VBAC bans - x-posted in Birth Professionals Forum - Page 2 - Mothering Forums

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#31 of 44 Old 11-08-2007, 11:58 PM - Thread Starter
 
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The latest news is this. The OB dept voted to only allow VBACs when anesthesia and OB were "immediately available" ie in house, in accordance with ACOG guidelines at our last meeting and to put us in line with our perinatal network. My OB back up at present does not want to sit in house for any of his own clients, or for my VBAC clients for that matter. We are getting a new anesthesia group in 2 months, so any kind of negotiation with anesthesia has to wait until the new group is in place.
So for now, we theoretically allow VBACs, IF I can get everybody to stay in house with me, but practically, I don't see how it can work. As a non-surgical birth attendant, I pretty much have no way to offer my clients VBAC, and if I refer them to the OB, he'll want to schedule repeats with them. Or, I can refer people out to another hospital entirely, which so far my clients have been very resistant to.
I haven't quite figured out what to do about this, because officially we now have a policy that says we can do VBACs, but practically, there is no way for ME to practice within the policy, and no way to force the OB to do what my clients want. It's possible the OB will choose to do his own VBACs again if the new anesthesia group is willing to stay in house, but I don't think I'll be able to convince him to sit in house for MY clients, because I don't think he can bill for that, unless I were to need him for a section. What will happen if a patient refuses to have a repeat, I don't know.
So it looks like, while officially, we haven't banned VBACs, I will have to give them up unless something changes, or I go elsewhere.
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#32 of 44 Old 11-09-2007, 04:18 AM
 
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They're considered the rules to follow and are really the foundation of the way most obs practice in this country.
But they *don't* follow the rules. If you actually read the rules as written by the ACOG, and you look at the reasons hospitals give for banning VBACs, those reasons are NOT justified by the rules as set forth by the ACOG. They're a distortion of the ACOG policy (which, while different in details, is pretty similar to the AAFP policy in the main points).

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Since they have a monopoly on childbirth
My midwives will be surprised to hear that. So would the OP, who isn't an OB, but is an MD who births babies. They don't even have a monopoly on *hospital* birth.

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Seriously...defending the ACOG by blaming lawyers? Sounds like a page from their own playbook.
I have not once tried to defend the ACOG. Please stop trying to twist what I'm saying. The OP's dilemma is largely a legal and political one, NOT a medical one, so I'm throwing out ideas that work the legal and political angles. Since the hospital is not using evidence-based, or even truly ACOG-guideline-based, medicine to shape policy, but instead adopting a CYA double-standard, it's likely easier to get them to decide that they're covering their butts better by supporting VBACs than by denying them, than to try to teach them what they already failed to learn in medical school (though many of the folks setting policy are probably MBAs more than they're MDs, even if they technically hold both degrees).
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#33 of 44 Old 11-09-2007, 08:40 PM
 
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Doctorjen, that news makes me so frustrated. I really don't like the idea that obstetricians can vote about a woman's obstetrical future and essentially negate her choices. Do you have any current VBAC clients? What will do you about them--can you do the "I can't offically offer VBAC but you have the right to refuse any procedure" spiel?

What do OB's tend to say in response to the fact that ACOG recommendations have no research to justify them? I just find it pretty callous to not allow women to decide what happens to their own bodies.

Preaching to the choir, I know.
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#34 of 44 Old 11-09-2007, 09:45 PM - Thread Starter
 
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I have 2 current VBAC clients (and I had one birth her baby 2 weeks ago) My OB already told me that he'd back me up for her and she's 38 weeks already, so I'm planning to do what I always do and just wait until she's in labor and call the OB then. I don't know what to do yet with the other one - she's had 3 previous vaginal births and then a cesarean and before the policy was changed my OB had said she was fine to VBAC, so I'll have to find out if that now means he'll sit in house with me.

OBs tend to say that they agree with the ACOG guidelines, and if they don't, they still tend to feel that they should follow them. The problem is, if you don't follow ACOG guidelines, and somebody sues you, it is very hard to defend yourself, even if you try to bring the literature into it. There isn't literature to say not having in house anesthesia makes it more dangerous to VBAC, but there isn't literature to say it doesn't, either. And there is an expert opinion by the biggest professional org saying no one should do it.

I feel really stuck on what to do with VBAC clients. I can certainly do the "you can refuse spiel." The problem is that all my VBAC clients have to see OB and be cleared (which up until now has been a pretty benign thing. The OB says "nice to meet you" and that's the end of it.) Now, since he's not willing to stay in house, I can't very well send them over to clear for VBAC, and have to officially be sending them over to get their cesarean scheduled. Even if clients want to refuse, there are plenty of ways to talk someone into a cesarean - it all depends on how you spin the data, after all. I tend to take the Henci Goer approach and tell them actual numbers, and what things make it more risky (induction especially) and then also go over the risks of a repeat - especially if the client is planning many children. My OB tends to say "there's a new rule we don't do VBACs because they are so dangerous" and most people are fairly scared off by that. It would take a fairly strong person to advocate for themselves in this situation, and sadly, that's not the grand majority of my clients.
I can refer them out to other hospitals, of course. It just ticks me off that I can't continue to attend my own clients, but I can't go against hospital policy or I could easily be discliplined or even risk losing my privileges. Unfortuantely, there is nothing that says they have to make a way for me, a non-surgical provider, to attend VBACs. Since we officially have a policy in place that allows VBACs, but no one willing to do them anymore except me, that effectively bans them. But since we are just going in line with the guidelines most of the country follows anyway, there is no real way to argue it.
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#35 of 44 Old 11-09-2007, 09:50 PM - Thread Starter
 
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In my OB backups defense, he is in his late 60s, and doesn't want to risk being sued at this point and compounding the problem by going against ACOG policy. He's also a surgeon and not a huge natural birth advocate, so advocating a cesarean is not a big deal to him. We practice somewhere where it's a not big deal to most clients, either, so there isn't much pressure on him to change. There is one other OB, but for many reasons, I don't feel comfortable using him for back up or encouraging my clients to go that way.
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#36 of 44 Old 11-10-2007, 05:10 AM
 
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maybe this got answered and i missed it but assuming you only have one hospital in the area how do they plan to not do vbacs?

they can pressure women all they want but if a women goes into labor and goes to the hospital without her signing that consent form they can't leagaly do a c/s.

and they cant turn down a women in labor, right? patients rights and doctors codes of ethics and all that.... s

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#37 of 44 Old 11-10-2007, 05:24 PM
 
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Ironica - consider yourself lucky to live in an area where they do not hold a monoply. Around these parts, especially if you're a VBAC, you have no choice w/in the hospital but an OB/GYN. FP docs are not "allowed" to attend a VBAC. In the two big hospitals about an hour or so away one hospital doesn't even employ midwives and the other one does, but they aren't "allowed" to attend VBACs. At the hospital in town FP docs aren't "allowed" to attend VBACs, the hospital does not employ any midwives, and they have by far the worst policies that are not anywhere near mother/baby friendly.

If I wasn't a VBAC there would be slightly more choice, but by in far the lions share of care providers who "deliver" babies are OB/GYNs. Our CPM legislation was *lucky* to have passed and even luckier to have gotten decent licensing guidelines. The same is not true of the bordering states.

My CPM does a lot of hotel homebirths because so many mamas head up from doctorjen's state b/c of their overall lack of choice.
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#38 of 44 Old 11-11-2007, 08:08 PM
 
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I keep thinking about the ban at your hospital. I know it's nothing new to a lot of hospitals, unfortunately, but here is another idea:

I think that pressure might have to come from consumers, and ICAN suggests a way to appeal VBAC bans in their Legal Primer (PDF). Basically it suggests that VBAC mamas register a complaint with the Center for Medicare and Medicaid Service’s (CMS) Conditions of Participation (CoP), on the grounds that a no-VBAC policy negates a patient's right to refuse treatment.

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All hospitals that receive federal funding (approximately 80% of them do) must adhere to the Center for Medicare and Medicaid Service’s (CMS) Conditions of Participation (CoP), which require hospitals to honor patient rights as defined by the Patient Self-Determination Act, the Consumer Bill
of Rights and Responsibilities, the Emergency Medical Treatment and Active Labor Act (EMTALA), and the large body of case law upholding the right to refuse treatment, to be fully informed of the risks, benefits, and alternatives of any proposed treatment, and to participate in all treatment decisions.

Hospitals that fail to adhere to the CoP are subject to heavy fines and risk losing their right to qualify for Medicare and Medicaid funding. In addition, the CoP require that hospitals institute an internal grievance process and give patients the information they need to know about how to file a complaint
and where to appeal in the case of an unfavorable ruling.
So, perhaps start with this? Have all your VBAC mamas try this out and see where it takes them (perhaps including ones who have VBAC'ed with you in the past, if they plan on having more children). What do you think? Has anyone tried this strategy with other hospitals?
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#39 of 44 Old 11-12-2007, 03:06 AM
 
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Ironica - consider yourself lucky to live in an area where they do not hold a monoply. Around these parts, especially if you're a VBAC, you have no choice w/in the hospital but an OB/GYN. FP docs are not "allowed" to attend a VBAC.
Then your situation is very different from the OP's, I guess, since she's an FP doctor and (should be) able to attend VBACs.

I understand that things are different in different places, but since doctorjen asked for ideas on her specific situation, it doesn't seem terribly useful to switch the discussion to a different circumstance.
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#40 of 44 Old 11-12-2007, 03:25 PM
 
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The ABA and its state versions do a LOT of setting guidelines and regulating practice of attorneys. They are the licensing organization and provide a major enforcement role. They take complaints, fine those not meeting standards, suspend licenses based on misconduct... a whole lot of regulatory stuff.
Ironica, this is not true in any of the (3, soon to be 4) jurisdictions in which I am licensed. Discipline is handled differently in the different states, but each disciplinary body is a subset of the courts themselves; it is not part of the voluntary professional organizations such as the ABA or its state cognates.

Sorry to be OT, but I want to clear up any misperceptions.
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#41 of 44 Old 11-12-2007, 05:38 PM
 
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Ironica, this is not true in any of the (3, soon to be 4) jurisdictions in which I am licensed. Discipline is handled differently in the different states, but each disciplinary body is a subset of the courts themselves; it is not part of the voluntary professional organizations such as the ABA or its state cognates.

Sorry to be OT, but I want to clear up any misperceptions.
Ok... I know that my FIL was sanctioned by the California Bar Association, NOT by the courts ;-). Maybe if it had been more official, he wouldn't have done the same crap AGAIN and gotten suspended for 2 years. :
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#42 of 44 Old 11-12-2007, 10:24 PM - Thread Starter
 
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Then your situation is very different from the OP's, I guess, since she's an FP doctor and (should be) able to attend VBACs.
Unfortunately, the new decision effectively bans me from attending VBACs. Technically I can - but only if OB and anesthesia stay in house with me, and OB doesn't intend to. In many bigger hospitals there are "house physicians" who are paid, often by the institution, sometimes by the groups of physicians that utilize their services to stay in house and manage any emergencies and sometimes to do deliveries for practicing docs who can't come or choose to stay in their office seeing patients. In teaching hospitals, usually faculty rotate call and staying in house and are then available for emergencies as well. In a small setting like my hospital, with only 6 docs who attend births, and only 2 who do surgery, the OBs don't want to stay in house for even their own clients let alone mine. And really, I don't think there is any way they can bill for their time if they did stay in house for my clients - except for many a consult fee if I formally consulted them on every client. I don't induce or augment VBACs (except under very specialized circumstances) so if OB were to sit in house for my VBAC clients, they could be looking at hours and hours of time. Realistically, it's hard to expect them to do that - especially when it's not something billable. It's a really hard sell to my 67 yr old back up OB to convince him to stay with me in the hospital for 12-14 hours while a VBAC client labors.
So, for now, I'm done attending VBACs I guess. I will likely refer my clients to one of the hospitals about 45 minutes away that has some midwives (I'm going to call and make sure they attend VBACs)
If a client feels strongly and wants to make a case with our administration I'll be behind her, but right now I don't have such a client - every client so far that I've told this whole story to is more inclined to schedule a repeat than to either be referred elsewhere or to stay here and insist.
I hate not being able as a non-surgical provider to not attend VBACs, because I believe that having a non-surgeon attend you decreases your chance of surgery - for all laboring mamas, really, but especially for VBACs!
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#43 of 44 Old 11-21-2007, 12:37 PM
 
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DrJen- that's so not fair. I'm so sorry... You've been such a huge help to so many vbac mamas I can't imagine how this is making you feel...

Our local hospital did something similar...until recenty they were huge vbac supporters. Now they still support vbac on paper but in reality there is very little chance since their new insurance company changed the surgical team guidelines for vbac (full dedicated team in house from 5cm till birth, dedicated OR as well). I was actually the last vbac for my OBs and one of their last births...they decided to leave obstetrics since they didn't feel like they could remain in the field if they couldn't offer women the sorts of births they feel are normal/healthy.

It's heartbreaking that they've tied your hands like this... I don't have any ideas but just wanted to thank you for everything you've done for birthing women and offer a hug.

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#44 of 44 Old 11-26-2007, 11:06 PM
 
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I'm not a provider and can't offer any help but wanted to say how happy I am to hear of a provider not only willing but encouraging VBAC. I'm currently pg after a medically necessary c/s and have to see a peri in order to VBAC because there are no other MD's willing to take the "risk".
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