I’m excited about ICAN’s blog carnival, “Why is VBAC a vital option?” There are so many reasons that I long for change in the attitude of modern obstetrics toward VBAC, that it is difficult to decide which reasons to write about. Since I’m sure there will be many bloggers writing about the abundance of good reasons for promoting and supporting VBAC, I’d like to approach the topic from the point of view of the provider.
As a midwife who attends VBAC births, I see a different side of the dilemma. While women are rightfully angry about the difficulty in finding providers willing to attend VBACs, there are multiple problems facing providers who wish to continue attending VBACs:
- Insurance issues: many malpractice insurance companies will not even cover a provider who attends VBACs. I worked with one female OB who was a strong proponent of VBACs, until her insurance carrier informed her she could no longer attend them, and if she did, her insurance would be dropped. Without malpractice coverage, a provider cannot contract with Medicaid or most private insurance companies. In today’s climate of health-care crisis, few providers can survive financially if they are unable to accept Medicaid or private insurance.
- Threat of lawsuits. In my experience, this has actually been a lesser factor for most providers in deciding whether to attend VBACs. However, it remains a consideration, particularly for women who are at higher risk of uterine rupture during a VBAC. One lawsuit can render a provider uninsurable for the future. This painful truth was detailed in midwife Peggy Vincent’s book, Baby Catcher. Following a lawsuit in which she was named, even though she had only been on the sidelines for the birth, Ms. Vincent’s insurance company dropped her. This is reality for many providers today, leaving them with the question: Do I risk my ability to provide evidence-based obstetric care to many women in order to help one woman have the birth she wants?
- Time contraints. With the current requirement that the obstetrician/surgeon remain in the hospital during the entire VBAC labor, many providers simply cannot financially afford to offer this option. Consider a typical scenario: the obstetrician is called at 7 a.m. to be present for a VBAC labor. The woman has not given birth vaginally before, and is 1 centimeter dilated. If her labor progresses in an average fashion, the OB will not leave the hospital until late that night. He will have to reschedule an entire day’s worth of patients, losing an entire day’s worth of income. The woman’s insurance company, if they pay anything extra for VBAC (most do not), will only give him $200 more than the regular payment. If he is one of the few doctors in his community who offer VBAC support, he will be inundated with women wanting VBACs, and can plan on regularly having to be out of the office for long periods of time. Few obstetricians can survive financially with this sort of scenario, not to mention the personal time commitment it requires away from one’s family.
Unless the restrictions for permitting VBAC labor are revised, I believe we will gradually see the few remaining physicians who offer VBAC cease to offer this option; not because they don’t care, but because hospitals, insurance providers, and ACOG guidelines are making it too stressful, both financially and personally, for VBAC-friendly providers.
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 tem standing by. Some examples are:
- Cord prolapse, with an incidence of 0.14-0.62 percent. This can cause permanent fetal injury or death.¹
- 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
- 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 Northern New England Perinatal Quality Improvement Project has proposed ranking VBAC risk according to low, moderate, and high-risk factors, and planning the level of provider attendance required based on the risk factors. A low risk woman would be managed differently than one at high risk of uterine rupture. Their document, Birth Choices After Cesarean, lays the groundwork for what should become standard procedure in all US hospitals.
It is imperative that providers of modern obstetrics speak up on behalf of women who want VBAC and insist that realistic, evidence-based guidelines are instituted: guidelines that support freedom of choice in childbirth; guidelines that do not discriminate against VBAC while ignoring equally serious risks of other birth complications; and guidelines which make it financially and personally feasible for providers to offer VBAC. One consideration might be the laborist, a physician who is in the hospital 24/7, immediately available if surgery is needed, and thus frees the OB provider to manage a VBAC labor just like any other labor.
Ultimately, it must be realized that women must be offered the freedom to birth the way they want, and receive support to do so. Providers have a large role to play in speaking up to demand these freedoms for women.
1. Belogolovkin V, Bush M, Eddleman K. Umbilical cord prolapse. give Retrieved 03/03/10 from: http://www.uptodate.com/patients/content/topic.do?topicKey=labordel/2191
2. Ananth CV, Wilcox AJ. Placental abruption and perinatal mortality in the United States. American Journal of Epidemiology Vol. 153, No. 4 : 332-337. Retrieved 03/03/10 from: http://www.google.com/#hl=en&source=hp&q=incidence+of+abruptio+placenta&aq=f&aqi=&aql=&oq=&fp=db64f927cfe7b756
3. Resnick R. Diagnosis and management of placenta accreta. Retrieved 03/03/10 from: http://www.utdol.com/patients/content/topic.do?topicKey=~iuuj5_1.hHBKd1m
This is the first time I haave read your blog. Finally, someone that makes sense.
Thank you! Spread the word!
I live in a small town in Canada where VBAC is an option for almost anyone who requests it (depending on risk factors), but have recently discovered an issue that it would be interesting having another impression on. I was speaking with a young woman who had had two previous c-sections, and her youngest baby was only 6 months old. She told me she was pregnant again, and was 2 months along, but that she was going for an abortion soon. The sad part is that she really didn’t want the abortion but was talked into it by her doctor who told her it was too soon to have another baby and would be too much of a risk for another c-section. I just think it’s criminal to force someone into a abortion like that. Are the risks of third repeat c-section so soon really that high? (I can understand it being too soon to risk a v-bac)
The risks of uterine rupture are higher if the pregnancies are less than 18 months apart. However, the risk of rupture is still much, much less than the chances of having a healthy, normal delivery! I don’t know that anyone has quantified it in numbers, but even the highest risks that I’ve seen, which are considered to be with a classical incision on the uterus (vertical) are about 12% chance of uterine rupture. If she is young, healthy, had no post-operative infection of her incicsion, and has not had a lot of babies, her risks are lower and I personally would not get an abortion for this reason. I have had several VBAC patients whose pregnancies were spaced about six months after delivery, and they’ve all done just fine.
“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 tem standing by.”
I have often wondered the same thing….Thanks for the post.
Great post! You brought up some issues I had not considered with care provider concerns.
Thank you for listing references for the various risks that are higher than rupture. I do wish though, when people talk about rupture, they would mention that even with rupture, most often the baby and mother are fine.
I live in a small town with no access to VBAC services (within several hundred miles). After searching for months, I’m convinced it’s time to take on the lawyers, exactly for the reasons stated above. Insurance companies are just trying to protect themselves, as are most doctors. While the threat of lawsuit is a necessary protection for the patient, it has been grossly abused by patients wanting to get-rich-quick, and their lawyers, who care only as much as their pocket-book is filled. We used to be a country of laws, now we’re a country where the law is determined by whomever is good in a legal debate. Anybody know any good lawyers who would be willing to sue other lawyers for damages caused by malpractice lawsuit abuse?
The problem of VBAC access is definitely multi-facted, but this is an important part of the difficulty. Many providers are truly under threat from frivolous lawsuits. Simply having the woman sign an informed consent does not protect a provider from lawsuit, contrary to popular opinion. All a woman needs to do is say that she didn’t understand what she was signing.
Can CNMs provide VBAC care?
The short answer to your question is yes. The long answer is that this is something determined by hospital policy, not by the CNM credentials. Our training does give us the background to provide VBAC care. The part we cannot do is emergency surgery, if it becomes necessary. I have always been able to offer VBACs to my clients, however, because I have worked in facilities where there were surgeons immediately available, and they were willing to provide backup for the CNMs if we needed a c-section. Most hospitals require in-house anesthesia and surgeon immediately available for VBACs. If those two criteria are met, CNMs generally can have privileges to provide VBAC care.