second counts, but even with anesthesia and OB standing by outcomes are usually awful. Less catastrophic ruptures usually need urgency, but we routinely hit reasonable guidelines for timely cesarean delivery even in our non-VBAC clients who we aren't standing by for. Another professional organizations are not given the ability to determine policy and ACOG, who doesn't even base theirs on actual evidence shouldn't be any different.
I happily support any woman making a VBAC decision, and I've had a few feel not having in-house anesthesia was a deal breaker, so they either chose a repeat or went elsewhere. Some women will add up the risks and benefits and make that decision, and others will fell that being close to home and in a supportive environment is important and will choose to stay with us.
Many of the VBAC lawsuits that drive this fear by doctors are pretty impressive if you read them: clients who were forced to have trial of labor by their insurance company, clients who were never informed of the risks of VBAC, and clients whose complaints of pain, bleeding, or wanting to go to cesarean where ignored and cases where there were multiple signs that mom and baby were in trouble but any care at all was delayed. There is not evidence that well informed women are suing for bad outcomes.
I have no intention of risking my malpractice insurance or privileges over this, thank you very much, but if someone does not take a stand and argue in favor of women having the right to make this decision themselves, how many more women will be coerced into surgery?
post #16 of 44
Quote:
Originally Posted by doctorjen View Post
I frankly don't really give a crap what ACOG says. I'm a family doc. Their guidelines are frequently not evidenced-based, but based on "expert opinion." There is not adequate evidence that having in house anesthesia makes a significant difference. Catastrophic rupture is rare, and when it happens every second counts, but even with anesthesia and OB standing by outcomes are usually awful. Less catastrophic ruptures usually need urgency, but we routinely hit reasonable guidelines for timely cesarean delivery even in our non-VBAC clients who we aren't standing by for. Another professional organizations are not given the ability to determine policy and ACOG, who doesn't even base theirs on actual evidence shouldn't be any different.
I happily support any woman making a VBAC decision, and I've had a few feel not having in-house anesthesia was a deal breaker, so they either chose a repeat or went elsewhere. Some women will add up the risks and benefits and make that decision, and others will fell that being close to home and in a supportive environment is important and will choose to stay with us.
Many of the VBAC lawsuits that drive this fear by doctors are pretty impressive if you read them: clients who were forced to have trial of labor by their insurance company, clients who were never informed of the risks of VBAC, and clients whose complaints of pain, bleeding, or wanting to go to cesarean where ignored and cases where there were multiple signs that mom and baby were in trouble but any care at all was delayed. There is not evidence that well informed women are suing for bad outcomes.
I have no intention of risking my malpractice insurance or privileges over this, thank you very much, but if someone does not take a stand and argue in favor of women having the right to make this decision themselves, how many more women will be coerced into surgery?
Well then.

I guess you told me.

Really, though, *you* may not care what ACOG says. And I get that. I really do.

However, your OP *seemed* to want advice on how to actually DO something about the problem. If you really just needed a place to rant, that's ok too.

But the fact is, addressing WHERE these bans are coming from is the only real option aside from obtaining 24/7 OB and anesthesia coverage. And the bans are arising from ACOG guidelines.

So, like it or not, ACOG is 'setting the bar' so to speak.

If they are doing so NOT based on research, NOT based on actual evidence that their recommendations improve outcomes, yet hospitals and malpractice carriers nationwide are taking what they say and running with it, doesn't it make sense to advocate change within ACOG?

If they are the ones saying 'You really ought to have 24/7 OB and anesthesia coverge' and that is what is driving the current trend towards banning VBACs everywhere you look, it doesn't take a rocket scientist to figure out that THAT is where it would make the most sense to focus efforts on education, research, evidence based medicine, etc.

If ACOG is truly pulling this 24/7 coverage concept out of their behinds, they need to be called on it. If enough providers got together and demanded answers as to why they are making recommendations that you say are completely unsubstantiated in research, perhaps it might do some good.

What other choices are there really? Demand that the hospital change their mind? They'll change their mind when ACOG changes the guidelines. Demand that individual doctors attend VBACs regardless of hospital priveledge and/or malpractice coverage? Good luck with that.

I stand by my opinion that there are really only two realistic options at this point. Get coverage or work on ways to change ACOG's stand.

I will also add that nowhere in my post did I suggest you NOT 'take a stand' or 'argue in favor of women'. On the contrary, I *do* think someone needs to rally the troops and figure out a way to insist on accountability within ACOG since it seems malpractice carriers and hospitals are just following their lead. That's exactly why I think it makes the most sense to focus efforts on ACOG.

Not once did I suggest that I believed it best if you would just throw in the towel and say 'Well, that's that, no more VBACs here.' You may not like what I suggested, and that's certainly fine, but please do not insinuate that I ever said anything to the effect of allowing women to be 'coerced' into surgery.

Unfortunately, until ACOG changes their guidelines, I'm shocked there are still hospitals and docs out there are willing to open themselves up to the liability of NOT complying. Fair or not, you and I both know that all it takes is ONE lawsuit. If the patient's attorney can show that the hospital and/or doctor weren't following current guidelines set forth by ACOG...well, how do YOU think that's going to end up?
post #17 of 44
Quote:
Originally Posted by doctorjen View Post
I know gathering data and proving safety sound like a good idea - but frankly, this is not about data or evidence. It is about CYA and legal mumbo-jumbo. ACOG says you shouldn't VBAC in a hospital without 24 in house OB and anesthesia. We don't have that, and aren't going to get it. ACOG doesn't care if that means once a section always a section, that is perfectly okay with them.
Hmmm... OTOH, ACOG has goals for lowering the overall section rate, and they're NOT getting anywhere near meeting them.

My question for them would be what the intended purpose of the in-house OB/anesthesia rule is. Is it to get hospitals to hire these people? Or is it to get patients to choose hospitals who can? I'm guessing that, whatever the purpose is, it's NOT to get women to choose between an hour or more drive while in labor or a repeat section.

That's the thing about policy... the hope is that policy shapes behavior in a desirable way for a particular outcome. The outcome that the ACOG wants is for babies to not die because mom chose to VBAC instead of an ERCS. But a secondary desired outcome is to have fewer cesareans performed.

Also... the ACOG guidelines do not say "in-house" or "24 hours" or any of that wording. They say "immediately available" to respond to emergencies. The common interpretation is "24 hour in-house." However, a hospital an hour or more away is NOT "immediately available" in ANY sense. So if a client with a previous cesarean goes into labor and suffers a rupture early on (before she can get to the other hospital), your hospital will be responding to the emergency *anyway*. Were that patient planning on birthing at your hospital, you'd already be on standby for them, they'd be pre-admitted, etc. But since she has to be sent soooo far away, you'll have to respond and will be less prepared for it.

That's why I think that a dialog with the policymaking agency might be in order. It sounds like their policy is being abused for purposes that don't match those of the ACOG. A "ruling" from them might help the larger hospital's lawyers see that they're darned if they do, darned if they don't (because if a VBAC client suffers a uterine rupture on the highway halfway to the hospital, and finds out that they might have been ok had that larger hospital allowed yours to take their birth, hello lawsuit).
post #18 of 44
Quote:
Originally Posted by doctorjen View Post
ACOG doesn't care if that means once a section always a section, that is perfectly okay with them. Our perinatal network feels the same way. No amount of evidence is going to change that.
Absolutely! I'm thinking "Born in the USA" by Marsden Wagner here.

Quote:
Originally Posted by doctorjen View Post
I frankly don't really give a crap what ACOG says. I'm a family doc. Their guidelines are frequently not evidenced-based, but based on "expert opinion." There is not adequate evidence that having in house anesthesia makes a significant difference.
I was actually amazed when I started reading ACOG guidelines at the number of their current practices that were based on level C reccomendations - i.e. those that are "based primarily on consensus and expert opinion." Again, Marsden Wagner anyone?

Quote:
Originally Posted by doctorjen View Post
I have no intention of risking my malpractice insurance or privileges over this, thank you very much, but if someone does not take a stand and argue in favor of women having the right to make this decision themselves, how many more women will be coerced into surgery?
Exactly! So far there really aren't all that many folks who are willing to do that. Grass-roots movements can be very powerful, but I can't help but think that with some other folks involved we can actually make some headway in this issue. Of course, it would take a radical change in the medical culture. (ala Robbie Davis-Floyd)

Quote:
Originally Posted by wifeandmom View Post
But the fact is, addressing WHERE these bans are coming from is the only real option aside from obtaining 24/7 OB and anesthesia coverage. And the bans are arising from ACOG guidelines.

So, like it or not, ACOG is 'setting the bar' so to speak.
Yes...and this sentiment exactly begs the question - why is a trade union whose primary purpose is to look out for the best interests of their members allowed to "set guidelines"? You don't see other professional membership organizations/trade unions setting guidelines for other areas of society.

The ACOG's really a trade union gone amock is what it is. How about actually wrestling the power from organizations like the ACOG who should stick to what they do best, protecting their members, and leave guideline setting and policy making to those who would actually recognize evidence if it smacked them in the face and understood the value of what the WHO has gone about doing by stating that the actual medically indicated c/s rate should be somewhere near 10-15%?

Quote:
Originally Posted by Ironica View Post
ACOG has goals for lowering the overall section rate, and they're NOT getting anywhere near meeting them.
It may just be my jaded self, but I actually think this is nothing more than a PR maneuver than it is about actually wanting to do something about the overall c/s rate. It's more like they can then point to their "goals" and say - see what we've done? See how much we care about laboring women?

Quote:
Originally Posted by Ironica View Post
That's the thing about policy... the hope is that policy shapes behavior in a desirable way for a particular outcome. The outcome that the ACOG wants is for babies to not die because mom chose to VBAC instead of an ERCS. But a secondary desired outcome is to have fewer cesareans performed.
Again, I really don't think this is in line with what the ACOG's actual purpose is. It's purpose is to first and foremost look out for it's members. The primary purpose of the ACOG is not to look out for pregnant/birthing moms.

From one of their own publications:

Quote:
Founded in 1951, ACOG became the specialty’s first
enduring, nationwide, democratic, professional membership organization.
(emphasis mine)

and

Quote:
ACOG works closely with the media to promote the specialty and keep the public informed of new research and current guidelines for women’s health care.
(emphasis)

and from their Strategic Plan:
Quote:
The American College of Obstetricians and Gynecologists, the pre-eminent authority on women’s health, is a professional membership organization dedicated to advancing women’s health by building and sustaining the obstetric and gynecologic community and actively supporting its members. The College pursues this mission through education, practice, research, and advocacy. ACOG will emphasize life-long learning, incorporate new knowledge and information technology, and evolve its governance structure. To achieve its strategic goals, ACOG will develop an operational plan that includes appropriate metrics.
(emphasis mine)

Anyone want to take a gander about what happens when supporting women in labor or supporting women in general conflicts with "building and sustaining the obstetric and gynecologic community and actively supporting it's members"? Which one will prevail?

Seriously...in this day and age with all that we've seen do we really believe that the ACOG is all that unbiased or altruistic?

I'd skip trying to "work with" the ACOG at all and focus instead on the publicity aspect. Hospitals, espcially for profit ones, don't want their share of the pie to shrink when it comes to labor/birth. Why not exploit that and put the spotlight back on them. If they truly believe that their customers will take their dollars elsewhere it can provoke change. It's worked well in other areas where they have succeeded in reversing bans like these.
post #19 of 44
Quote:
Originally Posted by pampered_mom View Post
I was actually amazed when I started reading ACOG guidelines at the number of their current practices that were based on level C reccomendations - i.e. those that are "based primarily on consensus and expert opinion." Again, Marsden Wagner anyone?
Can you tell me how to access their policy page without a password? I'd love to read it, but you have to be a member... : Things that make you go Hmmmm...

Anna
post #20 of 44
Quote:
Originally Posted by Da WIC Lady View Post
Can you tell me how to access their policy page without a password? I'd love to read it, but you have to be a member... : Things that make you go Hmmmm...
I haven't ever looked at them on their website, just the applicable ones at www.guideline.gov.
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