Reply turned post, VBAC consent form style

Jill has a great post up at The Unnecesarean that is a great example of the interactive nature of the internet birth advocacy community that Amy Romano talks about at Science and Sensibility. The post is almost a wiki of a VBAC consent form. A doctor who reads the site and its comments says he has changed the way he interacts with patients (!!) based on the voices there. He also has submitted a VBAC consent form he cannot edit but can add to. The comments and suggestions are fantastic and I recommend reading them all. I put up a small suggestion, then posted again almost immediately, musing about ACOG’s Practice Bulletin on VBAC:

Sorry for the double post here, but my comment made me think. I just read over the ACOG practice bulletin on VBAC last night (after getting into an annoying “devil’s advocate” conversation with a fellow medical student who was studying for his women’s health final) and the recommendation I posted above (which is a recommendation to offer a trial of labor to all eligible patients) is a highest level (level A) recommendation.

There are two interesting points. One, the suggestion that a physician be immediately available is a level C (the lowest level). I think ACOG is clear in saying this should be offered, and that is more important than the immediately available issue. Language about physicians being available for emergency cesarean also appear in their bulletin on inductions, but that is rarely mentioned. Finally, under “Intrapartum Management”, it says:

“Once labor has begun, a patient attempting VBAC should be evaluated promptly. Most authorities recommend continuous electronic monitoring. However, no data suggest monitoring with intrauterine pressure catheters is superior to external monitoring. Personnel who are familiar with the potential complications of VBAC should be present to watch for nonreassuring fetal heart rate patterns and inadequate progress in labor.”

I think this is a much lower standard than many people say this bulletin warrants.

Also, under delivery: (emphasis mine)

There is nothing unique about the delivery of the fetus during a trial of labor. The need to explore the uterus after a successful vaginal delivery is controversial. Most asymptomatic scar dehiscences heal well, and there are no data to suggest that future pregnancy outcome is better if the dehiscence is surgically repaired. Excessive vaginal bleeding or signs of hypovolemia at delivery require prompt and complete assessment of the previous scar and the entire genital tract.”

3 Comments

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3 responses to “Reply turned post, VBAC consent form style

  1. Kristin

    Do you know of anywhere that requires an IUPC and a manual exploration after a VBAC?

    • MomTFH

      No, I don’t. I do know that one of our local hospitals did use IUPCs and scalp monitors routinely, even in low-risk vaginal deliveries, for several years. Supposedly a few cases of neonatal herpes encephalopathy and a new attending from another institution put an end to that policy.

      In order to properly diagnose most uterine ruptures, which are primarily nonsymptomatic, from what I would understand, you would have to do some sort of exploration of the uterus afterward. I think some VBAC research does do this in their protocol to get more accurate statistics. Although the term “uterine rupture” sounds dramatic, ACOG doesn’t even think it needs to be screened for after a VBAC delivery.

      I did mean to bold the first sentence of that paragraph. That is what I think is important about that quote.

  2. Pingback: Plugging away « Mom’s Tinfoil Hat

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