Sunday, August 26, 2007

The War on VBACs

For those who haven't stayed up all night checking to see if mom's ready to push, a VBAC is a Vaginal Birth After a C-section. During a Caesarian, besides cutting through mommy's belly, mommy's uterus gets cut as well. When a woman has another child, the worry is that since the uterus has already been cut before, the spot of healing isn't as structurally sound as the original uterine wall, thus the pressure placed on the uterine wall during subsequent pregnancies would then result in uterine rupture, and the need for emergent surgery. Emergent surgeries carry a multitude of greater risks than elective procedures.

But then some studies cited in this NPR story mention that the actual rate of uterine rupture in VBACs isn't that large, but when a uterine rupture DOES occur during a VBAC, outcomes are comparably terrible. This lead ACOG to recommend that adequate surgical faculty be available when a woman was attempting a VBAC. The problem arises when smaller hospitals simply don't have the resources to ensure those adequate surgical backups are at hand, and hospitals then ban VBACs because they simply can't afford to keep a full back up team on call.

Which creates the interesting public health versus personal autonomy dilemma we've all come to know and love. Women absolutely have a right to attempt a VBAC (and yes, "attempt" is the correct terminology) with a fairly low threshold for proceeding to a repeat caesarian should complications arise. And hospitals have a right to not offer services they simply can't afford to offer when medically acceptable alternatives exist. "Medically acceptable" and "personally acceptable" are, of course, not always in agreement.

Where I've trained, the VBAC was always an option, mostly because the hospital is equipped with the staff to handle any complication that could arise because patient volume and the high-risk patient population justify their use. On a population level, the risk is astronomical. On a personal level, the risk is miniscule.

Of course, the naturalist spin is that obstetricians are evil bastards who want to cut so they can go home and get some sleep so they'll have time to wake up early enough to spend their hefty salaries. Actually, obstetricians, like other physicians, don't like the idea of folks dying during an emergency from a partially preventable incident.

The woman in the NPR story gives the most revealing quote, however. She is rightfully upset that she is being forced to have a VBAC. When presented with the rationale for why this is so, she replies:

"That's what they hospital is there for, to handle emergencies. And so, in that respect, the policy never made sense to me."
No, emergency rooms are there to handle emergencies, as long as by "handle," you mean do the best that anyone can to stabilize an unstable situation, recognizing that some unstable situations simply cannot be stabilized, and should be avoided if possible.

Hospitals exist to provide inpatient medical care following complicated medical algorithms in which physicians and patients take action to minimize the risks associated with illness and treatment. If a particular hospital can't handle a particular risk, it shouldn't try to do so. It should refer to a tertiary care center, and it should be blatantly honest with its patients about local limitations.

We don't send burn victims or trauma victims to any old hospital and expect that hospital to be staffed to handle those emergencies. We have regional burn centers and a tiered-trauma centers so that patients can receive quality care, and our society can afford to provide that quality care.

A woman has every right to demand an attempt at a vaginal delivery after a caesarian section for a prior pregnancy. Heck, I imagine if I were a woman on my second pregnancy after having a C-section the first time, I would almost certainly demand a VBAC. However, no hospital can be expected to offer a service it simply can't afford to offer. If I want the VBAC, I have to go find a facility that does offer that service, since I'm probably unwilling to spend the extra zillion dollars required to keep sufficient surgical staff available during my delivery. And my current providers have an obligation to help me find that facility.

For the most part, Starbucks has an obligation to give you precisely what you want, because coffee isn't dangerous, and they can charge you whatever that coffee is worth to them.

For the most part, your medical provider has an obligation to give you precisely what you want, as long as what you want is reasonably safe, economically viable, and consistent with what can comfortably be called standard of care. For example, elective abortions and emergency contraception meet each of those criteria, and thus each woman has a right to receive them. In some contexts, a VBAC doesn't meet those criteria (according to ACOG... that's certainly up for further debate). Thus, the provider's obligation is limited to directing the patient to a context in which the patient's preferences do meet those criteria.

Update: The Onion offers the proper supplement to this story:
Woman Overjoyed By Giant Uterine Parasite

The Onion

Woman Overjoyed By Giant Uterine Parasite

NEW BRIGHTON, MN— "I'm so happy!" Crowley said of the golf ball–sized, nutrient-sapping organism that will eventually require hospitalization in order to be removed.


Tiny Shrink said...

It's my understanding that in some cases, even when the obstetricians have the desire and skill to do VBAC, the hospitals don't always want to accept the liability of the procedure. So, even when an OR is readily available, and the obstetrician is skilled in VBAC, and the patient is willing, the hospitals don't always allow it to happen.

Garrett said...

Some of that is addressed in the NPR story, I'm not sure you got a chance to listen.

I'm sure there are tons of shades of gray in this picture. I'm thinking of some of the very small hospitals back home in Kentucky that probably couldn't afford to keep their obstetrical wards open if they permitted VBACS and actually adhered to ACOG guidelines regarding them. Where I've trained, you could run 2-3 ORs for emergent problems and still have staff available to tend to the rest of the busy ward. There are going to be some places where that is absolutely impossible. And then there are going to be tons of hospitals in between where the procedure is limited unfairly, which may be the case in the situation you describe. It's hard to delineate situations where the ward is covered by hospitalist obstetricians on call to cover all births in the hospital, and when private physicians are covering their own patients, etc.

Michael said...

I don't understand why someone would want to shove a seven pound mass through their vagina. Afterwards they start infecting their cooch, peeing when they laugh, and have their curtains flapping in the breeze. What possible drawback is there to a repeat C-section? The scar is already there. Anyway, I think all births should be done with a fetus backpack. There has to be a way to keep the placenta and stuff extraperitoneal, maybe hook it up to something like a cross between a Matrix pod and hemodialysis. I predict in 20 years we'll be growing our children in an incubator instead of inside women's bodies for 9 months. Pregnancy is nasty.

Philip said...

The operation just gets harder and harder with each c-section because the anatomy get more and more distorted by scar tissue each time. That makes for a longer procedure and the risks go up. Not to mention more and more adhesions and the fun that small bowel obstruction brings. Also, then there is more risk of the placenta growing into, or through, the c-section scar on the uterus in future pregnancies (just ask the patient who went in for a D&C for a missed abortion and ended up with a 6 unit transfusion and hysterectomy). As a family med doc, I would never do deliveries without c-section backup available. But there is a huge difference having an OB/GYN or c-section qualified family med doc (and OR team) available to be called in for failure to progress vs. having an OR team and OB/GYN ready at a moments notice for just about the worst possible OB scenario (according to one of our OB staff in the event of a rupture the fetal outcomes are 1/4 no problems, 1/2 cerebral palsy, 1/4 dead).

Anonymous said...

Michael is an idiot...hopefully he's been fixed.