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VBAC scare tactics (2): When bad outcomes in the past affect patient options in the future

June 30, 2009

This post is part of a continuing series on “VBAC scare tactics” and the questions that VBAC moms can ask their care provider when confronted with these scare tactics.

Many women who want to have a vaginal birth after cesarean (or VBAC, pronounced “vee-back”) in this country have faced some sort of opposition from their care providers when they have expressed their desire to VBAC.  Oftentimes, this opposition comes in the form of ” VBAC scare tactics.”

The (outrageous) statements are often misleading, exaggerated efforts by OBs (and yes, even midwives) to discourage women from VBAC and to encourage them to “choose” a repeat cesarean.  (Of course, it’s not really a choice if your provider won’t even “let” you VBAC, is it?)

And if you find yourself up against a barrage of scare tactics–as I once did–it can be exceedingly difficult to stake your claim and argue against the doctor (again, or midwife) who may or may not have your and your baby’s health prioritized higher than medico-legal concerns and who may or may not be hurling phrases like “catastrophic uterine rupture” and “dead baby” your way.

If you do find yourself facing such scare tactics, and if you do want to have a VBAC, there are some questions that your care provider should be able to answer when s/he hurls those scary and/or outrageous comments and standards your way.  And if s/he refuses to or even cannot answer these questions, then you might want to consider finding an alternative care provider–one who is making medical decisions based on research, evidence, and even respect for your patient autonomy and not on fear, willful ignorance, or even convenience.

Worth noting is that I do not intend to suggest in this series that I am overwhelmingly “anti-OB.”   However, I do think that there are a great many OB/GYNs (and midwives, for that matter) who, for whatever reason, mislead their VBAC patients by misrepresenting the facts about VBAC, exaggerating its risks, downplaying the risks of repeat cesarean, and seemingly making up reasons to exclude their patients from being “acceptable” VBAC candidates.  These actions are inexcusable, not only because they can undermine maternal and neonatal health but also because they undermine a mother’s autonomy over her body.  Nonetheless, I also know that there are some OB/GYNs who not only practice evidence-based medicine in regard to VBACs but also who wholeheartedly support (and even encourage) a woman’s right to choose a vaginal birth after a previous cesarean.  And I know this because one such OB attended the beautiful, triumphant birth of my second son.

Scare tactic #2: I’ve seen a bad VBAC outcome, and it was terrible.  You really don’t want to choose a VBAC over a repeat cesarean.

Questions to ask in response:

  • Does that mean that you do not support VBAC, or that you no longer feel comfortable attending VBACs?  (This is the obvious question–because if your care provider does not support VBACs, yet you still want to attempt a VBAC, then you need to find a new care provider!)
  • Are there any shared circumstances between myself and the mother whose VBAC attempt ended badly that would make you think that I had an increased risk of uterine rupture?  What type of incision did she have?  Was she induced with Cytotec, Cervidil, or pitocin?  Was her labor induced with pitocin?  (As uncomfortable as you might be to ask these questions, they are all worth asking.  This is because labor induction and augmentation and non-low-transverse incisions are all associated with higher uterine rupture rates in moms attempting VBAC.  Notably, for medico-legal reasons, your care provider might not be able to disclose this information to you.)
  • Is that outcome the only reason that you would disqualify me as a candidate for VBAC?  In other words, am I not a good candidate for VBAC, or do you no longer choose to attend VBACs?

A more nuanced analysis:

A response to this “scare tactic” is a bit trickier than the ones which exaggerate or even misrepresent the risks (and even benefits) of VBAC and repeat cesarean.  And this is because the fault of this “scare tactic” lies not in the care provider’s reporting of the facts about VBAC but in his or her logic and reasoning.

Before I go on to examine this fault, I’ll state the following in the care provider’s defense: any doctor or midwife with half-an-ounce of humanity will reel over the death of an infant or child.  This is not to say that they are not affected by the death of an adult.  But, as it would be even for a layperson, the death of an infant or child can have especially tremendous emotional consequences on a health care provider.

(Admittedly, I say this partly from the experience of observing my parents as they have grieved over dying or severely injured children in their work as an ER physician and a nurse in the NICU.   For instance, even after nearly thirty years of practicing medicine, my father will be devastated for days on end after the death of a child.  And my mother still remembers every single name of the infants who died in the NICU while she worked there over thirty years ago.)

In this respect, by some stretch of the imagination, one might understand why a recently grieving doctor or midwife would claim that they would no longer attend VBACs even if this decision is based not on reason or facts but on his or her emotions.

Nonetheless, this grief and the horror over the experience of a “bad VBAC outcome,” is not a legitimate reason to exclude all women from choosing a VBAC over a repeat cesarean.  For even if a “bad outcome” can make it seem emotionally as if a catastrophic uterine rupture occurs in 100% of VBAC attempts, this is simply and obviously–and statistically–not the case.

And as sad and terrible as a catastrophic uterine rupture is–and as important as it is to remember that real women and babies and not mere “statistics” experience them–current studies show that the rate of catastrophic uterine rupture occurs, at most, in .255% of VBAC attempts.  In fact, the landmark 2004 NEJM study on VBAC and repeat cesarean outcomes –a study that examined nearly 18,000 women attempting VBAC–reported the rate of neonatal death following a trial of labor as .08% (or 13 out of 15,338 VBAC attempts).

In this respect, it is simply unreasonable for a care provider to proclaim that no woman should attempt a VBAC based on his or her experience with a bad VBAC outcome when very, very few of VBAC attempts will end badly.

In other words, the care provider’s experience with a bad outcome does not thereby increase the rate of bad outcomes for other VBAC attempts.  It simply (albeit sadly) represents one of those very, very few VBAC attempts that do end badly.

To critique the logic of the care provider a bit further, it warrants asking (although I can all but guarantee you that it would result in huffiness and/or outrage on the part of the care provider) if a bad experience with cord prolapse would make the care provider cease to perform amniotomies.  Or if a severe case of uterine hyperstimulation and fetal distress would make him or her cease to use pitocin or Cytotec.  Or if a fatal maternal hemorrhage on the operating table would make him or her cease to perform cesareans.

And I’m guessing that the answer is “no.”

And this says a lot about the fear and irrationality that marks the current climate on VBACs within obstetrics these days.


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