VBAC rates are low, but are obstetricians to blame?

My daughter, who turns two years old in June, is becoming something of a medical rarity. This isn’t because she is showing signs of a late-developing handicap or extraordinary ability for her age – it’s because she came into the world as a vaginal birth after Cesarean section (VBAC), delivered by a certified nurse midwife.

Although more than three-quarters of women who choose a trial of labor over a repeat Cesarean section successfully deliver vaginally, studies showing slightly elevated risks of rupture or infection of the uterus with VBAC, pressure from insurance companies concerned about lawsuits, and restrictive medical guidelines discourage most women from even trying.

After reaching a high in 1996 of 28.3 percent of women who previously delivered by Cesarean, the national VBAC rate today is fewer than 1 in 10. As a result of all of these repeat Cesareans, 1 in 3 births in the U.S. today occur by Cesarean.

For the past two days, a conference at the National Institutes of Health has sought to understand the reasons for the decline of VBAC, and what might be done to reverse what most believe to be a negative trend. An independent panel will release a draft statement summarizing the take-home points from the conference. What the statement probably won’t say, but what I believe to be a large part of the truth, is that the U.S. has such a low VBAC and high Cesarean rate because obstetricians deliver most of our babies, and obstetricians aren’t primary care clinicians.

The old medical maxim “when you hear hoofbeats, think horses, not zebras” refers to the fact that common conditions are more likely to present than rare or estoteric conditions. A dry cough, for example, is more likely to be due to allergies than Erdheim-Chester disease. Vomiting and diarrhea are much more likely to be caused by rotavirus than Vibrio vulnificus.

Primary care clinicians internalize this maxim during their community-based training programs; specialist physicians – who spend most of their training learning to diagnose and treat “zebras” at academic medical centers where patients with uncommon conditions are referred for care – typically abandon it early on. And even though many women visit obstetricians for routine gynecologic care, when it comes to the primary care-specialist attitude divide, Ob/Gyns come down clearly on the side of the specialists.

I could offer lots of anecdotes about why the above is true from having worked with OB/GYN physicians throughout medical school and residency training (when I delivered more than 80 babies and assisted in about half as many Cesarean sections), but objective data support the notion that labor managed by family physicians and professional midwives is considerably more likely to result in a vaginal birth than labor managed by an obstetrician, even controlling for factors such as maternal age and risk status.

It isn’t difficult to understand why. If an obstetrician is feeling uncertain about how well a patient’s labor is progressing and has an inflated estimate of the probability that something might go wrong (the zebra), it’s very hard to resist the temptation to eliminate the uncertainty by delivering the baby surgically, then and there. On the other hand, if the surgeon is at least a phone call away (the American Academy of Family Physicians’ 2005 guideline on trial of labor after Cesarean noted that there’s no good evidence that having a 24-hour on-call surgeon and anesthetist in-house improves maternal or infant outcomes), the family physician or nurse midwife might be more patient with the hoofbeats, betting they’re hearing a horse.

And, in fact, in a 2004 study of nearly 18,000 women who attempted VBAC, the most feared complication of uterine rupture (which requires an emergency Cesarean), occurred in less than 1 percent of cases. As mentioned earlier, a trial of VBAC is successful more than 75 percent of the time.

It’s a real shame that women in the U.S. are discouraged from attempting them more often.

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor.

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  • http://momstinfoilhat.wordpress.com/ MomTFH

    Thanks for this post, and congratulations on your successful VBAC.

    I do want to point out one small correction. The major medical institution you are most likely referring to is ACOG, and they actually do support offering VBAC.

    Here are their recommendations. Their recommendations to offer VBAC has the top rating of A, and the “immediately available” language (which is not too far off from their induction language in that bulletin, which is routinely ignored for inductions) has a rating of C.

    Summary of Recommendations

    The following recommendations are based on good and consistent scientific evidence (Level A):

    * Most women with one previous cesarean delivery with a low-transverse incision are candidates for VBAC and should be counseled about VBAC and offered a trial of labor.
    * Epidural anesthesia may be used for VBAC.

    The following recommendations are based on limited or inconsistent scientific evidence (Level B):

    * Women with a vertical incision within the lower uterine segment that does not extend into the fundus are candidates for VBAC.
    * The use of prostaglandins for cervical ripening or induction of labor in most women with a previous cesarean delivery should be discouraged.

    The following recommendations are based primarily on consensus and expert opinion (Level C):

    * Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.
    * After thorough counseling that weighs the individual benefits and risks of VBAC, the ultimate decision to attempt this procedure or undergo a repeat cesarean delivery should be made by the patient and her physician. This discussion should be documented in the medical record.
    * Vaginal birth after a previous cesarean delivery is contraindicated in women with a previous classical uterine incision or extensive transfundal uterine surgery.

    • bp

      What the risks are is scientific.

      One’s tolerance for them is not.

      Most moms and doctors don’t want to take even a small risk, if it is risking the life and well-being of the baby. That’s their right.

  • http://www.theunnecesarean.com Jill–Unnecesarean

    “it’s very hard to resist the temptation to eliminate the uncertainty by delivering the baby surgically”

    The use of the word “temptation” is interesting here. It is tempting to seek the comfort of feeling safe and proactive, as well as to assuage ones fear that they might be punished. If the behavior can be repeated without any apparent negative consequence to the person performing it, then there’s seems to be no reason not to repeat the behavior over and over.

    The question is whether the reward to the person performing the behavior outweighs subjecting an unwitting patient unnecessarily to the risks associated with major surgery. Anyone who thinks that this line is ever acceptable to cross needs to do some soul-searching.

    Great post.

  • Doc99

    ACOG gave VBAC the Kiss of Death when they issued the “Immediately Available” Guideline.

  • docguy

    i understand that the risk is low but the complication is so grave what do you think we should do. I always wonder why we put someone on a statin with a ldl of 131 with no family history, what’s the risk of a heart attack in a 41 year old women with a ldl of 131, I would imagine it’s lower than the risk of a uterine rupture.

  • ninguem

    Not sure how you blame the obstetricians. My hospital, the obstetricians were told they weren’t allowed to do VBAC’s because of malpractice coverage. If our hospital was to do VBAC’s, a level of staffing would be required, that would either bankrupt the hospital with te increased staffing, or make existing staff kiss their families goodbye, and live in the hospital. Staffing was adequate for primary C-sections, but not for the increased risk of catastrophe with a VBAC.

    So, it’s not happening, period, no matter what the obstetricians said.

    Gotta suspect, though, the obstetricians had no objections to that rule.

  • http://drackies.blogspot.com Dr. Evil

    <1% chance of uterine rupture? so thats 180 multimillion dollar malpractice suits in that small study of 18,000.
    The real question is why are there ANY VBACs???

  • http://www.DrHoffmanMD.com Chris

    I am a practicing Obstetrician.
    I take offense at the comment “inflated estimate” comment in the quote below…
    “It isn’t difficult to understand why. If an obstetrician is feeling uncertain about how well a patient’s labor is progressing and has an inflated estimate of the probability that something might go wrong (the zebra), it’s very hard to resist the temptation to eliminate the uncertainty by delivering the baby surgically, then and there.”

    The major reason for the high cesarean section rate and low VBAC rate is malpractice lawsuits. I would not call it a zebra. It is a very real concern. You can be sued for anything. You need only read the reference about Dr. Daniel Merenstein towards the end of your post from yesterday “PSA screening for prostate cancer will continue”. He was sued (and his codefendent lost) for doing the right thing.

    The malpractice crisis is to the point where if you are sued, there is a real possibility that you may not get coverage, let alone afford it. Even if the suit is dropped/dismissed/won. Without insurance coverage, you cannot practice medicine.

    You never get sued for doing a cesarean section, you get sued for not doing one. So given the scenario with a questionable fetal heart rate tracing where any “expert witness” can find fault with, (even if is there none) I would rather perform a cesarean section than not. It comes down to a matter of staying in practice and making a living.

    I have been in a practice where we had a 3% cesarean section rate, a 100% VBAC attempt rate with a 95% success rate. The unique factor was that the population was a very homogenous, religious population that rarely if ever sued. “Bad outcomes” were generally viewed as “God’s Will” By the way, our outcomes were excellent.

    You may call me paranoid, but I would say walk a mile in my shoes before commenting. Most readers of this blog are primary care and therefore have a relatively low chance of being sued as compared to Ob’s, and most likely have not been sued.

    The real fault lies with the malpractice lawyers promoting the current skewed legal system, patients who cannot accept the fact that bad things happen to good people for no reason and want to blame someone, and the American public who views bad outcomes as equivalent to winning a lottery.

    • bp

      Perhaps the real fault lies in marginal absent OBs.

      They are relying on nursing staff to notify them and don’t respond quickly because they are doing other things at other hospitals. They may also be someone who really isn’t that good at assessing fetal well-being and who sections to protect himself from the liability associated with gaps in his expertise.

      How about OBs who think they have a right to the perfect career? Move from one patient to another on your schedule and treat them to the limits of your perhpas less than stellar expertise, then act like any delays and deficits are normal and the bad outcomes are acts of God.

  • Aly

    So true. I have to wonder why organizations like the National Institute of Health and U.S. Preventative Task Force, not to mention the actual scientific evidence, are so out of touch with mainstream obstetricians. I definitely think part of it is that some specialists rely on anecdotal rare catastrophic experience rather than peer reviewed research. I feel for the few obstetricians who would genuinely like to offer women the option to avoid a repeat cesarean, but have their hands tied by legal malpractice reasons. But it seems some of them are more concerned with controlling women and their bodies for personal, non evidence based reasons. These are the ones who are quite happy that women are restricted in their options to avoid surgery. Obstetrics has a long sordid history of denying women bodily autonomy, as we all know, always in the vein of “it’s for their own good.”

    I do wonder why a hospital that’s not staffed to perform an emergency cesarean section within minutes is a place for delivering babies at all.

    I’ll definitely be checking out your blog!

  • bp

    It is not a shame women don’t attempt this more often. It is a shame that they are not referred to facilities that can do this safely, as an option more often.

    The notion of “relaxing” the standard of immediate availability of surgery is another way of throwing women under the train. Facilities and their doctors who can’t do this and do it well need to tell women of their option to travel to a bigger medical center to do it safely, and let the revenue associated with informed consent go with them, if they choose. Rupture isn’t the only increased risk. Whatever led to the first section is often more likely to repeat.

    “Relaxed” VBAC standards put women and babies at risk for the benefit of the least trained professionals. They get the relatively high reimbursement of catching if things go well and they bum off all the death and disability to others when they don’t.

    As for OBs not being primary care– don’t make me laugh.
    They do outpatient gyny, prental office, OB, and gyny surgery, then they morphed into doing all women primary care, their psych issues (like post-partum depression, etc.).

    That’s beyond primary care. It’s the old-fashioned general practice of more than 50 years ago. If there is anything wrong it is that these sometimes surgeons get to cut on women and everyone else gets the surgeons who cuts all day everyday and works at it 70 hours a week to boot. Women with gyny and OB issues are the only patients left that are expected to deal with GPs. The lack of surgical expertise in the average OB is yet another reason VBAC should only be done in an advanced facility.

    Midwives and family doctors have more vaginal deliveries because they select out the patients that would have them anyway.

  • Anonymous

    Dr. Lin:

    Obviously, you’re a physician. Why did your wife choose to have a VBAC, and why did she choose a nurse midwife?

    Just wanted you to expand on your thoughts. Thanks.

  • Anonymous

    horses and zebras? please. the assumptions necessary to write this piece are arrogant. dr lin, you are, admittedly, not an obstetrician, yet you pompously presume to understand the thought process of an obstetrician via your 100-odd deliveries and personal, anecdotal observations. physician, specialist and primary care, know that an unusual presentation of a common disorder is more likely that a usual presentation of an uncommon disorder. being primary care does not give you domain over this line of reasoning. as has been stated by other postings, this is an issue driven by malpractice.

  • Not sure why lawsuits are to blame

    Why shouldn’t an injured party sue if you insist a patient attempt VBAC, don’t inform her of the risks, and there is a catastrophic event related to your care?

    Why shouldn’t a patient sue you and or the hospital if you attempt VBAC but you don’t monitor the patient closely enough to manage her case, or there isn’t equipment and staffing immediately avaliable to deal with a catastrophe?

    If you have equipment and staffing and an appropriately informed patient, who is an optimal candidate, who understands the greater risk prefers it for the benefits – chances for a verdict are zero unless you seriously screw up and don’t handle an emergency properly or injure the patient or baby doing so.

    I think the real problem is bad medicine causing bad outcomes. You should be paying attention to what is going on with the patient and her baby and keep the patient informed, and prepared to handle and emergency.

    If you aren’t I can’t understand why you shouldn’t be liable for injuries to the mother or baby.

  • ninguem

    “Not sure why lawsuits are to blame” – I guess you’re right. My hospital has decided they’re not smart enough or quick enough to satisfy that immediately available standard. No matter how fast they respond, it will not be fast enough in the eyes of a jury if the baby or mother do not do well.

    So don’t complain when our hospital says, “why don’t you try the University 120 miles away”? Plenty of hourse staff………and nice government tort limits for a public hospital.

    I was saying the bigger hospital 75 miles away, but I learned they won’t do them either……….so it’s the University or nothing.

    • bp

      “I was saying the bigger hospital 75 miles away, but I learned they won’t do them either……….so it’s the University or nothing.”

      As it should be. The stakes are high. This isn’t amateur hour.

  • June Cleaver

    Interesting to “hear” the debate from both sides. Personally, I’m one of those crazed patients that “insisted” on a VBAC and, when my OB/GYN said “no” I found a provider who was willing to attend my VBAC. The OB/GYN that wouldn’t attend my VBAC, for fear of complications, was the same one who sent me home 4 days after my c-section with a raging infection of my incision. The CNM who did attend was the provider I had wanted for my first delivery but couldn’t have because I was carrying twins.

    I could not be happier that I chopse to have a VBAC with my second delivery. My c-section was horrible. I woke up screaming in pain, developed an abscess that covered my lower abdomen, had to be readmitted for 4 additional days and had home health nurses, every day, for 2 months. With my VBAC, labor was slow and long (I delivered 3 days after contractions started) but baby and I both tolerated it well. I was discharged less than 24 hours after delivery and was back to myself, albeit a bit sore, 2 days after delivery.

    Sadly, I think the reason for OB/GYNs refusing c-sections isn’t the slightly increased risk but the fact that everyone seems to need someone to blame if something goes wrong. it would be interesting to see statistics of how many lawsuits result from vaginal deliveries with complications vs. c-sections with complications (not just catastrophic complications). I think people are less likely to persue legal action if the doctor was doing something – anything – when the complication happened. It’s hard for some people to understand that watchful waiting can be a viable, reasonable option and they want labor and delivery to follow some set guideline and, if it doesn’t go how they think it should, then the OB/GYN should be considering medical intervention.

    I wonder what the successful VBAC vs. repeat c-section rate would be if malpractice suits didn’t exist.

    • bp

      I wonder how you would feel if you were raising a severely brain-damaged child due to “watchful waiting” that turned out to be a sham — minimally skilled practitioners who really didn’t know what they were doing.

      Often minimalists like midwives and other natural nazi types are really just trying to polish a turd. They want to collect for standing around watching nature take its course. They want to call it something like non-interventalist, or natural or something. It is really taking just taking your insurance money for hanging out.

      • June Cleaver

        Well, first of all, I wouldn’t choose a “minimally skilled practioner who didn’t know what they were doing” to attend my delivery. The woman I chose (actually, she was part of a group of midwives and I just happen to luck out and the one I prefered was on call the night of my delivery) was/is a certified nurse midwife with many years of experience.

        Because I was a VBAC, I delivered in a hospital with OBs and anesthesiologst and neonatoligsts present 24/7 (they weren’t just there becasue I was a VBAC. The hospital is staffed 24/7). I was monitored throughout my labor including ultrasound when I presented, to check position, intermittent fetal heart monitoring while I was up and walking around (to encourage contractions and dilation) and then continuous fetal monitoring once I had an epidural. Once my water broke the midwife atached a scalp probe to the baby and in internal monitor to better assess contractions.

        The midwife monitored my labor in the same way an OB would. My baby’s heartrate was never dangerously high or dangerously low. There was never much of a change in her heartrate so no further action was indicated. The only “complication” I had, in the eyes on an OB, was a prolonged labor (I started contractions at 6am on April 26th, my due date, and delivered at 6:51 on April 30th).

        Since we were in a hospital and there was an on-call OB, from the practice the midwives refer to in the event of complications, the OB was kept abreast of my progress should a c-section become necessary. The second or third time I went to L&D (we made many trips back and forth), the OB was already asking why the midwife hadn’t “insisted” on breaking my water or pushing for a c-section. There was no pressing reason to do either and I refused both options when offered. Should complications have arisen, I have no doubt the midwife would have made the need for intervention very clear and I would have agreed.

        Had I not had confidence in the ability of the midwife group I had chosen I wouldn’t have trusted their care. I am not a careless patient and I take an active role in my healthcare. I don’t blindly follow what any doctor may tell me, having had more than 1 who totally screwed up (like the OB sending me home with a huge festering abscess post first c-section). Had I been seeing a lay-midwife I may have had concerns about my care. However, since I was being attended by a certified nurse midwife, in a well equipped and staff hospital setting, I was completely comfortable with the care I received.

        So, you’re scenario of me having a severely brain damaged child because of the ineptitude of a “minimally skilled practioner” wouldn’t have been a possibility as I wouldn’t have been seeing someone who wasn’t a skilled professional. It does beg the question why would someone see a “minimally skilled professional who didn’t know what they were doing” in the first place?

      • http://momstinfoilhat.wordpress.com/ MomTFH

        I find the term “natural nazi” to be extremely offensive. I live in a community with Holocaust survivors, and I am sure they would be horrified by you minimalizing what they went through to defend forcing women into unnecessary surgeries.

        This isn’t the only thing problematic about your replies (how is following evidence based care “amateur hour” or “hanging out”?), but it was the most offensive, and I felt it necessary to point it out.

  • docguy

    I used to do vbacs all of the time, encouraged them, but I have to have call coverage and most of my call partners didn’t want to do it because it requiring being in house, so I stopped.

    ps to the guy who thinks that any bad outcome is because the doctors are at fault. At my residency we had a uterine rupture and there were at least 5 docs present within 40 feet of her bed when it happened. She torn right into the uterine artery and bled out rapidly. we coded her twice on the table and kept her alive and she and baby made it barely That’s the type of complications we are talking about.

    • bp

      The plural of anecdote is not data.

      Take a look at closed claims analysis.

      Community docs not being around is a big factor. Not recognizing problems is a big factor.

      There’s a whole host of fetal assessment tools. Use them. Be there.

  • FaithfulFamilyDoc

    I am a practicing Family Physician who has delivered more than 300 babies in my first 6 years of practice, both in small towns without immediate availability for emergency C-sections and in large cities with an obstetrician and staff in house. From my experience, I would agree with Dr. Lin’s hypothesis that the temptation to eliminate the uncertainty of a vaginal delivery is a major driver for repeat C-sections. I have spent many long nights with a laboring woman, sometimes anxiously awaiting the birth of her baby. In obstetrics, situations can change suddenly even when a labor seems to be progressing well. So why wait wondering even briefly that something could go wrong, when you can quickly deliver the baby surgically and be done. Certainly the fear of malpractice suits may contribute to higher C-section rates, but convenience and payments certainly pay a role. C-sections are reimbursed at a much higher rate than vaginal deliveries. If you have a scheduled c-section that will typically take less than hour to perform, why wait for hours with a laboring woman to perform a vaginal delivery if the physician and hospital will make less money.

    I would also disagree that family physicians and mid-wives select out patients more likely to have vaginal deliveries. Family physicians who deliver typically work in underserved areas, usually in rural areas or inner cities, and so may be the only physician available for pregnant women to see. Additionally, in both residency and private practice, my obstetrician colleagues commented about the large number of high risk patients I would see, which was due to the fact that I served poorer patients from the inner city. Finally, I think the opposite may be true – patients may be more likely to choose a mid-wife or family physician if they are interested in having a vaginal delivery.

  • docguy

    Are you kidding me? A much higher rate? I believe it’s about 40 dollars more for a cesarean section and they always stay 3 days in the hospital versus one or two for a vaginal delivery. Sometimes 3 or 4 days for a cesarean, if any was doing it for the money it would be a vaginal every time because apparently all I am worth is 20 – 40 dollars a day extra for rounding.

    I would like to do vbacs on some patients but do have difficulty with call coverage and hospital policies, but to make this about higher reimbursement is just ridiculous.

  • http://momstinfoilhat.wordpress.com/ MomTFH

    Dr. Evil (and other people exaggerating the evidence of the risk from VBAC – most uterine rupture is not catastrophic, and there was not 180 lawsuits in that study.

    Here is evidence on absolute risk from the Lyerly et al article I link to on the other VBAC thread:

    According to Lyerly et al:
    “Although rates of delivery-related perinatal death are indistinguishable between VBAC and primary vaginal delivery, there is a genuine differential in the rate of uterine rupture–related hypoxicischemic encephalopathy. Such perinatal morbidity is indeed devastating. It is also extremely rare. In a recent large prospective study, the probability of this outcome was 0.00046 in infants whose mothers underwent a VBAC trial at term compared with no cases in infants whose mothers underwent repeat cesarean delivery.”

    This is not worth the scare mongering, sarcasm, and refusal or care we are seeing across the country, much on the two threads about VBAC here.

    We need to stop pretending this is somehow the only risky part of labor and delivery, and that it is very risky. The NIH evidence report on VBAC from this past month I also link to on the other thread concludes:
    “This report adds stronger evidence that VBAC is a reasonable and safe choice for the majority of women with prior cesarean. Moreover, there is emerging evidence of serious harms relating to multiple cesareans.”

    Fear mongering does not prevent malpractice or provide good medicine.

  • Surgical resident

    Bp, I find your inference that OB’s are lazy insulting. My wife is an OB. She won’t do VBAC’s because her hospital won’t allow it and her malpractice carrier won’t cover her. Period. You imply that it is bad that they are seeing other patients. What do you want them to do? Only have one patient at a time? That’s not practical.

    You also state that there are numerous fetal assessment tools available. Really? None of them have been shown to decrease fetal mortality in randomized trials. Of course the strips have been shown to increase lawsuits. Now I do realize that this is impractical to study, but it is still very much an art.

    • Anonymous

      “She won’t do VBAC’s because her hospital won’t allow it and her malpractice carrier won’t cover her. Period. ”

      Not period. They/she don’t have the ability or capability. That’s why the hospital doesn’t allow and malpractice doesn’t cover.

      “You imply that it is bad that they are seeing other patients. What do you want them to do? Only have one patient at a time? That’s not practical.”

      If you have a patient who comes into the hospital with an emergency including labor and they are at risk of rapid deterioration, they had better have a nurse (a very competent one) one on one and you had better be darned
      close by, not at another hospital.

      Everyone else does this in similar circumstances. I don’t know why OBs think they are above the law (and that is where the standard comes from BTW). You both might try reading EMTALA before you graduate.

      “You also state that there are numerous fetal assessment tools available. None of them have been shown to decrease fetal mortality in randomized trials. ”

      Oh really?. Cite a few for me. I was under the strange impression that intrapartum death dropped dramatically and was now nearly non-existant due to electronic fetal monitoring. Too slow a response may prevent death but not brain damage.

  • docguy

    actually i think that fetal monitoring has increased cesarean delivery rates and rates of lawsuits, but has not shown to decrease fetal complications.

    • Anonymous

      Citations? This is the battle cry of the OBs. Get rid of the fetal monitor so they can throw mom in beds and let nature take its course, then bill. Get rid of the smoking gun that would show they should have done something besides show up at the end and catch. If that’s all you want to do, become a midwife.

      If EFM leads a doctor to do unnecessary sections, then prehaps said docs should not be doing OB. (ie if you can’t read the monitor very well and need to do a section in a knee jerk fashion, then moms might be better off without you)

      • Doc99

        Your knowledge of EFM is surpassed only by your knowledge of the practice of Obstetrics.

      • June Cleaver

        “Get rid of the smoking gun that would show they should have done something besides show up at the end and catch. If that’s all you want to do, become a midwife.”

        Wow, I’m sure my midwife would love to hear that she’s been working way too hard for way too many years. The MW who monitored me through part of my labor never left L&D, to the best of my knowledge. She didn’t sit by my bed and hold a cool towel to my head the whole time but I didn’t expect her to. Once I was dilated to 6cm, I did have an experienced OB nurse, in my room, until after delivery. Once I was completley dilated, the onyl time the midwife left the room was to go to the nurses station (right outside my door) and ask the charge nurse to let the OB on call know that I was starting to push. After that, she stayed in my room, at my bed, through 2 hours of pushing (along with a nurse and a second nurse came in once my baby was born).

        After birth, she stitched my tear, helped me get started with breastfeeding, helped me get cleaned up, dressed and to the bedroom and didn’t leave my room until she walked out with me whe I was moved to the post-partum unit.

        What the hell kind of midwife do you know that does nothing but show up to catch the baby after leaving mom to labor alone? That kind of flies in the face of everything a midwife is supposed to do.

        You keep asking for citations. Where are your citations that show EFM has decreased fetal mortality? While you’re at it, where are the citations that show you’re so much more likely to end up with a bad outcome when you ar attended by a midwife than an OB (a CNM as opposed to a lay midwife)?

  • Anonymois

    Bp
    Just because you had a bad outcome foe not mean that all on are lazy, marginal, with inadequate skills.
    Perhaps your bad outcome was the result of negligance, perhaps your kid had cp prior to labor.
    There are good OB’s and there are bad ones. There are good GP’s and bad ones.
    There are good parents and bad ones.
    You cannot stereotype they way you are.
    Your experience with one doctor does not give you the right to call all OB’ lazy and incompetent.

    • bp

      What are you talking about? I don’t any kid with CP. Who said anything about any kid in particiular.

      If you look at closed claim analyses (what OB get successfully sued for) these are the problems.

      I am simply arguing these are inherent in the dysfunctional way many community OBs practice. I am also pointing out that it seems to be against the law. Any other patient that comes in through the ER has a doctor immediately available. If they are at risk of rapid deterioration, they have at least a nurse at their sides.

      The law doesn’t say you have to do things this way. But, if you do this for some patients at your hospital you must do for all. And whatever you do, if there is an emergency condition you have to stabilitize it before it goes bad.

      The typical way community OBs practice is far outside the law. We need better enforcement, whether it is “practical” for them or not, whether it is most profitable for them or not.

  • Anonymous

    Re intrapaerum fetal heart rate monitoring.
    Studea have shown that it does not decrease fetal injury or death.

    If you think it is perfect then I urge you to share the citations. I’ll bet you can’t.

  • ninguem

    Anonymous – “She won’t do VBAC’s because her hospital won’t allow it and her malpractice carrier won’t cover her. Period. ”

    “Not period. They/she don’t have the ability or capability. That’s why the hospital doesn’t allow and malpractice doesn’t cover.”

    Well……yes. And they’re not going to try to make the effort. With two OB’s in a rural hospital and several CRNA’s, no anesthesiologists, it’s the right choice. I suppose they would force the staff to kiss their families goodbye and live in the hospital when a VBAC patient comes by.

    And there **ARE** VBAC advocates who think that’s exactly what the OB’s and the CRNA’s should be doing. The policy came down because they have already had the fight. More than once, as I recall.

  • surgical resident

    Anonymous,

    You really have no clue about medicine or EMTALA so please don’t lecture us. I agree you have a right to be seen on arrival to a hospital, which people are. If a fetus is in distress than they go for C section. Not even VBAC advocates would disagree with that. What you do not have is a right to is a doctor that basically sits by your bedside. Of course, there will be a nurse that is with the patient. When I get a patient through the ED, I see them and write orders, and then leave. I have other things to do as do the OB’s. So please get your facts straight on this.

    The issue with VBAC’s is that it requires someone to be immediately available at all times during this. It isn’t cost effective to do this. Take the liability concerns, whether rational or not, and you have a compelling reason for hospitals to forgo them.

    Finally, it really isn’t fair for me to say that there are no studies showing decreased mortality/morbidity with fetal monitoring, and then to have you say “prove it” with citations. The onus is on you to prove it, which you won’t be able to.

    I can tell you that there are still intrapartum deaths. Heck at our University hospital where there are at least 4 OB’s present at all times they still lose babies. It’s the nature of the beast

  • reformed OB/GYN

    this is a very sweet story. sadly…….this doctor is completely out of touch with this situation because his name is NOT ON THE CHART!!!
    if it were, there would be no article……….

  • .

    You really have no clue about medicine or EMTALA so please don’t lecture us.”

    Oh, really? Funny, I just gave expert testimony to our elected representatives a short while ago on this very subject. I didn’t see you there.

    Medicine is not an upper middle class entitlement program. The law dictates what the requirements are. It is up to you to figure out a way to make a living out of it. If you aren’t smart enough, plenty of others are, so step aside.

    “What you do not have is a right to is a doctor that basically sits by your bedside. Of course, there will be a nurse that is with the patient. When I get a patient through the ED, I see them and write orders, and then leave. I have other things to do as do the OB’s. So please get your facts straight on this. ”

    YM “please substitute my self-serving interpreation of my limited personal experience and wishful thinking for actual facts.” This is why you are not invited to give expert testimony on EMTALA or anything else and probably never will be.

    If you leave before the patient is stabilized and can’t get back in time to prevent deterioration, then you are outside the law. Period. The law doesn’t say you have to stay right there. The law doesn’t tell you what exactly to do. It doesn’t say you can’t delegate this to a nurse. But, prudent practitioners simply don’t go far from patients at risk of rapid deterioration. If a hospital can’t provide this level of service, then they transfer to one that can.

    There’s no obligation to do VBAC. There is an obligation to do it correctly. If you don’t, eventually the youknowwhat will hit the fan and all those standards you would like to imagine don’t apply will be applied. CMS does not look kindly on those who play chicken with patients’ lives for their own profit and convenience.

    There are no defenses to failure to stabilize.

    “Finally, it really isn’t fair for me to say that there are no studies showing decreased mortality/morbidity with fetal monitoring, and then to have you say “prove it” with citations. The onus is on you to prove it, which you won’t be able to.”

    No, the burden of proof is always on the one making the assertion. Another standard of medicine that is too much work for you and beyond your capabilities, so you give spurious arguments that it isn’t true. Another reason you won’t be invited to give expert testimony any time in the future.

  • surgical resident

    Leaving an unstable patient and not being able to get back quickly is indefensible. However, there must be common sense applied to everything. A patient on high dose pressors in the unit doesn’t require a physician to be present at the bedside throughout the night unless he/she is constantly doing interventions. This is different than the patient that rolls into the ED in respiratory distress needing an emergent intubation. Both are unstable, but one clearly allows the physician to leave the bedside. If you disagree than, sorry, but there aren’t enough MD’s out there to do the kind of job you want.

    The point of the article is about VBAC’s. You and I probably aren’t to far off on this. People seem to think that they can just walk in and demand one. I don’t have a problem with someone saying that there needs to be an MD present at all times if you are going to do a VBAC. But don’t say that OB’s have to offer them in their particular setting. That isn’t fair. In addition, these aren’t the classical unstable patients that you seem to refer to. These are patients that have a very small potential to experience a catastrophic event. You say there “defenses to failure to stabilize,” but that’s not the case in this situation. They are stable, they just can crump at any time.

    “No, the burden of proof is always on the one making the assertion. Another standard of medicine that is too much work for you and beyond your capabilities, so you give spurious arguments that it isn’t true. Another reason you won’t be invited to give expert testimony any time in the future.”

    What? You must be a lawyer and not in medicine…. You are asking me to prove the null hypothesis? Here’s what you as an expert need to do. Go get me level 1 evidence supporting your assertion that monitoring decreases risk. Then you can disprove the null hypothesis and thereby proving your hypothesis that monitoring decreases mortality.

    I really don’t care if you are an expert on anything.

  • http://momstinfoilhat.wordpress.com/ MomTFH

    Allowing a trial of labor for VBAC is not much different than performing an induction, if you consider risk and the language of ACOG position statements. A trial of labor for VBAC is not at more risk for rapid deterioration than any other trial of labor, according to absolute risk (which is the appropriate and ethical way to present risk to patient, BTW), nor is it “play[ing] chicken with patient’s lives”.

    The problem with the current approach to VBAC by the medical establishment is the exaggeration of risk by many people, including a few on this thread and blog. Also, there is a difference between refusing to do a procedure as a physician and forcing a patient into a procedure. Remember, trial of labor is the physiological end to the pregnancy, and a repeat cesarean is an intervention with little evidence support to be better, and some evidence it is more risky, according to the very recent NIH evidence report.

    I would think the NIH evidence report may be the most likely thing to be hitting fans soon.

  • Surgical Resident

    “If the patient comes in through the ED, you must make sure that no deterioration is likely to occur from discharge. Any crumping before they are remote from your hospital in both time and space can be a problem. I will laugh the next time I see someone get cited for what you describe. I will bet it’s you.”

    Sounds like an impossible standard to me. No one really believes that a doc should be cited for allowing a patient to crump when it could not reasonable be expected. You imply that MD’s will be cited for a stable patient that codes expectantly (i.e. floor patient that throws a saddle embolus). In addition, if someone is admitted to the ICU, with a poor prognosis and everything within reason is being done, the doctor is allowed to go to sleep if constant interventions are not needed. It is clear that you “feel” like you know the letter of the law, but you have no idea of the practicality of the law.

    The problem with VBAC’s is that someone can have a uterine rupture which requires quick intervention and hence the required availability of anesthesia and OB. If a hospital feels that it is not cost effective for them to offer these then the patient can go somewhere else. If no where close is available, tough. Everyone has a right to care, but you don’t get to dictate what care you will get.

    Again, you clearly are not in the medical or scientific profession. I am aware of no prospective randomized trials that state fetal monitoring has decreased infant mortality. Now I’ll cede to you that it has been 4 years since my OBGYN clerkship, but a quick google scholar search revealed none. The way medical knowledge is accumulated is that someone has to prove that something works or is effective. You don’t get to invent something and proclaim that it works and then demand someone try to disprove your statement. This is where we get the “p” value. The p value basically represents that the odds that the results are due to random chance and hence fail to disprove the null hypothesis. We can set the p value threshold at whatever value we want. The point is that your assertion requires nullification of the null hypothesis (i.e. that there is no improvement in mortality).

  • Anonymous

    <>

    That’s funny. I have M.D. and a couple other letters after my name.

    I am simply someone who got into medicine through merit, not because my father was a doctor. And now we all are supposed to lower the standards because they are too hard for the latter group. People who don’t take positions, jobs and careers that they don’t earn, don’t get overwhelmed by them.

  • Anonymous

    And we have these wonderful thing called the FDA and similar govt regulatory bodies that do just that with each and every drug and device that comes on the market.

    I know because I worked my way through medical and all those other schools I went to doing research for regulatory.
    (Ohmigod, people actually WORK their way through medical school?? They must like, actually deserve to get itl!!!)

    They didn’t. See above.

    But, what is actually relevant here, is that you don’t introduce into an argument and ask other people to disprove.

    I know you are used to getting things without earning them. Sorry, not from me.

    In spite of your apparent advantage in gaining access to careers without proving yourself, no one died and made you God. You do not proclaim things and expect everyone else to accept them until proven otherwise. (which probably isn’t possible, since your understanding is limited to mindlessly repeating phrases from intro stats book)

    I taught this class during the school year. (‘nother job in school, what a concept) I would give that a B- if was in an intro/for non-majors class. It flunks in a real class. They made us pass morons whose understanding was like yours in the easy classes. The powers that be decided all these majors and degrees needed to have an “understanding of research”. But, when most of them couldn’t grasp the most basic concepts in any real way, they created these joke classes that the feeble-minded could regurg their way through and unleashed an entire generation of idiots who think they understand research. I got a tuition waiver for med school, so I can’t complain.

    Maybe you can explain the much simpler question of how EFM got through the regulatory process if it does nothing? I seem to recall this kept me and a lot of other people quite busy and quite well paid to do this for one drug or device for one step. I really thought we did this because, well, you just weren’t allowed to sell medical stuf in the US without it.

    But, I could be wrong. I’m just a doctor, not a doctor’s kid.

  • http://momstinfoilhat.wordpress.com/ MomTFH

    Oh my MAUDE this is not an episode of Scrubs, you two. It is not hard to look up what you two are fighting around. As witty as your banter may be, it doesn’t change the state of the evidence on external fetal monitoring during labor, which isn’t even the point of the original post.

    Here is the ACOG practice bulletin on continuous external fetal monitoring. If you can’t access it (you may need to be a member of ACOG), let me sum it up for you.

    In the introduction, it says:

    “Despite its widespread use, there is controversy about the efficacy of EFM, interobserver and intraobserver variability, nomenclature, systems for interpretation, and management algorithms. Moreover, there is evidence that the use of EFM increases the rate of cesarean deliveries and operative vaginal deliveries. The purpose of this document is to review nomenclature for fetal heart rate assessment, review the data on the efficacy of EFM, delineate the strengths and shortcomings of EFM, and describe a system for EFM classification.” (emphasis mine)

    Here is what they have to say about its efficacy:

    ” * The use of EFM compared with intermittent auscultation increased the overall cesarean delivery rate (relative risk [RR], 1.66; 95% confidence interval [CI], 1.30–2.13) and the cesarean delivery rate for abnormal FHR or acidosis or both (RR, 2.37; 95% CI, 1.88–3.00).
    * The use of EFM increased the risk of both vacuum and forceps operative vaginal delivery (RR, 1.16; 95% CI, 1.01–1.32).
    * The use of EFM did not reduce perinatal mortality (RR, 0.85; 95% CI, 0.59–1.23).
    * The use of EFM reduced the risk of neonatal seizures (RR, 0.50; 95% CI, 0.31–0.80).
    * The use of EFM did not reduce the risk of cerebral palsy (RR, 1.74; 95% CI, 0.97–3.11). ”

    And, their complete, unedited conclusions:

    “Conclusions

    The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):

    * The false-positive rate of EFM for predicting cerebral palsy is high, at greater than 99%.
    * The use of EFM is associated with an increased rate of both vacuum and forceps operative vaginal delivery, and cesarean delivery for abnormal FHR patterns or acidosis or both.
    * When the FHR tracing includes recurrent variable decelerations, amnioinfusion to relieve umbilical cord compression should be considered.
    * Pulse oximetry has not been demonstrated to be a clinically useful test in evaluating fetal status.

    The following conclusions are based on limited or inconsistent scientific evidence (Level B):

    * There is high interobserver and intraobserver variability in interpretation of FHR tracing.
    * Reinterpretation of the FHR tracing, especially if the neonatal outcome is known, may not be reliable.
    * The use of EFM does not result in a reduction of cerebral palsy.

    The following recommendations are based on expert opinion (Level C):

    * A three-tiered system for the categorization of FHR patterns is recommended.
    * The labor of women with high-risk conditions should be monitored with continuous FHR monitoring.
    * The terms hyperstimulation and hypercontractility should be abandoned. ”

    Not really a glowing recommendation.

    Hmm, well, maybe ACOG doesn’t like EFM because it is used to sue physicians. Maybe the Cochrane Database has something on it. Oh, wow, it does!

    Their unedited conclusions:

    “Authors’ conclusions
    Continuous cardiotocography during labour is associated with a reduction in neonatal seizures, but no significant differences in cerebral palsy, infant mortality or other standard measures of neonatal well-being. However, continuous cardiotocography was associated with an increase in caesarean sections and instrumental vaginal births. The real challenge is how best to convey this uncertainty to women to enable them to make an informed choice without compromising the normality of labour.”

    Continuous external fetal monitoring, as it is being applied as the most common obstetrical intervention used in birth in the United States, has not been proven to improve neonatal outcomes significantly other than a small reduction in neonatal seizures, which are uncommon and transient. It does free up labor nurses to monitor laboring mothers from a nursing station, and it provides a continuous metric that has a false positive rate of about 99%, and is being used to sue physicians. I am sure it is involved in many more malpractice cases against ob/gyns than a trial of labor for VBAC.

    It is amazing to me that it is not condemned with the same vehemence as VBACs. It has definite drawbacks that limit the mother’s autonomy and mobility, and I have never met a woman who thought they were comfortable.

    That is one of the reasons I included the use of continuous external fetal monitoring in my research, because I am honestly confused about why some interventions and practices are utilized and supported, while others are not.

  • surgical resident

    Good for you. I guess I didn’t earn my NIH fellowship, mathematics degree, medical degree, highly selective residency, and high in-service exam scores. Regardless of my inadequate past, the data is on my side.

    Here is a selection from a review article:

    EFM became the predominant form of fetal heart monitoring by the mid- to late 1970s.(1) However, experts now conclude that these promises remain unfulfilled and that EFM is, at best, a “disappointing story.”(2) In the twenty-five years of its almost ubiquitous use, no randomized controlled trial has demonstrated that electronic monitoring does a better job of saving babies or improving infant health than intermittent auscultation.(3) Moreover, studies indicate that the inaccuracy of the technique prompts unnecessary interventions and contributes to the nation’s excessively high rate of cesarean delivery, a major surgical procedure which places mother and infant at greater risk of injury and death than noncesarean delivery.(4) Despite the increased risks, the device remains employed in nearly all American delivery rooms. Continued high use of EFM is often attributed to physician concerns about medical malpractice liability and professional inertia. ”

    Please quit with the personal attacks. Also please don’t lecture me on the scientific method or statistics.

    The way this blog works is people argue ideas, not CV’s.

    Cya

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