No more VBACs - page 2

our ob unit has just stopped doing vbacs. now all previous c-sections will be repeats and those showing up in labor (unless precipping in the bed) will be stat sections. apparently anesthesia is... Read More

  1. by   SmilingBluEyes
    Well I am sorry but we cannot just ignore risks, either.....10 pounders CAN end up in terrible dystocias and with CP (or worse) resulting. Uteri do rupture in rare cases and babies can die. In a country where EVERYONE expects a "perfect" outcome, risks (even minute ones) are becoming simply unacceptable. This in turn, leads to hospitals, insurance carriers and risk managers disallowing TOLAC these days.
    Last edit by SmilingBluEyes on Apr 2, '07
  2. by   Spidey's mom
    Quote from SmilingBluEyes
    Well I am sorry but we cannot just, ignore risks, either.....10 pounders CAN end up in terrible dystocias and with CP later on. In a country where EVERYONE expects a "perfect" outcome, risks (even minute ones) are becoming simply unacceptable. This in turn, leads to hospitals, insurance carriers and risk managers disallowing TOLAC these days.
    We've had some recent dystocias from heck . .. . fortunately the outcomes were good but I HATE those deliveries.

    The risk of being sued is large - you can't blame docs completely. I'd certainly look at that risk realistically if I were a physician.

    My niece had a difficult delivery 8 years ago - shoulder dystocia and broken clavicle. She also had a fractured pelvis and had to crawl for awhile at home - very painful for her. She recently had a 2nd child (photo in the gallery) and her ob highly recommended a cesarean. She and I talked at length about her feelings of being a failure if she had surgery rather than tough it out and have a vag delivery. It was hard to convince her that it was OK to choose a cesarean. The point is the delivery of a healthy baby.

    She finally did choose surgery and it went well. Her recovery was a snap compared to the fractured pelvis.

    Interesting, her best friend had a baby here a few weeks ago - she didn't progress over 6 cm for 24 hours and was exhausted but didn't want an epidural because she felt like it was her fault that she wasn't dilating and having a epidural would mean she failed. Those tears were heartbreaking to me. I wonder where these two women got the idea that they were failures if they didn't have a "natural" birth.

    She did have the epidural. She slept. She dilated. She had a great delivery and a healthy boy. She thanked us for the advice about the epidural.

    All of this is off-topic of course . . . . . again as a nurse in a small rural hospital that is far from an NICU, I have no problem with not doing VBAC's.

    steph
  3. by   ElvishDNP
    We do VBACs and I am glad. I wish we did fewer primary c/s though. Most of it boils down to our docs being real quick to cut on a primip that's laboring slowly. Everybody gets a TOLAC if they want it.

    Maybe a little OT but I wish they would teach how to deliver breech again in med school. I know they don't at med schools around where I am, anyway.
  4. by   eden
    There are riskes to sections as well, that's why VBACS are a good option. Yes there is risk of rupture but with properly managed care, that risk is very low. There are also risks in getting an epidural, getting a wound infection/abcess ect.

    I think they are too many primary sections to start with. Yes some are necessary but many are avoidable. Why automatically section twins. If baby a is vertex, then our ob will let twin b deliver breech. Better if both are vertex but just having twins doesn't automatically have section written all over it.
  5. by   SmilingBluEyes
    Yes, there are risks to surgery. But you have to convince people that risks inherent in undergoing VBAC are worth it. And increasing numbers say "no" . This is the way it is.

    I would love to see states more open and welcoming to allowing/supporting a variety of venues for birth, be they midwife-run birth centers or the home environment for low-risk moms. I think a lot of folks would do well to stay away from the hospital in many cases.
  6. by   RN2Bn2006
    Hey - I sent you a private message



    Quote from obrnheather
    #1. PCS - Failure to Progress and fetal distress - stat - 8-15 oz, apgars 9/9.
    #2. RCS - failed VBAC, again FTP 8-10oz - discovered an appendiceal carcinoid tumor during the section.
    #3. Successful VBAC - SROM greater than 24 hrs, pit augment 14 hours, 7-11oz.
    #4. Successful VBAC - pit augment 10 hours, 6-13oz.

    #1 I agree with, #2 I question - had a midwife who had to leave for a meeting and 30 minutes later the attending had me in the OR - imagine that. BUT, if it wasn't for the section, they never would have found the tumor.
    #3 & #4 were both CNM deliveries. I see a theme.

    We do VBACs quite frequently and with very good success. Of course, we know the post-dates, gestational diabetics that had PCS for 12 lb baby - we know they will probably be RCS - but they too even surprise us.
  7. by   rbytsdy
    Quote from SmilingBluEyes
    Yes, there are risks to surgery. But you have to convince people that risks inherent in undergoing VBAC are worth it. And increasing numbers say "no" . This is the way it is.

    It's not that cut and dry. A woman needs to be presented ALL the facts and decide for herself what her prefered delivery option is. A c-section carry many risks including: maternal death, emergency hysterectomy, blood clots, infection, damage to neighboring organs such as the bladder. Babies born by c-s are more likely to suffer from respiratory problems, receive cuts during surgery, and there is evidence of increased risk of asthma and allergies.

    A vbac carries an increased risk of uterine rupture. After 1 c-s, the risk is about 0.7% (according the July 2006 Landon study) which includes women whose labors were induced for augmented. Never having a c-s or uterine surgery does not make your risk of UR non-existant. Women who have never had a c-s CAN rupture. Furthermore, if you really look through the data, many studies include women who had dihisences as a rupture. Dihisences are only discovered during repeat c-s so it's unknown how many women vbac with dihisences. Also - not all UR are catastrophic meaning not all UR result in the death or serious injury to the baby or mother.

    Implying that vbacs are inherently more dangerous than repeat surgery is not fair when you look at the whole picture.
  8. by   ElvishDNP
    I think SBE was looking at it from the other side, not because she necessarily feels that it's wrong to VBAC. I think she was just saying that in order to see the VBAC rate rise, you have to convince people that it's not more dangerous than a repeat c/s. Which is really hard to do, as most people have their minds made up already. Please correct me if I'm wrong, SBE.
  9. by   SmilingBluEyes
    Thank you Arwen EXACTLY what I mean.
  10. by   33-weeker
    Quote from eden
    There are riskes to sections as well, that's why VBACS are a good option. Yes there is risk of rupture but with properly managed care, that risk is very low. There are also risks in getting an epidural, getting a wound infection/abcess ect.

    I think they are too many primary sections to start with. Yes some are necessary but many are avoidable. Why automatically section twins. If baby a is vertex, then our ob will let twin b deliver breech. Better if both are vertex but just having twins doesn't automatically have section written all over it.
    Amen to that. There ARE too many primary sections to start with.

    I had my twins vag (vertex x2) with 9:10 & 10:10 apgars, respectively. 6# 2oz. & 7#s. My 9# daughter paved the way for them.
  11. by   33-weeker
    Quote from rbytsdy
    It's not that cut and dry. A woman needs to be presented ALL the facts and decide for herself what her prefered delivery option is. A c-section carry many risks including: maternal death, emergency hysterectomy, blood clots, infection, damage to neighboring organs such as the bladder. Babies born by c-s are more likely to suffer from respiratory problems, receive cuts during surgery, and there is evidence of increased risk of asthma and allergies.

    A vbac carries an increased risk of uterine rupture. After 1 c-s, the risk is about 0.7% (according the July 2006 Landon study) which includes women whose labors were induced for augmented. Never having a c-s or uterine surgery does not make your risk of UR non-existant. Women who have never had a c-s CAN rupture. Furthermore, if you really look through the data, many studies include women who had dihisences as a rupture. Dihisences are only discovered during repeat c-s so it's unknown how many women vbac with dihisences. Also - not all UR are catastrophic meaning not all UR result in the death or serious injury to the baby or mother.

    Implying that vbacs are inherently more dangerous than repeat surgery is not fair when you look at the whole picture.
    :yeahthat:
  12. by   2curlygirls
    We do VBAC's w/o batting an eyelash. But, we can also do a crash section in about 10 minutes flat should it become necessary. (The last one I was involved with was about 7 minutes)
    It's usually (IME) moms who wants rcs. If that's what I was familiar with, I might pick it too.
  13. by   SmilingBluEyes
    Anyone who has really read my posts knows how I feel about VBAC (supportive, in case it was missed).

    But we cannot ignore the risks any hospital and physician or midwife (and yes, L/D nurse)--- takes in attending any birth, VBAC included. The reason VBAC is seen as so "hairy" is due to the potential catastrophic possiblity that is raised when you attempt VBAC. On paper, it looks like a nightmare to those taking the risks. In no place did I ever say surgery was risk-free or completely desireable or safe. But the risks are more "manageable" if you will, in repeat scheduled c/s than TOLAC, at least in the statistical minds of insurers, who let's face it, pretty well RUN the hospitals and govern our practices. Don't shoot the messengers here; hate the message.

    I doubt too many here would forgo their right to sue if their outcome was unfavorable or tragic, even if the providers involved did nothing wrong to bring about such an outcome---sometimes bad things happen despite our efforts, as we know. Not all bad outcomes are a direct result of unwarranted intervention.

    Enough from me.
    Last edit by SmilingBluEyes on Apr 3, '07

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