• 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

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.

From The Feminist Breeder

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.

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.

Inside the released data, it showed an increasing trend in out of hospital births.  Home births rose about 5% from 1990 to 2005 and were steady in 2006.  About two thirds of these births were at homes and about another third were in birth centers. Which I believe has come from more education on the safety of home birth, as well as the increased interest in women who do not wish to be put through the hospital birthing system, or are looking to VBAC in an area with no hospitals currently permitting the hot button procedure.

What this study also showed was an increase in Midwife attended home birth, showing that women are planning these births and not just accidentally birthing at home, or not making it to the hospital in time. The number of midwife attended home births increased from 43% in 1990 to 61%.

What Robin pointed out on Pregnancy.about.com is that people will try and blame or say these trends are due to the popularity of the film The Business of Being Born, or the Big Push for Midwives campaign but these were unavailable during this time. The Business of Being Born was not released until 2007.

I find these statistics encouraging because women are becoming more educated on their options, and truly are being informed consumers.

_{MacDorman M, Menacker F, Declercq E. Trends and characteristics of home and other out-of-hospital births in the United States, 1990-2006. National vital statistics reports; vol 58 no 11. Hyattsville, MD: National Center for Health Statistics. 2010.}

When we look at how pregnancy and childbirth have changed through the years, there is a long line up of women who have advocated and outright fought to help women.  I’d like to announce that Birth Activist is hosting a blog carnival about women in history who have changed pregnancy and birth.  Who is your heroine?  Who amazes you?

The rules are simple:

• Write a post featuring your heroine from pregnancy and childbirth history. (Your amazing woman does not have to be deceased to be included!)
• Send us a link to your post at birthactivist@gmail.com by March 20
• The blog carnival will run on March 25, 2010

Need some inspiration?  Leave a comment and we’ll share with you some women who will knock your socks off!

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.