As I mentioned in an earlier post, I've kept pretty good records of all the births I've attended as a primary caregiver. I'm using the same Bellefontaine notebook as I started with and I believe I'm up to 476 or so births logged in that book. However, I've been around four times that many labors, newborns, and births as an assistant, and my perspective on birth comes as much from these experiences as the births that have occurred into my waiting hands. I'm going to be sharing some of those stories on this blog under the column title "Labor Files," and because a commentator recently asked if I have any VBAC experience I thought I'd start with my favorite VBAC story.
Veronica was a 38 year-old woman whom I met in the middle of her sixth pregnancy. She'd had uncomplicated pregnancies resulting in two vaginal deliveries, a C-section for breech, followed by two successful VBACs at my residency hospital. She was planning for this pregnancy to be her last and she really wanted to have another trial of labor after Cesarean section (ToLAC).
The problem was that our hospital's policy had changed during the interval between her last VBAC and her current pregnancy. Previously the only restriction on ToLAC was a prior classical (vertical) uterine incision or any other condition of pregnancy for which C-section was indicated (breech, placenta previa, etc.) When I started my intern year, our hospital had a very high successful VBAC rate and a relatively low C-section rate in the low twenty percent range. Women with prior C-sections came in, labored, and VBACed every day of the week. It was a great time to be learning at the hospital and I could see a lot of women were empowered to have a chance at a vaginal birth after a C-section.
Then the malpractice carrier changed their policy. A large settlement in a case completely unrelated to our hospital resulted in a blanket refusal to cover ToLAC unless the hospital provided 24-hour dedicated OB anesthesia. Our hospital was a medium-sized rural community hospital and we did have one anesthesiologist in house at all times, but this person was on-call for all anesthesia, general cases as well as OB, and so the hospital changed its policy to be in strict compliance with the malpractice carrier's new rules. The change came in stages: first, we were not allowed to use certain induction methods on women with a prior C-section, then all inductions were disallowed, and finally all ToLAC was eliminated at our hospital. We were the last hospital in a three-county region to offer ToLAC and when we stopped, there was no longer any facility at which a woman could have a VBAC within 100-150 miles.
The change came during my second year, and the way the new policy was explained to us, I understood we were to inform all pregnant women with a prior C-section that the hospital no longer permitted ToLAC. We were supposed to review the <1% risk of uterine rupture and explain we were now managing subsequent deliveries via repeat C-section. However, it was clear that no woman could be forced to undergo a major abdominal surgery if she did not want to do so. In those cases, we were supposed to refer her to an obstetrician to discuss the policy and the risks in more detail and, if the woman still wanted to avoid a repeat C-section, she was instructed to sign a declination form, which is like a consent form to refuse recommended treatment. In other words, there was a way around a repeat C-section but it was time-consuming, confusing and required a lot of talking.
What happens when a process is time-consuming and confusing is that doctors will only participate in the process to the extent they feel strongly about the outcome. Because human nature tends to follow the path of least resistance, doctors end up abandoning the troublesome process and go with the accepted policy. In the community there were a number of doctors encouraging their patients to sign declination forms and were therefore continuing to have good VBAC results, but the story was different among the residents' patients.
When I met Veronica, she was doing well and I asked if she was planning a childbirth class for this pregnancy. "No, because I have to have a C-section," she said grimly.
"Oh?" I said, and I'm pretty sure I began to emit little rays of defiance. "Who told you that?"
"Doctor M," she replied. She was talking about one of the junior residents who was much meeker than I am.
"I'm sure Dr. M told you about your other options," I said diplomatically, and explained the complicated process of declination to her. "What do you think? Do you want to talk to one of the doctors who specializes in pregnant women?"
Veronica said yes, so I referred her to one of our more liberal OBs for further risk counseling. I didn't see Veronica again for prenatal care, but I know she followed up with Dr. M because M asked me one day, "What's this about Veronica getting to VBAC? Really?"
For the second time I found myself explaining the declination process. "I'm not saying she should have a trial of labor," I explained to M. "I'm just saying she shouldn't be herded into a repeat C-section just because the damn hospital changed the rules." I'd had a really long talk with Veronica, and I knew the OB would have another, and I thought she grasped the risk of another ToLAC. This risk doesn't decrease with successful VBACs, but the fact that she'd had a couple of successful births after her C-section made Veronica a pretty good repeat candidate.
The next time I saw Veronica, I was on call as a third-year resident. She came in on one of those really busy call nights, the kind that makes a quick, painless death look so attractive. I don't remember what was going on in the medicine portion of our call, but I do remember that Labor & Delivery was hopping all night long. It was one of two occasions during my third year when we delivered eleven babies in eleven hours. We had primigravidas laboring hard and fast, women pushing for three hours and getting vacuumed, women pushing once and having vigorous babies, multips arriving completely dilated and proceeding to give magnificent birth, a couple of women who needed intrathecals, a couple of babies who needed a bit of resuscitation, and all of these events requiring notes, notes, and more notes to document in the medical record. It was one of those night when, as third-year on call, I couldn't take my eyes off of what my intern was doing. Interns were supposed to run Labor & Delivery, but this night was not a one-person show. It takes practice to juggle eight women in labor, six pushing at once, and keep all their needs and information straight. I was pretty good at this as a third year, so although I tried to defer the actual births to the intern, I was right there making sure everyone was okay.
At 0300 the OB tech told me, "We've only got two more sets of instruments left."
"What?" I asked. I was in that state of exhaustion which requires everything to be repeated two or three times.
"We've only got two more sets of delivery instruments sterilized," she said.
"So, what you're telling me is, we can only have two more babies," I said, a gleam of comprehension finally appearing through the fog.
"Yep."
"Fine with me," I said wearily. "Let's have two more then lock the doors."
Not an option. We had another four babies ahead of us. I can't remember how we worked the instrument problem, but I remember someone pulling individual instruments from the OR and throwing them onto a cafeteria cart. We'd used up all our usual delivery carts and were down to anything on wheels. I was aware of women waiting in our triage area, who were there for labor checks, ruptured membranes, and a number of other fiddly complaints that make OB call so challenging. However, the women in triage were, by necessity, a lower priority than the women giving birth. A lot of women waited several hours before being seen by a doctor that night, because the doctors were doing spinal analgesia and suturing lacerations and catching babies.
Day was breaking when one of the OB nurses grabbed me by the elbow. "You've got to come to room A," she said, referring to one of the private triage rooms.
"Okay," I said. "Can you hang on for one min---?"
"No, I can't," she said firmly. "This woman's been here for five hours, she wasn't active-looking when she got here but she looks like she's about to have that baby, and it's her sixth!"
First rule of call: Be flexible. I juggled my priorities and followed the nurse into room A. There was Veronica, breathing hard and heavy and grunting at the end of each breath.
"Are you pushing?" I asked, forgoing all niceties. There's a time for etiquette, and a time for direct questioning.
She nodded. "I'm trying not to, but--" Another breath, another grunt.
I got a glove on and did a quick exam. All I could feel was the baby's head already halfway down the birth canal. I looked at the nurse. We were on call with a prickly OB attending that night, the kind of person who blows up at the housestaff and the nurses over little violations of policy. "Let's move her to a big room," I said. "I mean, she's a VBAC and I can just see everyone freaking out if they find out--"
The nurse was unlocking the bed. "Let's roll."
Together we raced Veronica--who, by the way, had no monitors on, no IV, no nothing--into a full-sized labor room. The OB tech was close behind us with a rolling filing cabinet which had been deputized into delivery table duty. She pulled open a sterile towel pack and started dumping clamps onto the makeshift sterile field. Veronica was pushing full-out and her vulva immediately started to bulge.
"Never mind sterile," I said. "Are there any gloves?" Someone threw a pair at me and I got them on. I remember they were huge. The baby crowned and Veronica took in a lot of air and gave a mighty push, and a big baby boy was born with a gush of fluid following him. He made an immediate cry and I lifted him up to Veronica's arms.
"Way to go!" I said to the jubilant mother. "Now that's the way to have a baby."
I love Veronica's story and I re-tell it often because it illustrates the best side of VBAC, and because it reveals how absurd hospital policy can be when applied to real-life clinical medicine. Veronica got her VBAC because she had good, fast labor; because she knew what she wanted; and finally, because she had the good sense to go into labor on a night when everyone was too busy to make a big deal out of her refusal to undergo a repeat C-section. Of course, a ToLAC can have a much darker outcome than Veronica's--I'll save that for another story--but her story shows you what the extra trouble to get a woman through a complicated process is worth. I'll have more to say about VBAC policies as I progress through my labor files and birth archives, but I always think of Veronica as my Winged Victory.
I am also a physician (pediatrician) and I read your blog today. My perspective is a bit different because I felt much as you do, until the birth of my second child last March. I was a great candidate for VBAC, 4 years between kids, previous kid breech, planned to refuse induction due to risks. I went into early labor at 11 or so, quickly was having contractions every 2 minutes at home, rushed to the hospital and probably ruptured in the waiting room. My son took 20 minutes to breath and had neonatal seizures. He had brain cooling and is doing very well, all things considered, but I still struggle with this issue. I strongly believe in patient choice and autonomy, but what no one wants to admit is that you are gambling with the life of your baby. Although there are risks to CS, to mom and baby, the most catastrophic risk to baby is that of rupture. And it can't be completely "CONTROLLED" as I, and some of your readers have thought. The maternal guilt involved after this kind of decision is almost unbearable and I think that should be made clear when discussing this issue. Just another point of view, changed by hard experience
Posted by: Lauren Gold | January 31, 2009 at 01:09 PM
I'm new to your blog, & found it interesting that the patient, presumably the one whom both the physician and nurses have taken vows to protect HER interest, are at the behest of random, possibly paranoid and at the least overly cautious hospital policy, and at the least, insurance changes.
Is the patient told this? Is the patient told that her REAL risk is small but VERY controllable?
As no one other than just a mother, I am completely dismayed. I enjoy medical blogs. The confounding variables in the cases presented (not the least of which are evidence-based treatment recommendations) are enlightening. In other words, I'm not surprised that midwives and doulas like your blog.
While, Theresa, I highly respect the years that you put into your education and I appreciate your philosophy, I trust physicians less and less the more I read their blogs. Please correct me, it seems that many are not much more than white-coated cogs in a hamster wheel of insurance companies, profit seeking hospitals, and Big Pharma.
It's a wheel I do not want to find myself in if I can help it.
Posted by: APB | November 22, 2008 at 05:53 PM
I'm so glad to hear there are doctors who still allow women to birth naturally!
A few years ago I noticed a sign at my OBGYN's office: "Our doctors no longer perform VBAC."
It's ironic if you think about it... All those doctors are male. Do they really think they can perform BIRTH? But this is the crux of the problem, failing to understand that pregnant women are the ones who give birth.
Posted by: Jeannie | November 22, 2008 at 09:01 AM
I enjoy your blog so much and decided to comment since I had a VBAC with my second child. My first child was born by c/s after "arrest of descent" With my second I saw a family practice resident at a military hospital. I also hired a doula who had two years apprenticeship as a lay midwife under her belt. She had a doppler and I wanted her to monitor the baby at home until we went to the hospital. Well, my daughter came in a hurry and both my doctor and doula arrived at the hospital just in time to see her born. In fact, my husband and I arrived just in time for her to be born at the hospital :) You said in your post "...I thought she grasped the risk of another ToLAC. This risk doesn't decrease with successful VBACs, but the fact that she'd had a couple of successful births after her C-section made Veronica a pretty good repeat candidate." So I thought you might appreciate reading Labor outcomes with increasing number of prior vaginal births after cesarean delivery.Obstet Gynecol. 2008 Feb;111(2 Pt 1):285-91. These researchers concluded, "An increasing number of prior VBACs is associated with a greater probability of VBAC success, as well as a lower risk of uterine rupture and perinatal complications in the current pregnancy." Keep up the great work and wonderful blog!
Posted by: rem | November 14, 2008 at 09:37 PM
Thank you and thanks to your commenters for the positive VBAC stories. Everyone knows that VBAC is risky, but so are a lot of things in life- driving, eating oysters, etc, and we do these things without much consternation every day! I'm glad to hear there are doctors who actually encourage vaginal birth. Maybe if there were more like you out there the primary Cesarean rate, and therefore the refusal-to-allow-VBAC rate, could be reduced!
Posted by: Liz | November 14, 2008 at 11:41 AM
My hospital has gone to a no VBAC policy as well. Actually, we technically still do them as long as anesthesia, the surgery team, and a surgeon are willing to stand around in house, which they pretty much never are willing. Prior to the rule chage I did a lot of VBACs as the only provider in the community who was willing (a couple other providers could have their arms twisted into it, but were always unhappy about it and quick to jump to repeat.)
The last VBAC I did was one of my favorites. This client switched to me with her 2nd pregnancy, hoping for a VBAC, after having a cesarean for failure to descend while pushing with her first. The rules had changed just the week before she came for her 1st OB visit, and after I explained everything, she did not want to transfer out to another doctor in another hospital so planned to stay with me for regular care and have a repeat with my OB back up. The morning of her scheduled repeat, she arrived 2 hours early complaining of contractions. The nurse checked her and called me saying she was 4 cms. I came in immediately to have a big discussion with her about what she wanted to do. At this point she was hurting, and scared, and said she thought she'd just have a repeat anyway. I checked her again, and she was already 7 cms! I called my OB backup and he said he was on his way. We moved to the OR. When he arrived (we hadn't prepped yet or anything) he took one look at her laboring hard on the stupid little OR table, and said "Oh, just break her water and let her push." I asked the client if she was willing and she said "whatever!" Another quick check found her with just an anterior lip. With the nurse's help, somehow we managed to help her onto her side, since the little narrow table was so uncomfortable for lying on her back, and in less than 30 minutes, she VBAC'd her little boy, with one foot on my shoulder, and both hands with a death grip on my nurse's scrub top. Surprisingly, this baby was bigger than the one who had failed to descend, and she managed to push him out despite the uncomfortable table, bright lights, a whole surgical team standing around not knowing what to do with themselves, and an anesthesiologist sitting at her head watching the cardiac monitor he somehow managed to get on her. We don't have fetal monitor in the OR, so another nurse held a doppler on the whole time. The baby ended up being born about half an hour prior to her scheduled repeat cesarean!
That, is one of my favorite VBACs!
Posted by: doctorjen | November 11, 2008 at 05:18 PM
Lovely story! Butter birth!
We can attend VBACs in hospital, and have terrific outcomes. But 6 1/2 years ago we could attend non-primary VBAC labors in our birth center, until the rules changed. Imagine how telling an Amish woman that the c/section she had 14 years and 9 children ago now meant a hospital birth. What did they do? Obviously, transfer to a lay midwife who has a pretty much no transfer until dead policy, or call us too late.
THIS is what the establishment forces women into, instead of respecting their right to informed choice. GROWL!!!!!!!
Keep up the VBAC fight doc!
Posted by: CountryMidwife | November 11, 2008 at 04:49 PM
Thank you for posting this great story! I think the important thing is that mom is given the information and then she can make the choice. To force a mom into a repeat cesarean is so wrong to me.
Posted by: Sheridan | November 11, 2008 at 04:30 PM
Thank you, Prachi. I do have other VBAC stories of all shades and will write them up soon. Unfortunately, no one can really advise you about your VBAC risk other than your own doctor or midwife, assuming they have experience with VBAC themselves. You can seek out more than one opinion to help you decide.
Posted by: Theresa | November 11, 2008 at 02:31 PM
Lovely!, so do you have anything about VBAC gone wrong.
I am obsessed with reading birth stories after my horrible c section. I wish someone could really tell me if I am a great VBAC candidate
Posted by: Prachi | November 11, 2008 at 01:58 PM
The hospital that I had babies 1, 4, and 5 at went to a "once a cesarean, always a cesarean" policy between babies 4 and 5, even for VBAC#4. OB told me the only way anyone had avoided a C was because they showed up ready to push. Going to another hospital wasn't an option, so that's what I did.
Posted by: D | November 11, 2008 at 09:05 AM
What a great story!
Posted by: Emily | November 11, 2008 at 08:54 AM