Tuesday, June 24, 2008

Group protests birth policy


Complications forced Jessica Powell to have a cesarean delivery during the birth of her daughter. When the Santa Barbara resident subsequently decided to try for a natural birth with her son, however, she ran into a different set of complications.
Local doctors refused to perform the natural delivery, citing health concerns and telling her instead to get a repeat cesarean.
So when her son came calling, Powell packed the bags and headed to UCLA Medical Center with her husband, Abraham, where doctors still allow a natural birth following a cesarean.
Her son, Leo, now 10 months old, arrived without complications and was chewing on the end of a toy as her mother and father stood outside Santa Barbara Cottage Hospital with a group of other protesters lobbying for the right to have a vaginal birth after cesarean, or VBAC.

“Having done it both ways now, I can tell you the emotional and physical benefits of having a natural birth far outweigh the supposed health risks of a cesarean,” Powell said.
Her situation — having a cesarean birth, or c-section, and then asking for a natural birth during a subsequent pregnancy — is a hotly debated topic between parents and health officials.
Many mothers want a natural delivery rather than going under the knife again, but after the American College of Obstetricians and Gynecologists (ACOG) released recommendations that weighed more heavily against that approach, many doctors have refused to perform VBACs.
In 2003, obstetricians practicing at Cottage Hospital came to a group decision not to assist in natural deliveries when the mother had a prior c-section, hospital officials said, and few if any have been performed there since.
“There’s no ban on performing VBACS at Cottage, there are just no obstetricians that are willing to do it,” Cottage Hospital spokeswoman Janet O’Neill said. “…It does tend to be a trend across the country.”
In a 2004 report, ACOG officials noted an increased risk of the uterus rupturing along the cesarean scar during a VBAC, along with other potential complications, and recommended that hospitals have a physician and necessary personnel immediately available throughout the labor process if the need for an emergency c-section is needed.
“The word immediate is what really got it going,” said Dr. Robert Reid, a former obstetrician who now works as the director of medical affairs at Cottage Hospital.
The standard for community hospitals for responding to an emergency c-section is within 30 minutes, he said, but when a uterus ruptures from a previous scar, the risk is higher compared to other complications that require an emergency cesarean.
Since Cottage Hospital doesn’t have a residency program for obstetricians or gynecologists, local physicians determined they couldn’t meet ACOG’s recommendations and decided against VBACs.
But some protesting yesterday said the risk of a uterine rupture is very small and the chance of the infant dying during a VBAC is even smaller.
Jessica Barton, the Santa Barbara parent coordinator of the Birth Action Coalition, said VBACs are at least as safe as a repeat cesarean and 80 percent are successful. Most mothers have a 1 in 200 risk of experiencing a uterine rupture, she said, and only 1 in 3,000 infants would die as a result of that complication.
Barton said the risk of a newborn dying during delivery is at least equally as high for other complications.
“Nobody should be forced into surgery,” she said. “…I want that to be my choice with my doctor.”
The medical dictum of “once a cesarean, always a cesarean” started changing in the 80s, according to the ACOG report, which noted improvements in care that made birth safer.
From 1989 to 1996, the VBAC rate jumped from approximately 19 percent to 28 percent.
“Many physicians were pressured into offering VBAC to unsuitable candidates or to women who wanted to have a repeat cesarean delivery,” according to the report. “As the VBAC rate increased, so did the number of well-publicized reports of uterine rupture and other complications during trials of labor after previous cesarean deliveries.”
Dr. Reid said if a doctor came to the Cottage Hospital board requesting to perform a VBAC, that doctor would have to explain why they felt the approach is safe while their colleagues have decided against it.
“That person would have to make a pretty good case,” he said. “…Generally, I don’t believe that they’re safer than c-sections. I think that’s what our staff feels.”
But Barton argued that having a cesarean delivery, a major surgical procedure, comes with its own set of risks. She also cited shorter hospital stays, less blood loss, fewer transfusions and fewer infections associated with VBACs, which ACOG officials noted in their 2004 report.
However, ACOG officials also noted that a failed VBAC carries with it major complications beyond uterine rupture — complications that may require a hysterectomy or more blood transfusions, or could result in the death of the infant or mother.
Powell said she had few worries about her second pregnancy other than making it to UCLA Medical Center in time. If she has more children, she said she would try for a VBAC again.
“I felt I was able to complete a process I was naturally made to do,” she said. “It felt really good to me to say absolutely not. You’re not going to foist any decision on me.”
Jennifer Matthews, another mother protesting outside Cottage Hospital yesterday, said she had her two children, a 2-year-old son and 7-month-old daughter, by c-section at the hospital after learning she couldn’t try for a VBAC with her daughter.
She said she was saddened by the fact that she likely won’t be able to have more children as most doctors recommend having only two to three cesarean deliveries.
“I really had always wanted to have a lot of kids,” she said. “…It may be too late for me to have a VBAC.”


Jessica said...

Just wanted to clarify on this: "Most mothers have a 1 in 200 risk of experiencing a uterine rupture, she said, and only 1 in 3,000 infants would die as a result of that complication." This sentence makes it sound like out of 3000 ruptures only 1 baby would die, where what I meant was, out of every 3000 VBAC attempts, only one infant would die, thought there would have probably been 10 or 15 uterine ruptures. Most of the time, a cesarean can be performed fast enough and mother and baby are fine.

In any case the issue remains informed consent. Both VBAC and repeat cesarean carry different risks. It should be up to the mom and her care provider which risks and potential benefits she chooses to accept.

Anonymous said...

Based on an American College of Obstetricians and Gynecologists (ACOG) statement that emergency c-section should be “immediately” available for Vaginal Birth After Cesarean (VBAC) management, many hospitals around the country who do not have 24/7 anesthesia in house have stopped offering VBAC.

This is not due to patient safety, but due to fear of litigation, as evidenced by ACOG’s own public info brochure, currently available online, stating “A trial of labor after cesarean seems to be as safe for the mother and infant as planned cesarean delivery…” The Academy of American Family Physicians says, “Current risk management policies across the United States restricting a trial of labor after previous cesarean section appear to be based on malpractice concerns rather than on available statistical and scientific evidence.”

Anonymous said...

What I want to highlight is the ACOG recommendation that emergency support for VBAC be immediately available. Isn't the availability of emergency care standard in labor and delivery wards anyway?

Also, I would like Cottage Hospital to name which doctors formed this 'voluntary' ban.