Thoughts on Informed Consent, Refusal and VBAC

If you’ve been listening to the news lately, you’ve probably heard a lot about vaginal birth after cesarean (VBAC). The NIH held a consensus meeting to decide what was appropriate in VBAC care. The general thought was that the overall VBAC rate should increase and that the rate of primary cesareans should decrease due to the risks of surgery to the baby and mother. The panel had several recommendations that can be boiled down into:

• ACOG and ASA should revise their guidelines on the “immediately available” guidelines.
• The decision to do a VBAC or a repeat c-section should be made between a woman and her practitioner, after an informed discussion.

The problem with the last statement is that true informed consent and discussion is very rare in obstetrical care. The closest that we tend to come is the woman who is choosing a VBAC. She is likely to spend the last several months of her prenatal care being told of the risks of VBAC and the parameters in which it will happen. In contrast, had that same woman chosen to have an elective repeat cesarean, she would simply be handed an appointment card for her scheduled surgery and then sign a sheet of paper that would have to suffice as informed consent, all done a few minutes before her surgery. Neither of these is truly informed consent.

So how can women get informed consent, particularly when it comes to a hot topic like VBAC? My advice is:

• Do independent research.
• Seek out information from neutral sources.
• Talk to other mothers who have had a VBAC.
• Talk to other mothers who have had a repeat c-section (planned and not).
• Prepare for your birth by childbirth class, doula support and emotional support.
• Consider alternatives including midwifery led care.
• Make a decision only after a lengthy discussion with many people, including your practitioner.

Providers have to consider multiple issues when recommending one mode of birth over another: health of mother and baby, liability for complications, availability of self and staff during uncomplicated and complicated births, personal beliefs, medical malpractice insurance (if they choose to carry it), what other practitioners will think of their choices, etc.

Women have their own issues to consider when deciding her mode of birth: health of baby and mother, likelihood of the success of VBAC, physical and emotional pain after the birth, personal beliefs, etc.

The final point is that of informed refusal. ACOG has a policy of informed consent and refusal. This states that they believe that a woman who has all the information, is allowed to make a decision to choose not to receive the recommended procedure or therapy that is being suggested by her doctor.

At the panel yesterday, when asked specifically about the policy of informed refusal as it included forced repeat c-section, either by practice policy or individual recommendation, they basically said that this was unclear. Some advocates took this to mean that the consensus panel was suggesting that women did not have the right to choose a VBAC if that wasn’t the recommendation of her doctor or that if she did, it was acceptable to coerce her with threatened legal action. In other words, a woman is free to make any decision she would like, unless it conflicts with what her practitioner decides.

That leaves us in a sticky spot. What’s a birth activist to do?

Related:

• Maternal Decision Making, Ethics and the Law
• Refusal of Care Based on Religious Beliefs
• Women Need a Chance to Avoid Repeat Surgery

VBAC Consensus Statement (Draft)

The draft version of the NIH VBAC Consensus statement is up at: http://consensus.nih.gov/2010/images/vbac/vbac_statement.pdf

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VBAC from a Care Provider’s Perspective

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What is it really like to be a hospital care provider attending VBACs? Janelle from Birth Sense describes it in this post submitted to the ICAN VBAC Blog Carnival.

The whole post provides a very rational, no nonsense description of the actual problems that care providers face without an emotional “WE’RE ALL GOING TO BE SUED AND EVERYONE IS GOING TO DIE AND YOU JUST DON’T UNDERSTAND RISK!” She calls upon providers of modern obstetrics to “speak up on behalf of women who want VBAC and insist that realistic, evidence-based guidelines are instituted.”

Furthermore, Janelle points out something that would probably shock the public about hospitals. The “special” mandate that an OB remain in the hospital during the entire VBAC labor with an operating team standing by is hypocritical. If hospitals are so serious about having a team ready to handle VBAC-related emergencies, why would they not want to have the same safety net available to deal with comparable emergency scenarios in “low-risk” women? When I gave birth in a hospital for the first time, I mistakenly assumed that there was an OB and an operating team on hand for those rare emergencies. Why else would I have been in a hospital?

What is most perplexing to me is the mandate that the provider remain in the hospital during a VBAC labor “just in case”, yet other serious causes of perinatal morbidity and mortality are not considered adequate reason to have a surgeon and operating team standing by.  Some examples are:

1. Cord prolapse, with an incidence of 0.14-0.62 percent.  This can cause permanent fetal injury or death.¹
2. Placental abruption, with an incidence of 0.6 percent.  Again, this complication of labor can cause permanent fetal injury or death, as well as potentially life-threatening blood loss for the mother.²
3. Placenta accreta, and its variations (placenta increta and placenta percreta).  With a reported incidence of as many as 1 in 533 births, this is a serious maternal complication which can cause death.³

If we are serious about being able to take immediate action in the event of uterine rupture (approximately 0.5% incidence in low-risk labors VBAC labors), we should be equally serious about being prepared to immediately manage other perinatal emergencies.   The truth is, VBAC is not much riskier than a normal first birth, provided a few criteria are met:

• One low transverse uterine scar
• Normal onset of labor, no cervical ripening or induction
• No use of pitocin augmentation during labor
• Prior vaginal delivery increases chances of successful VBAC
• At least 18 months since cesarean birth

The risk associated with VBAC that concerns hospitals, insurance companies and care providers isn’t just the potential risk to women and babies. They are naturally concerned about the risk to their financial bottom line associated with a potentially predictable obstetric emergency.

The next time you hear anyone try to tell you that patients or laypeople just don’t understand risk, the question should be “The risk to whom?” I would argue that, given accurate information and percentages, most patients understand risk just fine. When you read between the lines, it’s clear that patients are expected to believe that the risk that lies behind scare tactics and lies about necessity of many cesareans and inductions is based on a certain risk to them or their baby. Unfortunately, it often has little or nothing to do with risk to the patient and everything risk to the care provider or institution.

And that’s the risk that most patients do not understand about how decisions are made about their bodies until it’s too late.

VBAC Varies by Hospital Type

From The Feminist Breeder

Adverse Outcomes Compared to VBAC

This shows a slide from the NIH VBAC Consensus webcast, taken by Gina at The Feminist Breeder. It talks about how VBAC compares to other adverse outcomes in perinatal period.

NIH VBAC Consensus Conference is live NOW

You can watch it at: http://consensus.nih.gov/2010/vbac.htm

VBAC is Vital

Vaginal birth after cesarean (VBAC) is a crucial option in maternity care today. I see VBAC as one of the key ways for us to attack the growing maternal mortality.

Many people do not think about the cesarean rate as a two-part issue. There is the primary cesarean rate, the number of women having their first cesarean. There is also the secondary or repeat cesarean rate. Currently, both numbers are growing.

The primary cesarean rate is growing for many reasons. Some of these reasons women can help control, like choosing practitioners who have faith in the process and only intervene when truly necessary. A good example of an intervention that can increase the cesarean rate and isn’t truly needed would be non-medical inductions.

But the secondary cesarean rate is where VBAC comes in. This rate is growing as well, largely because women are not being offered the ability to give birth vaginally after a previous cesarean. The growing body of research is showing that VBAC is safe and successful for more women who try it. Many women want to try it but are turned away by their doctors or midwives – leaving them the option of a repeat cesarean or fighting for a VBAC.

More and more women are choosing to fight for the VBAC. The question becomes – why should women have to fight for something that is likely to be safer for her and her baby?

This is part of the ICAN Blog Carnival.

But Why is VBAC so Important?

I am sure that I am not the only person to ask myself this with the announcement of the National Institute of Health VBAC Conference announcement.  But unlike most, I know more than my fair share about VBAC after having a cesarean with my first child it became more than a healthy obsession to me. But sadly the more I learned, the more sad I became about the access to VBAC nationally.

In a 2009 survey from The International Cesarean Awareness Network, it was found that nearly 50% of all hospitals in The United States has some sort of a VBAC Ban in place. Whether it be a formal policy written by hospital administrators, or a de facto ban, meaning there simply are no providers who will take on a patient who wishes to have a Vaginal Birth after Cesarean.

But what does this mean for women nationally? For the women who have had cesarean sections, whether medically necessary, or unnecessary?  It means that once they have experienced once cesarean birth, they have no choices regarding future pregnancies or deliveries. Essentially leaving them with no real informed consent.  To me, as a huge activist, that is not only a violation of a patients rights, but it is a major human rights and bodily anatomy violation.

Right now, 90% of women who have had one cesarean section will go on to deliver all of their children through multiple major abdominal surgeries, the next more risky than the last. When the safe and relatively low risk  option of a VBAC is not available.  But lets look at the numbers regarding the risks of VBAC as opposed to repeat cesarean sections.
The major risk associated with a Vaginal Birth after a Cesarean section is something most near the most not knowing the risk is so low. Uterine Rupture.  Not something we should discount or not worry about, but when we look at the statistics, the average healthy woman who has had one previous cesarean section has a 0.6% chance of experiencing a uterine rupture.

When I went through the process of filling out and signing my VBAC consent form for my second pregnancy, there was paragraph after paragraph panting VBAC in a scary pictre, then a small paragraph with the minor risks of a repeat cesarean, almost like the practice of Obstetricians backing my midwives wanted me to change my mind and run in fear.
This form was not informed consent by any means, it was skewed, biased, and provided misinformation, but sadly this is what we are seeing Nationwide today.

But I can hope with the NIH VBAC conference we can start to see a change in the way that VBAC is handled nationally.
Women have the right to real informed consent, and give birth vaginally if that is what they choose for their own birth.

For more information on Cesarean Awareness, and Advocacy, check out The International Cesarean Awareness Network.

VBAC Conference by the NIH

March 8-10, 2010 will have a consensus conference on vaginal birth after cesarean (VBAC).  It will address questions, including:

• What are the rates and patterns of utilization of trial of labor after prior cesarean, vaginal birth after cesarean, and repeat cesarean delivery in the United States?
• Among women who attempt a trial of labor after prior cesarean, what is the vaginal delivery rate and the factors that influence it?
• What are the short- and long-term benefits and harms to the mother of attempting trial of labor after prior cesarean versus elective repeat cesarean delivery, and what factors influence benefits and harms?
• What are the short- and long-term benefits and harms to the baby of maternal attempt at trial of labor after prior cesarean versus elective repeat cesarean delivery, and what factors influence benefits and harms?
• What are the nonmedical factors that influence the patterns and utilization of trial of labor after prior cesarean?
• What are the critical gaps in the evidence for decision-making, and what are the priority investigations needed to address these gaps?

Going in person isn’t really an option for most of us, but you can also sign up for the webcast online and/or to have the transcripts sent to you when it’s up. I’m sure that there will be a lot of activists there, I can’t wait to hear the guest list.

No Intervention Necessary: Woman Has Surprise HBAC

This surprise out-of-hospital birth story focused on the toddler-as-midwife angle. Just as interesting, however, was the fact that this woman avoided surgery. She was scheduled for her fourth cesarean on December 6, 2009.

Congratulations to the family.

Two-year-old Jeremiha Taylor doesn’t have to ask his mother where babies come from — he helped deliver his little brother at the foot of his family’s living room couch.

“He’s my little hero,” Jeremiha’s mom, Bobbye Favazza, 27, of Olive Branch, said Tuesday. “It was like he knew what to do.”

Favazza gave birth to a 7-pound, 4-ounce baby boy, Kamron Taylor, on Friday morning. Firefighters arrived moments later to cut the umbilical cord.

Greg Mynatt, an emergency services supervisor with the city, said the 911 call about Favazza was probably the third this year about a woman in labor, but usually the mother makes it to the hospital before delivery.

Even rarer is a child assisting with delivery. Mynatt did not recall it ever happening here.

“This would probably be the first,” he said.

Jeremiha can count to five, feed himself and go to the potty himself. He communicates in short sentences.

Of course, nothing about his brief childhood had prepared him to assist in delivering a baby, but Favazza said that of her four children, Jeremiha is the bold one, the one who “will try anything.”

Favazza had made proper plans. Baptist Memorial Hospital-DeSoto was expecting her — on Dec. 6, for her fourth caesarian section — not on Friday the 13th.

Looking back, Favazza realized she was in labor all through the night before the birth, but she did not realize it at the time. The discomfort was minor compared to the labor pains she remembered before giving birth to her sons, ages 2 and 3, and daughter, 5.

On Friday morning, Favazza complained to her mother, Leigh Favazza, about the pain, but neither woman believed delivery was imminent.

Leigh Favazza considered taking the day off from her sales job if indeed her daughter was going to give birth, but first she had to get her granddaughter, Keely Taylor, settled at school.

Leigh Favazza left the house to take the 5-year-old to the bus stop at the end of Maury Drive, then she headed for Olive Branch Elementary School to drop off snacks for her granddaughter’s classroom. While en route, Bobbye Favazza called.

“Mom, I’m having the baby,” Bobbye Favazza said.

Leigh Favazza hung up and called 911. It was 8:26 a.m. She was frantic. Her daughter was alone in the house with a 2-year-old, a 3-year-old, a bull mastiff and a poodle and her water had just broken.

Bobbye Favazza’s oldest son, 3-year-old Jamison Taylor, had awakened to discover his mother bleeding and in pain.

“He sat on the couch right here and cried,” Bobbye Favazza said. “He was terrified. He’s my emotional one.”

The 2-year-old was calm.

“I laid on the couch and he went and got a towel,” Bobbye Favazza said. “He grabbed a towel on his own.

“It happened so fast. My water broke and the baby came two to three minutes later. I just pushed and he caught him.”

Bobbye Favazza said she held her baby, still attached to her by the cord, as she walked a few feet to unlock the front door for emergency personnel. They cut the cord.

Jeremiha, quizzed about the birth of his brother, can point to the spot at the end of the couch where Kamron Taylor was born.

“Over there,” he said.

“Sometimes these things happen, especially to mothers who’ve had multiple births,” said Mynatt, the city’s emergency services supervisor. “The time gets less and less with each delivery.”

Mother and son were discharged from Baptist-DeSoto. Neither suffered any complications.

“I’ve had three,” said Leigh Favazza, the proud grandmother, “and I can’t imagine having any of them like this.”