Calling women who plan home VBACs “stupid” misses the point

Calling women who plan home VBACs “stupid” misses the point

I’m in an online group for labor & delivery nurses where the discussion of vaginal birth after cesarean (VBAC) at home came up. While some understood the massive VBAC barriers many women face, others simply said, “Find a hospital that supports VBAC.”

I left a late-night comment stating that “finding another hospital that supports VBAC” is just not a reality in many areas of the country. It’s literally not possible. Not even in the highly populated state of California. (Barger, 2013)

I also suggested rather than calling women stupid or debating the validity of the decision to have a home VBAC , we should consider why women make this decision.

First, it is not one they take lightly.  Every parent wants a safe, healthy birth for themselves and their baby. It takes more research, work, and energy to plan a home VBAC—and it usually means thousands of out-of-pocket dollars up front. It is most certainly not the easy way out.

Women choose out-of-hospital birth due to disrespectful and abusive care, including obstetric violence and forced/coerced cesareans, delivered by hospitals. Parents also choose out-of-hospital VBAC due to VBAC bans and restrictive VBAC policies (i.e., repeat CS scheduled at 39 weeks, labor can only last 12 hours, baby must weigh less than _____, no induction/ augmentation, etc.).

These are serious issues:

Disrespectful care.

Abusive care.

Obstetric violence.

Forced/coerced cesareans.

VBAC bans.

Restrictive VBAC policies.

And this isn’t a comprehensive list of why women choose home VBAC, but it’s the ones that many nurses, providers, and administrators have control over.

In my comment on the nurses’ group, I posted the link to my California Medical Board testimony addressing these barriers and the resulting importance of access to out-of-hospital VBAC.

We shouldn’t be asking why women are so stupid and reckless.  We should be asking:

“What can we do to make women feel safe coming to our hospital to give birth?”

And:

“How can we increase access to VBAC in all hospital settings?”

I also suggested that coming from a place of judgment on this option may very well color the tone of their communication. Even if they’re not using the words “stupid” or “reckless,” parents will pick up on what’s not being said. That’s not good for the provider-patient relationship. People want to be heard, understood, and respected. All of us.

It’s important to hear parents when they talk about their past hospital experiences, without being defensive.

Hear them and see it as an opportunity to make a change. Consider how you can make a difference in your practice and facility.

If this were any other business, we would probably say that this is a services and marketing problem.

If you have a restaurant, and you start to lose customers to a competitor, you figure out why your customers are leaving and appeal to that.

You don’t slam the other restaurant.

You don’t call your customers stupid because someone else is offering a product that they like better.

Even if you would never personally eat there, that other restaurant is offering something that people want. And they are leaving your restaurant to get it.

So, find out what that thing is and change it.

Yes, I said all that in this nurses’ group.  The next morning, I checked to see how my comments were taken, because I know from experience that not everyone wants to hear or acknowledge the realities I outlined.

I smiled to see that the conversation had remained respectful, even from some folks who disagreed with me.  There was no name calling. No personal attacks.  My comments even had a couple likes!

It is possible to disagree without being disagreeable. And I think it’s so important to consider that many women around the country do not have access to respectful care in a facility that supports VBAC.

What are some other reasons that women choose out-of-hospital birth? Leave your comment below.

Resources Cited

Askins, L., & Pascucci, C. (n.d.). Retrieved from Exposing the Silence Project: http://www.exposingthesilenceproject.com/

Barger, M. K., Dunn, T. J., Bearman, S., DeLain, M., & Gates, E. (2013). A survey of access to trial of labor in California hospitals in 2012. BMC Pregnancy Childbirth. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3636061/pdf/1471-2393-13-83.pdf

Kamel, J. (2014, Dec 17). What I told the California Medical Board about home VBAC. Retrieved from VBAC Facts: http://www.vbacfacts.com/2014/12/17/what-i-told-medical-board-home-vbac-part-1/

Kamel, J. (2016, Jan 6). “No one can force you to have a cesarean” is false. Retrieved from VBAC Facts: http://www.vbacfacts.com/2016/01/06/no-force-cesarean-false/

Pascucci, C. (2014, Feb 17). Home Birth vs. Hospital Birth: YOU’RE MISSING THE POINT, PEOPLE. Retrieved from Improving Birth: http://improvingbirth.org/2014/02/versus/

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.

I’m in an online group for labor & delivery nurses where the discussion of vaginal birth after cesarean (VBAC) at home came up. While some understood the massive VBAC barriers many women face, others simply said, “Find a hospital that supports VBAC.”

I left a late-night comment stating that “finding another hospital that supports VBAC” is just not a reality in many areas of the country. It’s literally not possible. Not even in the highly populated state of California. (Barger, 2013)

I also suggested rather than calling women stupid or debating the validity of the decision to have a home VBAC​, we should consider why women make this decision.

First, it is not one they take lightly.  Every parent wants a safe, healthy birth for themselves and their baby. It takes more research, work, and energy to plan a home VBAC—and it usually means thousands of out-of-pocket dollars up front. It is most certainly not the easy way out.

Women choose out-of-hospital birth due to disrespectful and abusive care, including obstetric violence and forced/coerced cesareans, delivered by hospitals. Parents also choose out-of-hospital VBAC due to VBAC bans and restrictive VBAC policies (i.e., repeat CS scheduled at 39 weeks, labor can only last 12 hours, baby must weigh less than _____, no induction/ augmentation, etc.).

These are serious issues:

Disrespectful care.

Abusive care.

Obstetric violence.

Forced/coerced cesareans.

VBAC bans.

Restrictive VBAC policies.

And this isn’t a comprehensive list of why women choose home VBAC, but it’s the ones that many nurses, providers, and administrators have control over.

In my comment on the nurses’ group, I posted the link to my California Medical Board testimony addressing these barriers and the resulting importance of access to out-of-hospital VBAC.​

We shouldn’t be asking why women are so stupid and reckless.  We should be asking:

“What can we do to make women feel safe coming to our hospital to give birth?”

And:

“How can we increase access to VBAC in all hospital settings?”

I also suggested that coming from a place of judgment on this option may very well color the tone of their communication. Even if they’re not using the words “stupid” or “reckless,” parents will pick up on what’s not being said. That’s not good for the provider-patient relationship. People want to be heard, understood, and respected. All of us.

It’s important to hear parents when they talk about their past hospital experiences, without being defensive.

Hear them and see it as an opportunity to make a change. Consider, how can you make a difference in your practice and facility?

If this were any other business, we would probably say that this is a services and marketing problem.

If you have a restaurant, and you start to lose customers to a competitor, you figure out why your customers are leaving and appeal to that.

You don’t slam the other restaurant.

You don’t call your customers stupid because someone else is offering a product that they like better.

Even if you would never personally eat there, that other restaurant is offering something that people want. And they are leaving your restaurant to get it.

So, find out what that thing is and change it.

Yes, I said all that in this nurses’ group.  The next morning, I checked to see how my comments were taken, because I know from experience that not everyone wants to hear or acknowledge the realities I outlined.

I smiled to see that the conversation had remained respectful, even from some folks who disagreed with me.  There was no name calling. No personal attacks.  My comments even had a couple likes!

It is possible to disagree without being disagreeable. And I think it’s so important to consider that many women around the country do not have access to respectful care in a facility that supports VBAC.

What are some other reasons that women choose out-of-hospital birth? Leave your comment below.

Learn more:

Askins, L., & Pascucci, C. (n.d.). Retrieved from Exposing the Silence Project: http://www.exposingthesilenceproject.com/

Barger, M. K., Dunn, T. J., Bearman, S., DeLain, M., & Gates, E. (2013). A survey of access to trial of labor in California hospitals in 2012. BMC Pregnancy Childbirth. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3636061/pdf/1471-2393-13-83.pdf

Kamel, J. (2014, Dec 17). What I told the California Medical Board about home VBAC. Retrieved from VBAC Facts: http://www.vbacfacts.com/2014/12/17/what-i-told-medical-board-home-vbac-part-1/

Kamel, J. (2016, Jan 6). “No one can force you to have a cesarean” is false. Retrieved from VBAC Facts: http://www.vbacfacts.com/2016/01/06/no-force-cesarean-false/

Pascucci, C. (2014, Feb 17). Home Birth vs. Hospital Birth: YOU’RE MISSING THE POINT, PEOPLE. Retrieved from Improving Birth: http://improvingbirth.org/2014/02/versus/

What do you think? Leave a comment.

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction. DOWNLOAD NOW

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.

“No one can force you to have a cesarean” is false

“No one can force you to have a cesarean” is false

Update: Since this article was originally published, it has been updated with several new resources (listed at the bottom) as well as a video.

“No one can force you to have a cesarean.” I see this all the time in message boards.

Don’t worry about

… the VBAC ban

…your unsupportive provider

… your provider’s 40 week deadline

… [insert other VBAC barrier here]no one can force you to have a cesarean.

That’s just not true.

Let’s start with what is ethical and legal: Yes, no one can legally force you to have a cesarean.

ACOG even says in their latest VBAC guidelines that “restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will.” So even if your facility has a VBAC ban, they still cannot force you to have surgery… legally or ethically.

But then you have reality: It happens all the time, but it may look different than you expect.

It’s often NOT a woman screaming “I do not consent” as she is wheeled into the OR, though that has happened.

It’s through lies. It’s through fear.

“The risk of uterine rupture is 25%.”

“Do you want a healthy baby or a birth experience?”

“Planning a VBAC is like running across a busy freeway.”

Hospital policy and provider preference are presented as superseding the woman’s right to decline surgery.

“No one attends VBAC here.”

“It’s against our policy.”

“We don’t allow VBACs.”

Or unreasonable timelines are assigned giving the woman the illusion of choice.

“You have to go into labor by 39 weeks.”

“Your labor can’t be longer than 12 hours.”

“You have to dilate at least 1 centimeter per hour.”

Or it can be a slow process where a seemingly once supportive provider quietly withdraws support exchanging words of encouragement with caution. Dr. Brad Bootstaylor, an Atlanta based OBGYN, describes how this can unfold at 4:00 in this video after a woman describes her experience:

Or, if the birthing parents don’t listen, it can escalate to calling social services, ordering a psychiatric evaluation, or even getting a court order for a forced cesarean.

It can be as simple as, “Your baby is in distress.” How do you know if this is true or not? Are you willing to take that risk?

Some people suggest that parents should learn how to interpret fetal heart tones so they can evaluate their baby’s status. But I think this is a wholly unreasonable expectation for non-medical professionals, especially when one is in labor. It is as much an art as it is a science.

In short, coercion frequently isn’t by physical force. It’s through manipulation. This is why it’s worth your time and effort to search for a supportive provider who you trust to attend your birth.

Don’t just think, “Well, I can hire anyone and simply refuse.”

Sometimes it’s not that simple as Rinat Dray, was forced to have a cesarean, and Kimberly Turbin, who received a 12-cut episiotomy while yelling “Do not cut me,” know all too well.

And this is why understanding the complete picture is important. It’s not enough to ponder how things are “supposed to be” or how we want them to be, but how they actually are. The difference between perception and reality is huge. Learn more in my online workshop, “The Truth About VBAC.”

Resources Cited

ACLU. (n.d.). Coercive and punitive governmental responses womens conduct during pregnancy. Retrieved from ACLU: https://www.aclu.org/coercive-and-punitive-governmental-responses-womens-conduct-during-pregnancy

Cantor, J. D. (2012, Jun 14). Court-Ordered Care — A Complication of Pregnancy to Avoid. New England Journal of Medicine, 366, 2237-2240. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMp1203742?

Hartocollis, A. (2014, May 16). Mother accuses doctors of forcing a c-section and files suit. Retrieved from The New York Times: http://nytimes.com/2014/05/17/nyregion/mother-accuses-doctors-of-forcing-a-c-section-and-files-suit.html?referrer=&_r=0

Human Rights in Childbirth. (2015, Jan 14). Rinat Dray is not alone, Part 1. Retrieved from Human Rights in Childbirth: http://www.humanrightsinchildbirth.org/amicusbriefpart1/

International Cesarean Awareness Network. (n.d.). Your right to refuse: What to do if your hospital has “banned” VBAC. Retrieved from Feminist Women’s Health Center: http://www.fwhc.org/health/pdf_about_vbac.pdf

Jacobson, J. (2014, Jul 25). Florida hospital demands woman undergo forced c-section. Retrieved from RH Reality Check: http://rhrealitycheck.org/article/2014/07/25/florida-hospital-demands-woman-undergo-forced-c-section/

Kamel, J. (2012, Mar 2). Options for a mom who will be ‘forced’ to have a cesarean. Retrieved from VBAC Facts: http://www.vbacfacts.com/2012/03/02/options-mom-forced-repeat-cs/

Maryland Families for Safe Birth. (2015, Jan 28). The truth about VBAC: Maryland families need access. Retrieved from YouTube: https://youtu.be/C5nymk3IGqE

Paltrow, L. M., & Flavin, J. (2013, April). Arrests of and forced interventions on pregnant women in the United States, 1973-2005: Implications for women’s legal status and public health. Journal of Health Politics, Policy and Law, 38(2), 299-343. Retrieved from http://jhppl.dukejournals.org/content/early/2013/01/15/03616878-1966324.full.pdf+html

Pascucci, C. (2015, Jun 4). Press Release: Woman charges OB with assault & battery for forced episiotomy. Retrieved from Improving Birth: http://improvingbirth.org/2015/06/preview-woman-charges-ob-with-assault-battery-for-forced-episiotomy/

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.

What I told the California Medical Board about home VBAC

What I told the California Medical Board about home VBAC

A little backstory

Back in October, I attended my first Interested Parties Meeting held by the Medical Board of California regarding new midwifery regulations as required by AB1308. (Read more about AB1308 here.)

Up for discussion was which conditions or histories among women seeking a home birth with a Licensed Midwife (LM) should be required to obtain physician approval.

A prior cesarean was on the list of over 60 conditions or histories and home VBAC was the one subject that generated the most comment and discussion that day.

What does AB1308 mean in terms of home VBAC in California?

There has been a lot of confusion regarding what AB1308 means in terms of home VBAC in California. In an effort to clear things up, Constance Rock-Stillman, LM, CPM, President, California Association of Midwives said this on January 23, 2014:

AB 1308 went into effect on 1/1/14, but there is nothing in the new legislation that says LMs cannot do VBACs.

LMs can do VBACs.

We just need to define in our regulations what preexisting conditions will require physician consultation. [Which is what the October 15 and December 15th Interested Party meetings were about.]

Until the new regulations are written LMs should continue to follow their current regulations which only require LMs to provide certain disclosures and informed consent to clients.

Please let the community know that if they want to have a say in whether or not VBACs with California LMs require a physician consultation, they should come to the Interested Parties meeting that the medical board will be holding and tell the board how they feel about it.

The medical board is a consumer protection agency, so they need to hear what consumers want to be protected from.

We will let you know as soon as the meeting is scheduled.

[Ms. Rock-Stillman responds when questioned by those who have not been involved it the creation of this legislation yet insist this legislation removes the option of home VBAC entirely:]I’m in my third year as president of the California Association of Midwives, and I’m a practicing Licensed Midwife.

I have been at every Midwifery Advisory Counsel meeting and at the Capitol 30 times last year.

I’ve spoken in legislative committee hearings.

I’ve sat in weekly meetings with CAM’s legal counsel who worked side-by-side with us on the legislation.

I’ve been in Assemblywoman Susan Bonilla’s boardroom with ACOG and at every one of the public events where Susan Bonilla promised that the LMs would still be able to do VBACs.

So I think I qualify as a knowledgeable stakeholder in this issue.

Yes, we intentionally left VBAC out of the list of prohibited conditions, so at this point there is no question as to whether or not we can do VBACs. The only part that’s in question is whether or not all VBACs will require physician consultation.

Regulations that clarify under what circumstances physician consultation will be required will be written by the California Medical Board.  This is a process that takes time. Maybe even a year or more.

The regulations that will be adopted will be based on evidence and input from all the stakeholders.

This is why I think it’s so important that midwives and consumers be at the meetings to insure their voices get heard.

At the last Interested Parties meeting that the medical board held, I asked what we were suppose to do until the new regulations are written and we were told that we should follow our current regulations and our community standards until new regulations are adopted.

Why I attended

My intention in attending the October 15, 2014 meeting was to amplify the voice of the consumer.  I think sometimes it’s difficult for OBs who attend VBACs, or for those who live in communities where they have access to hospitals that attend VBAC, to understand that not everyone lives in that world.

Some live in a world where if they want a VBAC in a hospital with a supportive midwife or doctor who takes their insurance, that means driving over 50 miles each way for prenatal care and delivery while they literally drive by other facilities that offer labor and delivery, but ban VBAC.

Or it means acquiescing to a unnecessary repeat cesarean whose risks compound with every surgery. Or it means planning an unassisted birth which comes with its own set of risks. This is a tremendous burden.

As VBAC and repeat cesarean both carry risks and benefits, and women are the ones who bear and endure those risks, they should be the ones who choose which mode of delivery is acceptable to them.

I celebrate when women have access to supportive hospital-based practitioners.  But the reality is, many women do not enjoy that privilege and yet they still wish to avoid the serious complications that come with each cesarean surgery.

Who else was at the meeting?

Other people in the room included the Senior Staff Counsel of the Medical Board, an OB-GYN representing ACOG, an ACOG lobbyist, Constance Rock-Stillman along with many other CAM representatives and midwives, California Families for Access to Midwives, a few other consumers, and me.

Senior Staff Counsel was tasked with writing these regulations and as the meeting progressed, items were reworded or removed from the list.

My statement

Only having five minutes to speak means that as soon as you take your seat, adjust the microphone, and look into the eyes of Medical Board, you have to establish yourself as a credible source.

And then you start to speak. You have to be clear and concise with an unwavering voice. The Medical Board is your captive audience and you need to use every second weaving the facts with the personal experiences of mothers, midwives, and doctors so you can convey the whole story.

Often Medical Boards are not well versed on Licensed Midwives, home birth, and the politics of VBAC, so there is a lot of education that has to quickly happen in a few short minutes. You must maximize your time and, while talking at a normal pace, swiftly move from fact to fact continually highlighting yet another piece of evidence that supports your case.

Those that sit on Medical Boards often have access to whatever medical care they need. So sharing the challenges real families throughout the state face when trying to obtain a VBAC is crucial.

With all those factors in mind, I focused on the importance of VBAC access, the politics of hospital VBAC, and the public health implications if families can’t access VBAC.

Throughout my entire presentation, I emphasized how increasing VBAC access was aligned with the mission of the Medical Board: to protect consumers.

It was quite challenging to adequately convey these key points in such a brief format. But as I looked into the eyes of each board member during my presentation, I felt heard. I knew they were receiving the message I intended and that all the hard work that went into preparing for that day made a difference.

Legislative consulting is yet another way that I serve the mission of VBAC Facts. To schedule a legislative consulting call, please click here.

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.

Thoughts on VBAC after three or more prior cesareans

Thoughts on VBAC after three or more prior cesareans

Note regarding “TOLAC.”  When reading from medical texts, remember that you are no longer in the land of emotion and warm fuzzies.  Rather, envision that you have been transported to another world, a clinical world, where terms like TOLAC/TOLAMC, or trial of labor after (multiple) cesareans, are used.  I don’t think that most care providers understand the emotional sting that many women seeking VBAC associate with the term TOLAC.  It’s important for women to understand the language care providers use so that they can translate TOLAC into “planning a VBAC” and not feel slighted.  You might want to read this article which describes what the term TOLAC means, how it’s used in medical research, and why it’s not synonymous with VBAC.

________________________________

A mom recently asked, “Does anyone have some facts on VBA3C?”

I provided this collection of info…

Who makes a good VBAC/VBAMC candidate?

ACOG’s 2010 VBAC recommendations affirm that VBA2C (vaginal birth after two cesareans) is reasonable in “some” women.  But they remain silent on VBAMC (VBAC after multiple cesareans.)

Some have interpreted that silence to mean that ACOG does not recommend VBAMC, yet ACOG is clear that women shouldn’t be forced to have cesareans.

Between what they say about VBA2C and who is a good VBAC candidate, we might be able to discern who might be a good VBAMC candidate.

A couple things to keep in mind while reading…

Reason for prior cesarean/history of vaginal birth.  Research has shown that women who have had cesareans for malpresentation (breech, transverse lie, etc) and/or a history of a prior vaginal delivery would have the highest VBAMC success rates.

Scar type.  Low transverse incisions (also called bikini cuts) carry the lowest risk of rupture in comparison to classical, high vertical and T/J incisions.  With the likely increased risk of uterine rupture in a VBAMC, having low transverse scars is a way to minimize that risk as much as possible.

What does ACOG say about VBAC?

In ACOG’s 2010 VBAC guidelines, it describes the qualities of a good VBAC candidate:

The preponderance of evidence suggests that most women with one previous cesarean delivery with a low transverse incision are candidates for and should be counseled about VBAC and offered TOLAC.  Conversely, those at high risk for complications (eg, those with previous classical or T-incision, prior uterine rupture, or extensive transfundal uterine surgery) and those in whom vaginal delivery is otherwise contraindicated are not generally candidates for planned TOLAC.  Individual circumstances must be considered in all cases, and if, for example, a patient who may not otherwise be a candidate for TOLAC presents in advanced labor, the patient and her health care providers may judge it best to proceed with TOLAC.

What does ACOG say about VBA2C?

In those same guidelines, ACOG specifically addresses VBA2C:

Given the overall data, it is reasonable to consider women with two previous low transverse cesarean deliveries to be candidates for TOLAC, and to counsel them based on the combination of other factors that affect their probability of achieving a successful VBAC.  Data regarding the risk for women undergoing TOLAC with more than two previous cesarean deliveries are limited (69).

The power of context and training

How a provider approaches VBAMC depends a lot on their training as well as the support of their hospital administration. In the video below, Dr. Craig Klose discusses the merits of vaginal birth after cesarean and the various factors that may impede women obtaining VBAC.

One thing that stood out to me was Dr. Klose’s comments on VBAC after multiple prior low transverse cesareans (TLC). To sum, he says that he was taught that multiple LTCs were “no biggie” and he has attended up to VBA5C. This is the power of training and context!

ACOG guidelines, your legal rights, and “forced” cesareans

As attorney Lisa Pratt asserts, “ACOG guidelines are just that, guidelines, they are not law; while it is nice when they put out a guideline that supports your factual situation, falling outside of their recommendation does not mean you must consent to something you do not want.”  You can read in the article, “VBAC bans, exercising your rights, and when to contact an attorney.”

Further, ACOG’s 2010 VBAC guidelines also says that women cannot be forced to have cesareans even if there is a VBAC ban in place:

Respect for patient autonomy also argues that even if a center does not offer TOLAC, such a policy cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery.

You may also wish to review your options when encountering a VBAC ban and the story of a mom seeking VBA2C who was threatened with a “forced” cesarean when her OB group withdrew support at 38 weeks.

Making a plan and moving forward

Your best bet is to review your medical records with several VBAC supportive care providers and get their opinion.  Obtain a copy of your medical records and operative reports from each prior cesarean, get the names of VBAC supportive providers, and ask the right questions.

If you want to get up to speed quick on VBAC, repeat cesarean, hospital birth, home birth, and VBAC bans, the best way is via my online program, “The Truth About VBAC.”

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.

VBAC bans, exercising your rights, and when to contact an attorney

VBAC bans, exercising your rights, and when to contact an attorney

A mom recently left this comment and I thought many other women likely have the same question. Keep in mind that this article does discuss America law which may not be applicable to other countries.

________________________________________

Jen,

First thank you for your site!

I’m under the care of an OB who practices at a hospital that does not “allow VBACs” but has stated the only way to deliver at said hospital is to show up in labor & pushing.

Quoting from your site quoting the ACOG bulletin:

The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC.

If a patient (Me 3 prior sections), presents one’s self in labor at said hospital and declines a section, the hospital then has to heed the wishes of the patient? Am I understanding this correctly? Does the hospital have the right to stop contractions and section the patient? This is what I’m hearing in my birthing community and I really cannot believe a hospital would/could do that.

_____________________________

Hi Thia!

Many women believe that all one must do to prevent an unwanted cesarean is declare, “I do not consent!” While technically true, you are entitled to control what happens to your body, the reality is, it often doesn’t play out that way. A hospital does not have a legal right to perform a cesarean on you without your consent. However, it still happens either by coercion or lies and even more rarely, by court order.

I think part of the problem is, many women are not familiar with ACOG’s guidelines. As a result, they don’t understand what ACOG recommends and discourages. (For example, many women believe that VBACs should never be induced. That is false.) Women frequently take their OB’s word as the truth. However, ACOG’s recommendations are often obscured by unsupportive care providers to mimic what the care provider wants the mom to think ACOG says. In other words, unsupportive care providers want moms to think that their options are limited per ACOG and that is just not the case.

The fact that you are doing your research gives you a massive advantage over women who just take their OB’s word for it. I highly recommend you review the article I wrote about a mom who was threatened with a forced cesarean after her OB withdrew support of her planned VBA2C at 37 weeks. It includes legal and media contacts. Through the help of the ACLU, ACLU Women’s Rights Project, National Birth Policy Coalition, and National Advocates for Pregnant Women, the mom was granted a trial of labor. I use the (demonized) term TOL because the mom ultimately did have a medically necessary cesarean during labor due to a placental abruption. However, the mom was still happy that she had the opportunity to labor.

That is as much as I can say as a non-attorney. I consulted with the brilliant Lisa Pratt who is an attorney specializing in the legal issues that uniquely affect women during pregnancy and childbirth. She said,

This answer is true for all women, not just this one. If she needs legal advice specific for her situation then she should consult an attorney. You have the right to refuse any treatment you do not want. I am sure that what she is hearing is the same horror stories that we hear of a mom being harassed by the doctor and staff to consent to a c/s or threatening to seek a court order or call CPS. I know this is a scary thought to have to deal with any of these scenarios, but fear of something happening should not keep you from exerting your legal rights, unless you really are okay with what you are consenting to. You cannot assume that the staff is not going to honor your refusal. They are people just like us, some are jerks and some are ethical and will follow your refusal, but you won’t know what you are dealing with until you are in the moment. ACOG guidelines are just that, guidelines, they are not law; while it is nice when they put out a guideline that supports your factual situation, falling outside of their recommendation does not mean you must consent to something you do not want.

You can learn more about Lisa, and schedule a phone consultation if you have further questions, via her website.

Lisa presented at the 2012 VBAC Summit in Miami. Her session, “A Legal Guide to VBAC,” is available for download.

Warmly,

Jen

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.

Just kicking the can of risk down the road

Just kicking the can of risk down the road

This is why cesareans should not be casual or performed for the convenience of anyone.  They should be reserved for real medical reasons so that the benefits of having the cesarean outweigh the risks.  And there are real risks to cesareans, but since the ones list below are future risks, they may seem less real.  Per a November 2011 study published in the Journal of Maternal-Fetal and Neonatal Medicine:

If primary and secondary cesarean rates continue to rise as they have in recent years, by 2020 the cesarean delivery rate will be 56.2%, and there will be an additional 6236 placenta previas, 4504 placenta accretas, and 130 maternal deaths annually. The rise in these complications will lag behind the rise in cesareans by approximately 6 years.

Placenta previa and accreta are nothing to mess around with.  Accreta in particular has a very high maternal mortality rate and many mothers end up having cesarean hysterectomies.   I write more about accreta here.

Many women do not think these complications are applicable to them as they don’t plan on more children after their two cesareans.  But I know many women, and I’m sure you do too, who were not planning on more children, but got pregnant nonetheless.  Unless you or your partner get sterilized or practice abstinence (what fun!), the chance of you getting pregnant is there.

By performing routine scheduled repeat cesareans, we do reduce the risk of uterine rupture in the current pregnancy, but we are also increasing the risks of accreta, previa, maternal death as well as uterine rupture in future pregnancies.  In addition, another large study found

[t]he risks of placenta accreta, cystotomy [surgical incision of the urinary bladder], bowel injury, ureteral [ureters are muscular ducts that propel urine from the kidneys to the urinary bladder] injury, and ileus [disruption of the normal propulsive gastrointestinal motor activity], the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries.

And this is especially relevant in rural hospitals which institute VBAC bans because they don’t offer 24/7 anesthesia.  Even though the “immediately available” clause was removed in the latest (2010) ACOG VBAC Practice Bulletin, many of these bans still stand.

However, in order to rapidly respond to the potentially sudden diagnosis of accreta, previa, or abruption, the hospital will have to enact many of the same ideas provided at the 2010 NIH VBAC Conference on how a hospital without 24/7 anesthesia can safely offer VBAC and respond to uterine rupture.  So why not just institute those ideas from the get-go and offer VBAC to those who want it?  (I know, I know: medico-legal reasons, which the NIH also addressed, but that is another post.)  From VBAC Ban Rationale is Irrational:

 As David J. Birnbach, M.D., M.P.H (2010), who presented on the impact of anesthesiologists on the incidence of VBAC [at the 2010 NIH VBAC Conference] asserted:

Lack of immediate available of anesthesia may not always be a key factor in outcome [during a uterine rupture], especially in cases where the obstetrician is not present. Many cases of uterine rupture can be stabilized while the anesthesiologists becomes available, and examples have been suggested of ways to reduce the risk associated with such a crisis. These include antepartum [prenatal] consultation of VBAC patients with the anesthesia departments, development of cesarean delivery under local anesthesia protocols, finding methods of improving communication on labor and delivery suites, practice “fire-drills,” and development of protocols matching resources to risk.

I urge you to watch Dr. Birnbach’s presentation along with all the presentations from the 2010 NIH VBAC conference.

Read more about the how the risk of serious complications increase with each cesarean surgery.

Below is Silver’s (2006) study abstract:

J Matern Fetal Neonatal Med. 2011 Nov;24(11):1341-6. Epub 2011 Mar 7.

The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality.

Solheim KN, Esakoff TF, Little SE, Cheng YW, Sparks TN, Caughey AB. Source Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA. Abstract

OBJECTIVE: The overall annual incidence rate of caesarean delivery in the United States has been steadily rising since 1996, reaching 32.9% in 2009. Primary cesareans often lead to repeat cesareans, which may lead to placenta previa and placenta accreta. This study’s goal was to forecast the effect of rising primary and secondary cesarean rates on annual incidence of placenta previa, placenta accreta, and maternal mortality.

METHODS: A decision-analytic model was built using TreeAge Pro software to estimate the future annual incidence of placenta previa, placenta accreta, and maternal mortality using data on national birthing order trends and cesarean and vaginal birth after cesarean rates. Baseline assumptions were derived from the literature, including the likelihood of previa and accreta among women with multiple previous cesarean deliveries.

RESULTS: If primary and secondary cesarean rates continue to rise as they have in recent years, by 2020 the cesarean delivery rate will be 56.2%, and there will be an additional 6236 placenta previas, 4504 placenta accretas, and 130 maternal deaths annually. The rise in these complications will lag behind the rise in cesareans by approximately 6 years.

CONCLUSIONS: If cesarean rates continue to increase, the annual incidence of placenta previa, placenta accreta, and maternal death will also rise substantially.

Resources Cited

http://www.ncbi.nlm.nih.gov/pubmed/21381881

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.