[sgent]

Originally Posted by HeartsOpenWide

What can be done to stop this? BANNING VBAC?? Is arguing that a law should be passed that all woman should be allowed a trial of labor even worth it? Or possible?

VBAC is one of highest threats for malpractice for OB/GYN's. Many malpratice carriers will not cover a VBAC -- period.

In addition, new JACHO requirements basically make a VBAC an impossiblity in any but Level I tramua centers -- you must have a GS (not in scheduled surgery), OB/GYN, and Anesthesiology on site for the entire duration of the delivery. Since hospitals aren't big about offering it anyway, and GS get ****** at being woke up and told to sit around for hours with nothing to do, the VBAC is generally going the way of the Dodo.

Even at our local hospital, which is a Level I, they have a separate women's hospital (with a couple of OR's), and JACHO won't let them do it since the surgeon is at the main building.

[RNnL&D]

Originally Posted by sgent

VBAC is one of highest threats for malpractice for OB/GYN's. Many malpratice carriers will not cover a VBAC -- period.

In addition, new JACHO requirements basically make a VBAC an impossiblity in any but Level I tramua centers -- you must have a GS (not in scheduled surgery), OB/GYN, and Anesthesiology on site for the entire duration of the delivery.

What's this about a GS needing to be available? Since when is an OBGYN not a surgeon? Why would they require a GS?

[sgent]

Originally Posted by RNnL&D

What's this about a GS needing to be available? Since when is an OBGYN not a surgeon? Why would they require a GS?

Cause I'm in nana land with my brain ... Glad I'm not working this week.

The standard is OB or Surgeon (in some rural hospitals the GS does the emergency c-sections, and there is no OB on staff. FP or CNM does normal deliveries).

The problem is that it requires immediate availability, which usually means decision to cut is 10 minutes, so both the OB and Anesthesia have to be ready to go the entire time the lady is in labor. This might not be a problem with a large OB group which rotates the hospital duty, and it isn't a problem in a level I trauma where anesthesia is readily available, but its a nightmare at smaller hospitals.

[FrumDoula]

The decision of so many hospitals to disallow VBAC is unsupported by medical evidence and bespeaks a truth about smaller and rural hospitals in general; that is, if it isn't "safe enough" to VBAC there, is it going to be safe enough to birth there at all, given that obstetric emergencies can happen to primips and multips with no history of cesarean?

I thought it was 30 minutes from "decision to incision" by ACOG standards, though I could be wrong. Anyone? SBE?

When I logged onto this board tonight, I saw the thread and inwardly groaned a little. As the local PITA representative for natural birth I thought I would hear a bunch of lame defenses for elective cesarean from some of the nurses, including my personal pet peeve, elective cesarean as a feminist and reproductive rights issue. The argument that it's a "woman's right to choose" her c/s is remarkable only in its uncritical viewing of what the body politic has become. And I say that as a former women studies minor.

Imagine my suprise when I read so many fiery defenses of VBAC - no suprise at all that SmilingBlueEyes led the charge. I was just tickled to read all the responses and wish each and every one of those OB nurses could help make policy decisions about VBAC. It warmed the cockles of my heart, ladies.

And heaven knows I need it tonight. At 39 wks + 5 days pregnant, I am feeling a tad cranky anyhow. I mean, even the gas station lady said when I walked in for some ice, "You're still pregnant?!". And a complete stranger asked me my due date in Target tonight. (My husband joked he was suprised that she didn't ask if I had any cervical dilation yet!) Although I am obviously not going to schedule an induction anytime too soon, and certainly not an elective cesarean, my time as Gestating Goddess is coming to a close, and I'm ready to begin my new role as Lactating 24-Hour Buffet.

So I can see why some ladies get impatient. But it's no reason to schedule major abdominal surgery for mere convenience, and ACOG should be ashamed of itself, bowing to the lawyers and their own conflicts of interest. Apparently, "do no harm" now applies more to the docs than to their patients.

For those who know Henci Goer and those who don't, here's a link to a variety of articles written by her on VBAC and other childbirth subjects. She is a medical researcher and childbirth advocate with some impressive books to her credit. They are noteworthy for their medical thoroughness, intelligence and passion.

http://hencigoer.com/articles/

You guys made my night.

Alison

[sgent]

Summary of Recommendations

The following recommendations are based on good and consistent scientific evidence (Strength of Recommendation Taxonomy [SORT] = A; see page 1201 for an explanation of SORT):

• Most women with one previous cesarean delivery with a low-transverse incision are candidates for VBAC and should be counseled about VBAC and offered a trial of labor.

• Epidural anesthesia may be used for VBAC.

The following recommendations are based on limited or inconsistent scientific evidence (SORT = B):

• Women with a vertical incision within the lower uterine segment that does not extend into the fundus are candidates for VBAC.

• The use of prostaglandins for cervical ripening or induction of labor in most women with a previous cesarean delivery should be discouraged.

The following recommendations are based primarily on consensus and expert opinion (SORT = C):

• Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.

• After thorough counseling that weighs the individual benefits and risks of VBAC, the ultimate decision to attempt this procedure or undergo a repeat cesarean delivery should be made by the patient and her physician. This discussion should be documented in the medical record.

• Vaginal birth after a previous cesarean delivery is contraindicated in women with a previous classical uterine incision or extensive transfundal uterine surgery.

www.aafp.org/afp/20041001/practice.html is the ACOG recommendations (even though its aafp).

Rural/small hospitals aren't like that out of choice, the reality that we've seen in my state is that if the hospital closes their OB ward, the emergency room physician becomes a OB by default.

[DDRN4me]

Originally Posted by FrumDoula

The decision of so many hospitals to disallow VBAC is unsupported by medical evidence and bespeaks a truth about smaller and rural hospitals in general; that is, if it isn't "safe enough" to VBAC there, is it going to be safe enough to birth there at all, given that obstetric emergencies can happen to primips and multips with no history of cesarean?

I thought it was 30 minutes from "decision to incision" by ACOG standards, though I could be wrong. Anyone? SBE?

When I logged onto this board tonight, I saw the thread and inwardly groaned a little. As the local PITA representative for natural birth I thought I would hear a bunch of lame defenses for elective cesarean from some of the nurses, including my personal pet peeve, elective cesarean as a feminist and reproductive rights issue. The argument that it's a "woman's right to choose" her c/s is remarkable only in its uncritical viewing of what the body politic has become. And I say that as a former women studies minor.

Imagine my suprise when I read so many fiery defenses of VBAC - no suprise at all that SmilingBlueEyes led the charge. I was just tickled to read all the responses and wish each and every one of those OB nurses could help make policy decisions about VBAC. It warmed the cockles of my heart, ladies.

And heaven knows I need it tonight. At 39 wks + 5 days pregnant, I am feeling a tad cranky anyhow. I mean, even the gas station lady said when I walked in for some ice, "You're still pregnant?!". And a complete stranger asked me my due date in Target tonight. (My husband joked he was suprised that she didn't ask if I had any cervical dilation yet!) Although I am obviously not going to schedule an induction anytime too soon, and certainly not an elective cesarean, my time as Gestating Goddess is coming to a close, and I'm ready to begin my new role as Lactating 24-Hour Buffet.

So I can see why some ladies get impatient. But it's no reason to schedule major abdominal surgery for mere convenience, and ACOG should be ashamed of itself, bowing to the lawyers and their own conflicts of interest. Apparently, "do no harm" now applies more to the docs than to their patients.

For those who know Henci Goer and those who don't, here's a link to a variety of articles written by her on VBAC and other childbirth subjects. She is a medical researcher and childbirth advocate with some impressive books to her credit. They are noteworthy for their medical thoroughness, intelligence and passion.

http://hencigoer.com/articles/

You guys made my night.

Alison

Alison, best wishes for a wonderful birth experience and a happy, healthy baby.
I have a sil who "schedules " her inductions and goes into the hospital with a birth plan that starts " I will have an epidural as soon as humanly possible" " I will not use a rocking chair, ball, tub or other alternative labor tool" I MAY decide to walk in the hall if i so choose, if not i will lay in bed and let things happen as they may"
surprisingly enough, she has had 2 uneventful, faily quick labors and looks fantastic after ward!(she's only 4'11 and has 71/2 lb babies, so she's doing something right! )baby # 3 is scheduled to arrive next week..cant wait! after my one preemie with easy. quick labor and a post term horrible induction, i dont blame her for having a plan!

[BETSRN]

Originally Posted by sgent

Nationally the c/s rate is about 50%. ACOG (assoc. of OB's) put out a statement last year which essentially said that c/s on demand was acceptable medical practice.

When and if a patient demands an elective primary c/section, a physician would be a fool NOT to go along with this (in our litigious society). Hopefully, most physicians would try and talk their patient out of this, but to flatly refuse would be folly.

A physician could get around this by suggesting the patient to go to another physician who will do this (that is not abandonment). Hopefully, the physician would review the risks of any type of surgery.

We have only ever had two patients (that I can think of) in that category. We are low risk, midwife friendly, and have great low intervention doctors. It would not be our philosophy to have many patients who would demand that. They would likely go elsewhere.

[BETSRN]

Originally Posted by SmilingBluEyes

Well, to me, for strictly "maternal discomfort" no, it is NOT legitimate........

for other reasons related to it, maybe. I think all women are quite uncomfortable in that last 4-6 weeks of pregnancy----some discomforts are severe and need relief (badly pinched sciatic nerves come to mind right off the top)----and your example of arthritis may well be, too. The case of a breech baby puts her in the category of "medical necessity" anyhow!

That is not what I was talking about when I brought up unnecessary inductions; there are legitimate medical concerns that need to be considered, obviously......

However----- Being "tired of being pregnant" or citing "maternal discomfort" for the convenience of the obstetrician or the patient, are to me, NOT legitmate reasons to play around with Mother Nature by inducing labor.

I know about discomfort; I contracted from 31 weeks' on w/my daughter. I am only 5 feet 2 and had a baby who was 9lb. at 38 weeks (she was breech and kicking my bladder). I waited as long as I could before having my csection, for her benefit and safety. It certainly was NOT comfortable having her feet in my pelvis and bladder and her head in my ribs for 9 weeks, all while contracting every day, often frequently enough to send me to the hospital.

I know from the OB's standpoint, there are patients who literally "park it" at their offices, whining and begging "to get it over with" or come to the hospital time after time after time, for little to nothing going on, and leave angry we are not inducing them cause "it's time"....no medical considerations or complaints, they just are "ready" for it to be done

Heck----some as soon as 30 weeks have asked why can't they get it over with, they know "so and so's cousin's kid" who did GREAT in the NICU at 30 weeks....and on it goes.......I have had others want it over cause they have an out of town wedding or some other event they want to make. Yep it gets that silly!

From MY standpoint: Labor induction is NOT without some risks of its own----and serious liabilities for all personnel involved. I don't take labor-inducing agents such as pitocin or cytotec and their potential side effects lightly, EVER. Nor should our patients. Truly informed consent is one of my great concerns regarding labor induction and its indications. I think matters of convenience are being considered and weighted much more than they should be, these days. If a person wants convenience, she should not have kids or----from a medical standpoint, maybe should consider why he/she is practicing OB medicine !

At my place, if they "park it and whine" they still get sent home. We just sent a G3P2 home because her induction didn't start anything. She'll be back all in good time.

[BETSRN]

Originally Posted by FrumDoula

The decision of so many hospitals to disallow VBAC is unsupported by medical evidence and bespeaks a truth about smaller and rural hospitals in general; that is, if it isn't "safe enough" to VBAC there, is it going to be safe enough to birth there at all, given that obstetric emergencies can happen to primips and multips with no history of cesarean?

I thought it was 30 minutes from "decision to incision" by ACOG standards, though I could be wrong. Anyone? SBE?

When I logged onto this board tonight, I saw the thread and inwardly groaned a little. As the local PITA representative for natural birth I thought I would hear a bunch of lame defenses for elective cesarean from some of the nurses, including my personal pet peeve, elective cesarean as a feminist and reproductive rights issue. The argument that it's a "woman's right to choose" her c/s is remarkable only in its uncritical viewing of what the body politic has become. And I say that as a former women studies minor.

Imagine my suprise when I read so many fiery defenses of VBAC - no suprise at all that SmilingBlueEyes led the charge. I was just tickled to read all the responses and wish each and every one of those OB nurses could help make policy decisions about VBAC. It warmed the cockles of my heart, ladies.

And heaven knows I need it tonight. At 39 wks + 5 days pregnant, I am feeling a tad cranky anyhow. I mean, even the gas station lady said when I walked in for some ice, "You're still pregnant?!". And a complete stranger asked me my due date in Target tonight. (My husband joked he was suprised that she didn't ask if I had any cervical dilation yet!) Although I am obviously not going to schedule an induction anytime too soon, and certainly not an elective cesarean, my time as Gestating Goddess is coming to a close, and I'm ready to begin my new role as Lactating 24-Hour Buffet.

So I can see why some ladies get impatient. But it's no reason to schedule major abdominal surgery for mere convenience, and ACOG should be ashamed of itself, bowing to the lawyers and their own conflicts of interest. Apparently, "do no harm" now applies more to the docs than to their patients.

For those who know Henci Goer and those who don't, here's a link to a variety of articles written by her on VBAC and other childbirth subjects. She is a medical researcher and childbirth advocate with some impressive books to her credit. They are noteworthy for their medical thoroughness, intelligence and passion.

http://hencigoer.com/articles/

You guys made my night.

Alison

If it makes you any less cranky, we still do VBAC's: usually quite successfully!

[amber1142]

Originally Posted by BETSRN

When and if a patient demands an elective primary c/section, a physician would be a fool NOT to go along with this (in our litigious society). Hopefully, most physicians would try and talk their patient out of this, but to flatly refuse would be folly.

A physician could get around this by suggesting the patient to go to another physician who will do this (that is not abandonment). Hopefully, the physician would review the risks of any type of surgery.

We have only ever had two patients (that I can think of) in that category. We are low risk, midwife friendly, and have great low intervention doctors. It would not be our philosophy to have many patients who would demand that. They would likely go elsewhere.

Just to play devil's advocate, why should a doctor refuse a surgery that the patient requests? Elective surgery is very common- we take out tonsils, we do breast augmentation, we do myringotomies, we replace joints, etc. All surgery carries a risk. Is a doctor the only one allowed to weigh risk/benefits? or should patients be allowed to do that too?

As pro-natural childbirth as I am, I cannot think of a good reason, other than my personal belief about the amazing potential in a good birth experience, why a well-informed woman shouldn't have a cesarean section if she wants one. I do think an argument could be made that insurance companies shouldn't have to pay for elective cesareans, but that's very tricky because we, in general, don't like our insurance companies limiting our choices.

BTW, BETSRN, this isn't directed only at you. It's a general question.