alath
December 30th 04, 08:38 PM
Not a bad article, but he barely mentions one of the major drivers of
the anti-VBAC backlash - OB malpractice lawsuits. As an obstetrician
colleague of mine says, "I'll start practicing evidence-based medicine
as soon as they start practicing evidence-based law."
--------------------------------
http://slate.msn.com/id/2111499/
VBAC Backlash
Why are hospitals forbidding women who have had C-sections the right to
have vaginal births?
By David Dobbs
Posted Tuesday, Dec. 28, 2004, at 3:00 PM PT
Our first child, head askew, had to be delivered by Caesarean. We loved
the obstetrical surgeon who extracted him: Dr. Burgee worked fast, made
us laugh, and left almost no scar. He saved the lives of my wife and
son. I thanked my stars we lived in a Caesarean world.
But the operation hit Alice hard. Her legs ballooned with fluid,
stranding her in bed; her incision hurt every time she moved or nursed;
and her milk production faltered, stunting Nick's growth so that he
required hospitalization. Mother and baby both took months to recover.
So, two years later, when Alice got pregnant again, the first thing she
said to our midwife, Martha, was, "Please tell me I don't have to have
another Caesarean."
Martha obliged her, explaining that a normal vaginal delivery after
C-section did carry extra risk, but that it was minimal. The best
studies found that choosing a vaginal birth after having had a
Caesarean (also known as VBAC) instead of a repeat C-section, roughly
doubled the risk of uterine rupture, bringing it up from 0.3
percent-0.5 percent to around 0.6 percent-1 percent. And though a
serious rupture can require an emergency Caesarean, these rarely occur
and seldom cause lasting harm if a surgical team is in-house (as is the
case at our birthing center in tiny Gifford Hospital in Randolph, Vt.).
Roughly 75 percent of all VBACs go routinely, and those that don't
usually end up as non-emergency Caesareans. This means that if a woman
accepts a 1-in-200 chance of a rupture and emergency Caesarean, she has
a 75 percent chance of avoiding another C-section altogether. Perhaps
due to the recognition of these favorable odds, the rate of VBACs among
mothers with previous Caesareans increased from 3 percent to 28 percent
between 1981 and 1996. The change from the old "once a Caesarean,
always a Caesarean" rule that had held for most of the 20th century had
spared millions of women unnecessary surgery.
So, our daughter Linnea was born by vaginal delivery. Alice felt better
after four hours than she had after four months following the
Caesarean. We thanked our stars we lived in a VBAC world.
Unfortunately, during the past decade, more than 300 hospitals have
stopped performing VBACs-and more do so monthly. The VBAC rate fell
from 28 percent in 1996 to 12.7 percent in 2002, with double-digit
drops in 2001 and 2002; repeat Caesareans now account for 13 percent of
all births. The drop in VBACs accounts for most of the rise in overall
Caesareans, from 20 percent in 1996 to 2002's record high of 27
percent. Many of these mothers who undergo Caesareans want VBACs but
are denied that option by hospital bans that run counter to medicine's
growing emphasis on patient autonomy and informed consent.
Why the turnabout?
Hospitals usually claim they're trying to protect mothers and babies
from harm. But the truth is that hospitals ban VBACs for legal and
business reasons, not medical ones. Several mothers have sued in recent
years when VBACs led to uterine ruptures and damage to mother or baby.
Some of these women won awards in the millions, usually because the
emergency C-section had taken too long or the doctor hadn't warned them
of increased risk. A key issue in such suits is a 1999 American College
of Obstetricians and Gynecologists guideline calling for "immediate"
availability of O.R. teams to support VBACs. Immediate, on-site
availability of such teams thus quickly became a de facto legal
standard.
Hospitals can sharply reduce their legal exposure by having such teams
on call. But staffing these teams creates its own problem, which our
Dr. Burgee calls "the harmony on the ship issue." Some hospital staffs
rebel at the request to remain in-house while a mother attempts a VBAC.
Hospitals with round-the-clock staffs might already have all the people
needed-a surgeon or OB, anesthesiologist, operating room crew,
pediatrician, assistant surgeon-on the premises. But at other
hospitals, particularly smaller ones, those people might have to make
special trips to the hospital to stand by during a VBAC for as long as
the labor takes. Such hospitals may have to choose between VBACs and a
happy surgical unit.
As it happens, Burgee and the rest of the Gifford staff support the
hospital's VBAC commitment, even though the hospital (15 beds in the
main unit, another eight in the birthing center) is the sort of small
operation considered unsuitable for VBACs. The staff is unusually
cohesive, and the birthing center-the first such center in Vermont,
established in 1977-has long supported a team of midwives who work
with the hospital's obstetricians with unusual collegiality and ease.
In short, the hospital leans toward patient choice and a
noninterventionist approach.
Gifford's staff and administration were also influenced by the findings
of the Vermont/New Hampshire VBAC Project, which from 2000 to 2002
enlisted OBs, midwives, and birthing-center and obstetrical staffs from
the region's hospitals to draw on the scientific literature and their
own experience to create sensible VBAC policies. The resulting
guidelines offer both small hospitals like Gifford and big academic
centers like Dartmouth advice on how to provide VBACs safely and
economically. (The guidelines outline how to assess the risk level of
each patient-low, medium, or high-and set staffing levels and
availability accordingly; they also remind hospitals to fully review
risks and possible procedures with the patient.) That the project
involved staff from so many hospitals has helped give it broad support
in the two states, where almost all the large hospitals and many
smaller ones continue to offer VBACs. The results are encouraging.
Gifford's birthing center, for instance, hosts some 12 to 15 attempted
VBACs a year-hundreds over the past three decades. About 1 in 5 of
these women ended up having a Caesarean, but none has ruptured or gone
to emergency Caesareans.
A study just released in the New England Journal of Medicine-the
largest and most rigorous to date, involving almost 34,000 births at 19
academic hospitals from 2000 to 2003-confirms the VBAC's minimal
risk. The study included roughly 18,000 women who chose VBAC and 16,000
who elected a repeat Caesarean. Mishaps struck a small percentage of
each group. Of those who chose VBAC, 74 percent delivered vaginally,
and the rest had Caesareans. One-hundred-twenty-four VBACers (0.7
percent) experienced uterine ruptures (14 of these were discovered
after a vaginal birth, and 110 were discovered during Caesareans that
were initiated when labor stalled or a fetal monitor indicated
distress); seven of the babies whose mothers' uteruses ruptured (0.04
percent of all the planned VBAC births) suffered hypoxia-related brain
damage that was likely caused by these uterine ruptures, and two of
those babies (0.01 percent) died. The Caesarean group, meanwhile, saw
twice as many maternal deaths (7 versus 3, or 0.04 percent for
Caesareans versus 0.02 percent for VBAC). Overall, "adverse events,"
ranging from minor complications to those dozen deaths, occurred in 5.5
percent of the VBAC births and 3.6 percent of the elective Caesareans.
VBACs posed more risk to infants, C-sections to mothers. A woman
choosing VBAC over repeat Caesarean, the report study concluded,
increased her overall risk of adverse outcome by 0.046 percent=AD=AD-a
factor of about 1 in 2,000.
These odds make the hospitals' complaints about VBAC's safety sound
rather disingenuous. To be sure, the most serious adverse outcomes hold
our attention, as well they might; brain-damaged and dead infants and
mothers who die, lose their uteruses, or live their lives in pain rank
among our worst nightmares. But these horrors attend Caesareans, too.
And VBAC carries a risk premium similar to or less than that of
numerous elective procedures-or birth in general. Fallopian tube
ligation for birth control, for instance, fails in 1 of 200 cases,
creating the possibility of a life-threatening ectopic pregnancy.
Epidural anesthesia during labor raises the chance of
instrument-assisted delivery, stalled or long labor, maternal fever,
maternal low blood pressure, and Caesarean-all of which cause
further, often grave, dangers. A VBAC goes badly, however, with extreme
rarity. Covering a VBAC, says Burgee, is usually quite boring.
Given his support of VBACs, I was surprised to learn that Burgee
himself doesn't perform them. He did for two decades, but he stopped in
1990 when he reduced his practice to half-time while he got a law
degree (so far unused). When he resumed his full-time practice, he
didn't take them up again. He stopped, he says, partly because his
legal education made him see his legal risks more starkly. Managing the
cases thus seemed more complicated than ever: The OB in him would be
pulling for the VBAC, while the surgeon, lawyer, and potential trial
defendant would worry that he should wheel the mother to the O.R. Now
he explains to his patients why he doesn't perform VBACs, outlines the
odds as well as the arguments for and against, and offers the names of
midwives and doctors who will perform the procedure. Burgee's stand,
distinctly personal, provides excellent care for his patients while
leaving them every option; one can scarcely object.
Likewise, who can question my wife's choice to pursue a VBAC? Given two
nearly equal risks she chose the risk she felt most comfortable with.
Both decisions highlight the perversity of hospitals banning VBACs.
When a hospital bans the practice, it takes away the right of doctors,
midwives, and patients to make such personal choices; it settles by
institutional edict a decision that should belong to patient and
caretaker. The choice is indeed serious: A Caesarean is major surgery,
and a VBAC adds a risk that is tiny but terrible. But choosing between
the two options isn't a matter of right or wrong, statistical clarity,
or policy imperatives. It's a judgment call-one that a hospital has
no business making.
the anti-VBAC backlash - OB malpractice lawsuits. As an obstetrician
colleague of mine says, "I'll start practicing evidence-based medicine
as soon as they start practicing evidence-based law."
--------------------------------
http://slate.msn.com/id/2111499/
VBAC Backlash
Why are hospitals forbidding women who have had C-sections the right to
have vaginal births?
By David Dobbs
Posted Tuesday, Dec. 28, 2004, at 3:00 PM PT
Our first child, head askew, had to be delivered by Caesarean. We loved
the obstetrical surgeon who extracted him: Dr. Burgee worked fast, made
us laugh, and left almost no scar. He saved the lives of my wife and
son. I thanked my stars we lived in a Caesarean world.
But the operation hit Alice hard. Her legs ballooned with fluid,
stranding her in bed; her incision hurt every time she moved or nursed;
and her milk production faltered, stunting Nick's growth so that he
required hospitalization. Mother and baby both took months to recover.
So, two years later, when Alice got pregnant again, the first thing she
said to our midwife, Martha, was, "Please tell me I don't have to have
another Caesarean."
Martha obliged her, explaining that a normal vaginal delivery after
C-section did carry extra risk, but that it was minimal. The best
studies found that choosing a vaginal birth after having had a
Caesarean (also known as VBAC) instead of a repeat C-section, roughly
doubled the risk of uterine rupture, bringing it up from 0.3
percent-0.5 percent to around 0.6 percent-1 percent. And though a
serious rupture can require an emergency Caesarean, these rarely occur
and seldom cause lasting harm if a surgical team is in-house (as is the
case at our birthing center in tiny Gifford Hospital in Randolph, Vt.).
Roughly 75 percent of all VBACs go routinely, and those that don't
usually end up as non-emergency Caesareans. This means that if a woman
accepts a 1-in-200 chance of a rupture and emergency Caesarean, she has
a 75 percent chance of avoiding another C-section altogether. Perhaps
due to the recognition of these favorable odds, the rate of VBACs among
mothers with previous Caesareans increased from 3 percent to 28 percent
between 1981 and 1996. The change from the old "once a Caesarean,
always a Caesarean" rule that had held for most of the 20th century had
spared millions of women unnecessary surgery.
So, our daughter Linnea was born by vaginal delivery. Alice felt better
after four hours than she had after four months following the
Caesarean. We thanked our stars we lived in a VBAC world.
Unfortunately, during the past decade, more than 300 hospitals have
stopped performing VBACs-and more do so monthly. The VBAC rate fell
from 28 percent in 1996 to 12.7 percent in 2002, with double-digit
drops in 2001 and 2002; repeat Caesareans now account for 13 percent of
all births. The drop in VBACs accounts for most of the rise in overall
Caesareans, from 20 percent in 1996 to 2002's record high of 27
percent. Many of these mothers who undergo Caesareans want VBACs but
are denied that option by hospital bans that run counter to medicine's
growing emphasis on patient autonomy and informed consent.
Why the turnabout?
Hospitals usually claim they're trying to protect mothers and babies
from harm. But the truth is that hospitals ban VBACs for legal and
business reasons, not medical ones. Several mothers have sued in recent
years when VBACs led to uterine ruptures and damage to mother or baby.
Some of these women won awards in the millions, usually because the
emergency C-section had taken too long or the doctor hadn't warned them
of increased risk. A key issue in such suits is a 1999 American College
of Obstetricians and Gynecologists guideline calling for "immediate"
availability of O.R. teams to support VBACs. Immediate, on-site
availability of such teams thus quickly became a de facto legal
standard.
Hospitals can sharply reduce their legal exposure by having such teams
on call. But staffing these teams creates its own problem, which our
Dr. Burgee calls "the harmony on the ship issue." Some hospital staffs
rebel at the request to remain in-house while a mother attempts a VBAC.
Hospitals with round-the-clock staffs might already have all the people
needed-a surgeon or OB, anesthesiologist, operating room crew,
pediatrician, assistant surgeon-on the premises. But at other
hospitals, particularly smaller ones, those people might have to make
special trips to the hospital to stand by during a VBAC for as long as
the labor takes. Such hospitals may have to choose between VBACs and a
happy surgical unit.
As it happens, Burgee and the rest of the Gifford staff support the
hospital's VBAC commitment, even though the hospital (15 beds in the
main unit, another eight in the birthing center) is the sort of small
operation considered unsuitable for VBACs. The staff is unusually
cohesive, and the birthing center-the first such center in Vermont,
established in 1977-has long supported a team of midwives who work
with the hospital's obstetricians with unusual collegiality and ease.
In short, the hospital leans toward patient choice and a
noninterventionist approach.
Gifford's staff and administration were also influenced by the findings
of the Vermont/New Hampshire VBAC Project, which from 2000 to 2002
enlisted OBs, midwives, and birthing-center and obstetrical staffs from
the region's hospitals to draw on the scientific literature and their
own experience to create sensible VBAC policies. The resulting
guidelines offer both small hospitals like Gifford and big academic
centers like Dartmouth advice on how to provide VBACs safely and
economically. (The guidelines outline how to assess the risk level of
each patient-low, medium, or high-and set staffing levels and
availability accordingly; they also remind hospitals to fully review
risks and possible procedures with the patient.) That the project
involved staff from so many hospitals has helped give it broad support
in the two states, where almost all the large hospitals and many
smaller ones continue to offer VBACs. The results are encouraging.
Gifford's birthing center, for instance, hosts some 12 to 15 attempted
VBACs a year-hundreds over the past three decades. About 1 in 5 of
these women ended up having a Caesarean, but none has ruptured or gone
to emergency Caesareans.
A study just released in the New England Journal of Medicine-the
largest and most rigorous to date, involving almost 34,000 births at 19
academic hospitals from 2000 to 2003-confirms the VBAC's minimal
risk. The study included roughly 18,000 women who chose VBAC and 16,000
who elected a repeat Caesarean. Mishaps struck a small percentage of
each group. Of those who chose VBAC, 74 percent delivered vaginally,
and the rest had Caesareans. One-hundred-twenty-four VBACers (0.7
percent) experienced uterine ruptures (14 of these were discovered
after a vaginal birth, and 110 were discovered during Caesareans that
were initiated when labor stalled or a fetal monitor indicated
distress); seven of the babies whose mothers' uteruses ruptured (0.04
percent of all the planned VBAC births) suffered hypoxia-related brain
damage that was likely caused by these uterine ruptures, and two of
those babies (0.01 percent) died. The Caesarean group, meanwhile, saw
twice as many maternal deaths (7 versus 3, or 0.04 percent for
Caesareans versus 0.02 percent for VBAC). Overall, "adverse events,"
ranging from minor complications to those dozen deaths, occurred in 5.5
percent of the VBAC births and 3.6 percent of the elective Caesareans.
VBACs posed more risk to infants, C-sections to mothers. A woman
choosing VBAC over repeat Caesarean, the report study concluded,
increased her overall risk of adverse outcome by 0.046 percent=AD=AD-a
factor of about 1 in 2,000.
These odds make the hospitals' complaints about VBAC's safety sound
rather disingenuous. To be sure, the most serious adverse outcomes hold
our attention, as well they might; brain-damaged and dead infants and
mothers who die, lose their uteruses, or live their lives in pain rank
among our worst nightmares. But these horrors attend Caesareans, too.
And VBAC carries a risk premium similar to or less than that of
numerous elective procedures-or birth in general. Fallopian tube
ligation for birth control, for instance, fails in 1 of 200 cases,
creating the possibility of a life-threatening ectopic pregnancy.
Epidural anesthesia during labor raises the chance of
instrument-assisted delivery, stalled or long labor, maternal fever,
maternal low blood pressure, and Caesarean-all of which cause
further, often grave, dangers. A VBAC goes badly, however, with extreme
rarity. Covering a VBAC, says Burgee, is usually quite boring.
Given his support of VBACs, I was surprised to learn that Burgee
himself doesn't perform them. He did for two decades, but he stopped in
1990 when he reduced his practice to half-time while he got a law
degree (so far unused). When he resumed his full-time practice, he
didn't take them up again. He stopped, he says, partly because his
legal education made him see his legal risks more starkly. Managing the
cases thus seemed more complicated than ever: The OB in him would be
pulling for the VBAC, while the surgeon, lawyer, and potential trial
defendant would worry that he should wheel the mother to the O.R. Now
he explains to his patients why he doesn't perform VBACs, outlines the
odds as well as the arguments for and against, and offers the names of
midwives and doctors who will perform the procedure. Burgee's stand,
distinctly personal, provides excellent care for his patients while
leaving them every option; one can scarcely object.
Likewise, who can question my wife's choice to pursue a VBAC? Given two
nearly equal risks she chose the risk she felt most comfortable with.
Both decisions highlight the perversity of hospitals banning VBACs.
When a hospital bans the practice, it takes away the right of doctors,
midwives, and patients to make such personal choices; it settles by
institutional edict a decision that should belong to patient and
caretaker. The choice is indeed serious: A Caesarean is major surgery,
and a VBAC adds a risk that is tiny but terrible. But choosing between
the two options isn't a matter of right or wrong, statistical clarity,
or policy imperatives. It's a judgment call-one that a hospital has
no business making.