Congrats, and a shame

I just heard a cousin Susan of mine went into labor yesterday. She had a cesarean. She was scheduled to have a cesarean today, a repeat cesarean because she had a primary cesarean about five years ago after a failed induction indicated by worsening preeclampsia. No similar problems this time around.

When our mutual friend called to tell me last week to tell me about our cousin Susan’s impending scheduled repeat cesarean, I had literally just downloaded Neonatal Outcomes After Elective Cesarean delivery from this month’s issue of Obstetrics and Gyneocology. This article compares elective repeat cesareans to VBACs, and includes analysis of “failed VBACs”. VBACs had the best neonatal outcomes, significantly better than elective repeat cesarean, and failed VBACS were the worst.

Our mutual friend said “Isn’t it great that her doctor gave her a referral to another doctor if she wanted to try for a vaginal delivery?” I am amazed at what a different outlook I have than other people. I guess it depends on where you get your info.

Huh? You mean he didn’t tell her she needed therapy, or ask her to bring in her husband so they could both talk sense into her? (Both stories I have heard from mothers). I try not to rant at my family, but she brought it up. I answered something to the effect of, no, I thought it was a shame that his own organization’s journal put out an article just this month that a vaginal delivery is better for the baby (we already know it is better for the mom) and he refuses to even consider “allowing” it if she remained in his practice. And, because of his refusal of care, and the implied negativity associated with the attempted trial of labor, she did not decide to try for the vaginal delivery.

Of course he should refer. Is he going to forbid her from seeking another practitioner? At least he went through the trouble of offering a specific name.

But, it gets worse. She did go into spontaneous labor. Studies, including this one, indicate that a cesarean after labor starts in a VBAC situation may be worse than a cesarean without labor initiation (of course there are a ton of confounders there). Did they let her labor? Of course not. It was the day before her scheduled cesarean. So they sectioned her. Even thought this study (and others) indicate the best outcome would have been from a successful vaginal delivery.

The most expensive outcome was for the path her doctor chose. Is that an influence? I should hope not. I am more prone to believe that people are more afraid of standing by than taking action, they are trained to do sections, the ACOG statement that they need to be there for the whole VBAC labor is a liability, etc etc. But, I would hope that that the higher health care costs associated with the repeat cesarean (especially once labor has started) combined with poorer outcomes would lead to pressures, either from the government, advocate groups, or the “free market” or private insurance, to curb this.

Sigh.

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13 Comments

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13 responses to “Congrats, and a shame

  1. Argh, this kind of situation is so frustrating! I mean, she’s in labor and they still sectioned her?

    I remember reading last week on an obgyn list-serve an OB complaining about how VBACs and vaginal breeches have been “foisted upon” OBs, as if a) all OBs have to do them (which is patently not the case) and b) the patient’s desires really have no relevance at all.

    • MomTFH

      Isn’t it ironic how evidence of better outcomes is just hog-tying our doctors?

      Oh, LOL, I need to go wipe my eyes. The irony, it stings them.

  2. The CDC had some stats recently about how often singletons, twins, and triplets or higher order multiples are delivered by section – for twins it has gone from 50% to 72.9% over the past 10 years – couldn’t help wondering if that’s because more providers now just see “twins” and automatically schedule a section. Thoughts?

    http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5819a9.htm?s_cid=mm5819a9_x

    • MomTFH

      I just saw that link – was it off one of your round ups?

      I think many doctors are automatically sectioning twins. I know in South Florida that is the case. Vertex vertex, dizygotic,doesn’t matter. South Florida is the harbinger of things to come nationally, intervention wise.

  3. Weird. When women come into my hospital in labor we try to encourage them to Vbac. It takes way more nursing staff to do the C-section! And it ties up 2 Doctors. If the baby is destine to just fly right out the vagina, give it a shot!

    Many Doctors will now not delilver twin number 2 breech and will not do a version of twin 2 so this put the poor woman in a terrible spot because the Doc will only deliver baby 2 if it is a perfect condition and it almost never is. I hate to see women come in and labor all night then push out twin one with a huge laceration then stat c-section baby 2. Personally, I would rather you do the c-section on me in the first place.

    Also intubating a pregnant woman is very very risky. Not at all easy. And the death rate increases with the intubation….So anesthesia staff don’t like the situation either.

  4. Pingback: Reply turned post, VBAC study style « Mom’s Tinfoil Hat

  5. Captain Kirk

    what is that line from Shakespeare? First let’s kill all the lawyers – that would help.

  6. MM

    What a shame, indeed.

  7. I was the first-born in my mother’s “brood”, and delivered by caesarian section after the midwife discovered I was breech presented.

    My younger brother, the second, also presented a difficult delivery but was a vaginal birth.

    When my sister (the youngest of the family) was due, my parents made plans to be in hospital well in advance, and made plans to go to the much bigger hospital in the next town, which had better facilities. After all, two difficult births already meant the third was expected to present difficulties too.

    My sister was the easiest and swiftest delivery my mother ever had. So easy and so swift, that had the ambulance been trying to reach the next town’s hospital, my sister would probably have been born halfway down the main road between the two towns. The driver made the decision instead to head straight for the local, much smaller, hospital, and that’s where my sister was born shortly afterwards.

    So, yeah, from this story, I’d definitely agree, “If the baby is destined to just fly right out the vagina, give it a shot!” My sister didn’t really give anyone a choice in the matter, she was so eager to see the world.

  8. Pingback: Reply turned post, Academic thoughts on VBAC style « Mom’s Tinfoil Hat

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