Others write letters, EBM style

Go read this excellent letter of support on behalf of a physician who is being harassed by his hospital for supporting midwives, VBAC attempts and vaginal breech deliveries.

Here is an excerpt:

When medicine is practiced primarily for profit, convenience and out of fear of litigation it is not good medical practice nor is it evidence-based medicine. The c/section rate in this country is nearing 1/3 of all births. While the current hospital model will profit from this trend you must ask at what cost? Evidence is clear that repeated c/sections put women at greater risk and the evidence mounts that babies born this way have higher rates of breathing difficulties, breastfeeding difficulties and learning disabilities. Doctors and midwives who stand up for patients rights are often the target of ridicule and harassment by the very hospitals and organizations that their hard work supports. Does this sound like what is happening at your facility??

Another part I like is this line:

“If a hospital is not safe to have VBAC, it is not safe to give birth.”

It is so stunningly simple. I may have even heard it before, but forgotten, but right now it sounds incisively brilliant.

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8 Comments

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8 responses to “Others write letters, EBM style

  1. I always wonder about that, the “well, we don’t have the anesthesia or the surgeons around the clock…” kind of explanation – so what happens when other surgical emergencies come in?

  2. M'Lynn

    The availability of surgeons and anesthesia has to do with a hospital’s trauma rating. A community/suburban/rural hospital will likely not have it in house.

    Uterine rupture, while rare, requires intervention within minutes. Most “stat” sections give you a lot more time than that.

    I worked for a community hospital as a nurse in the OR. We had a 30 minute response time to report to the hospital once called. We did stable gunshot wounds/stabbings. THe majority of our cases were appendicits, broken bones… Higher level trauma centers have staff in house at all times. If you are severely injured, the first responders know which facilities are appropriate for transport. That is why, sometimes, they call a helicopter.

    • MomTFH

      From what I understand, most uterine ruptures do not require interventions within minutes. Out of the few that rarely do occur, most are asymptomatic, and the most likely symptoms would be fetal distress on the external fetal monitor. And then, if whoever is reading it thinks it merits a cesarean, there is one. Just as there would be for a strip indicating fetal distress in any labor.

  3. I have been reading a lot of posts recently about VBACS and comments saying they are required to get the baby out in minutes or 5 minutes. I can tell you right now in reality, that is impossible. The gold standard is a decision to incision time of 30 minutes. We are not magicians. We can not blink our eyes and nod our heads and poof, baby is out. In a true uterine rupture, which unfortunately I have witnessed a handful of times, the fetus crashes and the mom suffers severe pain (even with an epidural) with change in vital signs. It is rare, but a real uterine rupture is often fatal for the infant, even if we delivered in 5 minutes or less.
    I want to stress that a VBAC uterine rupture is still rare. As rare as any other catastrophe like a cord prolapse or abruption. I was personally willing to take the risk and have a VBAC. If I had a true uterine rupture, I am not convinced the place of birth would have changed any neonatal outcomes.

    • MomTFH

      In the recent research in AJOG and the Green Journal on VBACs, I don’t remember there being any fetal losses even in hundreds of births with a certain amount of ruptures, but I may be mistaken. It’s late and I don’t want to look up the studies. I do believe you that you have seen more than me in the trenches, and that catastrophic ruptures can occur. I think that the majority are not, even among the rare ones that do occur, and most are asymptomatic.

      • MomTFH

        OK, I found a site that everyone should have access to. I have full text access to a lot of journals, but if I link to the articles on here, you all don’t necessarily have access. And, if I only link to the abstract, you can’t see the tables on neonatal outcomes. But, I found a site about uterine rupture with some numbers:

        The uterus can rupture before or during labor. In a large study of mothers who had one previous low transverse cesarean, the risk of uterine rupture was 1 per 625 women who chose repeat cesarean without labor, 1 per 192 women who went into labor and tried for VBAC, 1 per 129 for those who had their labor induced without prostaglandins (usually with Pitocin), and 1 per 41 when prostaglandin medications were used for induction. When the uterus did rupture, 1 in 18 babies died, and 1 in 23 of the women required a hysterectomy.

        from http://www.drspock.com/article/0,1510,5926,00.html

        That site lists the risk of rupture at 1 in 129 trials of labor that are not induced, but this study:

        http://www.ncbi.nlm.nih.gov/pubmed/19579095

        had no uterine ruptures in almost 300 non induced labors, but they also did not use pitocin induction or augmentation.

        I think the method of determining uterine rupture, especially a uterine rupture that is not symptomatic or clinically important, may vary from study to study.

  4. 7 minutes from decision to incision is the best time I have ever seen at my hospital. It is possible only when all the players are there and ready and do this regularly. I am told 10 minutes is the minimum time and that this time was discovered by doing post mortem C-sections back in the day when many more women died in childbirth. So my impression is that we have 10 minutes.

  5. A hospital that is not equipped to handle a VBAC is not equipped to handle any medical emergency, period. They need to stop using that excuse.

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