No more VBACs

[33-weeker]

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 tired of having to stay in house for them and the obs are, too. they were constantly grumbling among themselves... but she's your patient, you told her you'd do the vbac, not me... yada, yada, yada...

if doc's did more to prevent the primary c-section, this wouldn't be so bad - but with all the social inductions and sections for ftp (aka. failure to be patient) and cpd (aka. couldn't produce a real diagnosis), the future for lady partsl birth around here looks grim.

where are the feminists when you need them. :chair:

[magz53]

I have mixed feelings about VBACs, knowing so many of the primary sections were done for no medical reason. I also am uncomfortable with our small hospital doing them.........the midwives need the OB on premises, but what good is that when the surgical team is 30 minutes out ??? Recently a VBAC kept rubbing her lower abdomen and that was her main complaint. I was somewhat nervous. The birth turned out well. However, the only uterine rupture I have encountered was discovered postpartum in the hour after delivery........the patient's heartrate kept going up, BP going down, pale, clammy etc. Her lochia was well within normal limits.......she was taken to the OR for repair.....a portion of her uterine scar had separated and was oozing. So the poor honey had a mediolateral epis ( big babe and doctor panicked ) and ended up with abdominal surgery again. I think the answer lies in decreasing the primary section rate but that will never happen. Too many docs ( and midwives where I work ) want 9-5 obstetrics. Can't interfere with those office hours....UGH.........don't get me started !!!!!!!!!!!!!!!!!!!!!!!!!!

[crissrn27, RN]

I have mixed feelings about VBACs, knowing so many of the primary sections were done for no medical reason. I also am uncomfortable with our small hospital doing them.........the midwives need the OB on premises, but what good is that when the surgical team is 30 minutes out ??? Recently a VBAC kept rubbing her lower abdomen and that was her main complaint. I was somewhat nervous. The birth turned out well. However, the only uterine rupture I have encountered was discovered postpartum in the hour after delivery........the patient's heartrate kept going up, BP going down, pale, clammy etc. Her lochia was well within normal limits.......she was taken to the OR for repair.....a portion of her uterine scar had separated and was oozing. So the poor honey had a mediolateral epis ( big babe and doctor panicked ) and ended up with abdominal surgery again. I think the answer lies in decreasing the primary section rate but that will never happen. Too many docs ( and midwives where I work ) want 9-5 obstetrics. Can't interfere with those office hours....UGH.........don't get me started !!!!!!!!!!!!!!!!!!!!!!!!!!

I just thought about the only uterine rupture I have ever seen. It was in a primagravida! I do have a friend that ruptured during a VBAC........they were trying a cytotec induction......idiots

[rnmomtobe2010]

I don't like that decision. I had to have a repeat with my daughter. I wanted so bad to experience a lady partsl birth. Who came up with that idea?

[HappyNurse2005, RN]

We do allow vbac's.

had a doc the other day say that he thought vbac's shouldn't be allowed b/c of the risk of rupture and how if the uterus ruptures, baby must be out in 7 mins to save baby, so many poor outcomes with rupture, etc. i say, yeah, but the risk of vbac rupture is awful low, but then he says if you see 1 or 2 babies die you still start to think that any risk is too high.

i twas not in the mood to argue. just glad he's in a supervisory position and not one who gets to directly decide if they vbac or not

[Jniniffer]

I am not a nurse yet--But I have had lady partsl twins (at 32 weeks) and a c-section (42 weeks) with my most recent child. I was induced and my daughter was in distress so I had an emegency c-section. My doctor is willing to do a VBAC if I have another child and I live in a small town. I would definalty not go to your hospital either!

[NBMom1225]

I had a c-section with my first daughter for failure to progress and rising BP. Was told there was a 50/50 chance of the same thing w/ my second daughter, and she was going to be 1 1/2 lb bigger. Thank God I didn't try VBAC, she was 9lb 12z, sunny-side up w/ a loose knot in the cord...not to mention a 6in malignant tumor in her abdomen that we didn't know about! That definitely would have ruptured during a vag birth, it ruptured anyway four days later at Children's. (She's now been in remission for EXACTLY 6 years today!)

My friend had a c-section due to breech with her 1st child, successful VBAC with her 2nd, and VBAC with her 3rd that resulted in uterine rupture as the baby was delivered. It took three hours of emergency surgery to save her life...

[mitchsmom]

Small community hospital, we don't do VBACS. Consequently, since I'm a relatively new nurse, I have never participated in one!

We did have a hospital employee that talked the MD's into letting her TOLAC but she never went into labor and baby was big so she ended up just getting the section after all.

We don't have 24 hour coverage for OB's, anesthesia, or other OR crew so VBAC is not going to happen. They did do them up until shortly before I was hired, though. They did have a uterine rupture (not sure of the outcome) that I believe prompted the change.

For whatever I have to do with births, I really try hard to help avoid primary sections. If MD is trying to hint that someome isn't making enough change and I think everything is ok, I'll point it out ("yeah but she was only 1 when she came in, so she's getting there" etc etc). And anyone that is comfortable enough to do it, labors waaayyyy down... especially those epidural girls with no pressure or urge to push. I think starting the "pushing clock" too soon leads to many unecessary c/s.

When it's appropriate, I also advocate for latent/early labor check mamas to go back home or go walk and come back, instead of getting admitted too early (on our unit that = continuous monitoring, AROM, ice chips only, pitocin, c/s for 'failure to progress', etc.... cascade of interventions that leads down the hall).

On our unit, I think the nurses do have some influence over section rate. Obviously, not for breech's, fetal distress, etc... but I mean regarding the type of situations I described above. We have a few nurses that are like "I don't know why he (MD) doesn't just cut her and get it over with" kind of attitude. (Not that I haven't ever said that when I can see that a vag delivery just isn't going to happen, but you know what I mean). Or "The MD's (in the place where I come from) don't do all this, they just cut them and be done with it" (ummmm, that is why the place where you come from has a astronomical c/s rate!).

Of course it is ultimately up to the MD's but I would love to see the c/s rate broken down by individual nurses on our unit. Sorry for straying from the VBAC thing :)

[rn/writer, RN]

For a VBAC to be a reasonable risk you have to have a mom and babe(s) who are good candidates AND a hospital that is ready to do an emergent section if need be.

The PCS rate at the hospital where I work (large urban teaching hospital with level 3 NICU) is 12-14%. The total C/S rate is about 22%. VBACS are encouraged when the conditions are right. OB senior residents can be there in a flash when needed, but our L&D nurses are very good with helping their patients to avoid unnecessary surgery. And yet, they're also Johnny-on-the-spot calling for help when everything goes to pieces.

Something must be going right according to the numbers. I've had postpartum patients with vag twins, breech birth (once in a while), multiple VBACs, VBAC after several C/S, you name it. We have some excellent attendings and I do believe the overall push among the physicians is to reduce the PCS rate as much as possible without verging into negative outcomes. Being a teaching hospital also helps tremendously.

I had three of my six kids at my hospital many years ago (long before I became a nurse). If I had it to do over, I would go there again.

[rbytsdy]

There's a hospital in Southern NJ where 2 women (who knew each other and taught at the same elementary school) died within 15 days of each other after having a c-section delivery. One bled out and I don't know what the other reason was. That pretty much scared me away from elective repeat c-section.

[Belinda-wales, RN]

The whole point is chioce - I tried and failed VBAC with a ruputred uterus and bladder-baby in SCBU for two weeks and a long stay in hospital for me- but that try it is what I wanted when things went wrong the doctor took over and did what needed to be done- we are both well and I was lucky enough to have another child no VBAC that time- As a midwife when my friend wanted a VBAC was despirate to try even though she new what had happened to me I supported her- we were both delighted when I helped her to birth her son naturally.

As for USA on my unit it depends on the doctor- son are calm and patient some doctors dont like to wait so it depends on who the family chooses!

[Kiwimid]

we have something called the pink kit in New Zealand and it helps vbac patients learn about muscles and postions and stuff to help have a vb. our rate is still high, and vbacs get knocked by docs alot. like the ob doc i met who told me she had seen to many dead babies from vbacs, and told me about her friends who tried a vbac after 2 c sections at home in a pool. well, her comments were less that positive......

[DutchgirlRN, ASN, RN]

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.