Labor Files: What it Takes to VBAC in Rural County

One of our pregnant citizens had a successful vaginal birth after Cesarean (VBAC) this weekend. Not to take a single credit away from her, but this is the kind of event which takes a village to achieve. Here's why:

A bit of background: at this time, Gimbels is the only hospital offering attempts at VBAC, and these attempts must be attended by a doctor who has C-section privileges. The doctor must be in the hospital at all times when the woman is in active labor, and the OR team must be alerted to "VBAC Watch," in case the trial of labor is not successful and a prompt C-section is needed. These are the absurd strict criteria of Gimbel's protocol, and all of the OB providers have to play along, otherwise the hospital's insurance carrier will threaten to raise premiums and Gimbels would have to eliminate the option entirely.

There are only two docs with C-section privileges who support VBACs in the community. One of them is Doc Super, who was on call this weekend. He's an old-school family doctor who used to do it all: deliveries, C-sections, vasectomies, primary care, ER shifts, ICU, etc. Lately he's doing more ER and OB, and limits his primary care to some of the most underserved outlying clinics in our community. He also works for the same weekend family planning outreach clinic I cover occasionally, only he manages to cover it more than half the time, thanks to his mastery at the art of Being Everywhere At the Same Time.

Here's how Doc Super managed events this weekend:

0500: The VBAC candidate arrived at Labor & Delivery in early active labor.

0730: Doc Super arrived to evaluate the candidate. There were some concerns about the fetal heart tones but he decided to keep an eye on the strip and continue the trial of labor.

0810: Super called me at home: "Heads up, Theresa," he said. "My VBAC patient is 6-7 centimeters, so I might have to get to clinic late. Can you get things started?" We have an informal arrangement to cover each other in case one of us is assigned to outreach clinic.

0815: I stagger out of bed after getting off the phone with Super. Reheat coffee and contemplate the loss of my morning off after a rough night of hospitalist coverage.

0900: Super calls back. "She's 9 centimeters, but I'm going to be here for a while. Can you get to outreach? When I'm done here, I'll relieve you."

0915: Undercaffeinated, I drove to clinic. Was mildly gratified to see the hardworking staff there, and they were relieved clinic didn't have to be cancelled. Everyone atwitter about the laboring woman at Gimbels.

0930: Before seeing the first patient, I called Labor & Delivery for an update: "She's almost completely dilated!" 

1030: Three outreach patients seen. I call for another update. "She's complete, but not feeling any urge to push yet," the L&D nurse tells me. "Super is starting to coach." I returned to patients.

1130: Another update: "She's pushing well!" The news cheered me up. I returned to seeing patients with a bit of genuine vigor.

1230: Outreach was thankfully light. Before seeing the last patient, I called for another update. "The baby was just born, and Super is getting ready to repair a laceration," came the good news. I passed on the message to Super that outreach was finished, so he had no reason to rush.

1300: News of the successful VBAC is disseminated throughout clinic. I can hear cheers erupting down the hallway as I leave, strangely elated, at last.

We do good work in Rural. Sometimes we get it done by the skin off our asses, but we get it done.

Comments

[melgirl]

As a VBAC mom x2, all I can say is thank you. We need choices...evidence-based choices in fact. Thank you for preserving our rights and sticking to what the research says!

[Angela]

Feels good to do the right thing, huh? Too bad so many others don't. Time will tell though...the swing towards normal/the middle will happen. It HAS to.

[rlbates]

Good for the mom and the "village". Wonderful!

[teapot]

Hooray for the mom and hooray for you for covering the clinic so that Dr. Super could stay w/the mom!!

My VBAC was 26 years ago, and it was the smartest medical decision I ever made.

What a pity that it's become so difficult (in so many ways) for women to do what their bodies are made to do.

[doctorjen]

Yay! My hospital has the same guidelines, with the difference being none of the OBs with c-section privileges are willing to sit in house for labor clients, so effectiviely we don't offer VBACs. Before this change in policy (about a year and a half a go) I attended a lot of VBACs, with my OB back up on call (and available within 5-10 minutes) and had a lot of successful VBACs, now I tell my potential VBAC clients they have 2 choices: schedule a cesarean, or transfer to another doc who can attend them at a hospital with a different policy (which in our area means an hour drive.) I'm glad you are still able to offer more choices for your clients!

[Rixa]

Absurdly strict is right--I mean, how can hospitals or insurance companies justify those strict criteria for VBACs when catastrophic emergencies can happen in any birth? I am glad she was able to have a VBAC and glad you still have some docs who will do them.