C Sections and following pregnancies

[jwk]

Here's the real story on VBAC / TOLAC.

Almost nobody does what is referred to as a "classical" C-Section anymore, which it the vertical incision. We still come across these somewhat frequently due to our large immigrant patient population that might have had their previous C-Section in the wilds of Brazil or Guatemala or something similar. Those patients pretty much are not allowed to try a VBAC. The risk of rupture is simply too high.

With the low transverse C-Section, the risk of rupture is far less. But, it's still a risk, and the incidence of rupture with a previous low transverse C-Section (less than 1 %) is still 25 times higher than it would be with a non-surgically scarred uterus.

There are an increasing number of OB's who are going back to VBAC. If the OB stays in-house and has anesthesia coverage in-house, it's a reasonable thing. However, I know a few that do it and aren't in-house. They are absolute fools. If the patient ruptures and has to wait for the OB to drive in, the baby is dead. As someone else has already mentioned, malpractice rates for OB docs are sky-high. That's why there are now so many GYN-only docs around - they have dropped the OB side of their practice altogether. It's also why many family practice docs in small towns have quit doing OB. They can't afford the additional malpractice insurance for the relatively few OB patients they have.

I can't tell you how many C-Sections I've done (and I've done anesthesia for thousands of them) where the uterine wall is paper-thin at delivery. When you open the abdomen and can see the baby's face and the uterus hasn't been cut yet, it leaves a very strong impression. I've also done some uterine ruptures - in our hospital where we can literally start a section in about two minutes, we get fairly lucky. But I've also been in hospitals that didn't have in-house OB and anesthesia coverage where the baby died and the mother nearly did.

 

[Veneficus]

For anyone that thinks the OBs are wrong in their overly defensive decisions I'll tell a little story I witnessed on my time on L&D. Women comes in, has been laboring at home for several hours, came in because a CNMW insisted it had been too long. She comes in, refuses all care, initially. She was told MULTIPLE time by myself, the nurses, the residents, and the attending that she was endangering her baby. Couple more hours go by, she has not progressed, we finally convince her to let us just put a HR monitor on. FHT in the 60's. She refuses emergent section, labors for several more hours, finally delivers a previously healthy, deceased fetus.

Immediately begins yelling that no one told her the risks, etc, etc. Attending was served my last week on the rotation.

Now, will she win? I truly hope not. But even if she doesn't "win", this attending has to take time off work, hire a lawyer, a deal with the stress of a lawsuit. Then there is the chance that his malpractice could just settle if they decide the case isn't worth taking to trial, no big deal right? Wrong, that goes against the physician even if he has no say in the matter, because for the malpractice carrier it is purely a monetary decision.

Now, these scenarios aren't as uncommon as people believe, and they exist in every specialty in medicine. So as much as it pains me to see some wasted decisions and entirely overly conservative decisions made by docs, believe me I get it.

I am thinking there was absolutely nothing that could be done to avoid getting sued in this case.

 

[Dwindlin]

I am thinking there was absolutely nothing that could be done to avoid getting sued in this case.

Probably not. But there was also no malpractice on the part of the attending, he did everything he could to try and get this person to let him intervene earlier (essentially from the moment they came in), likely when the fetus still had a good chance. She was never incapacitated, refused all drugs, and vehemently refused care other than a nurse being in there to help coaching thru contractions with husband. Not to mention that she was reminded of the risk she was taking every few minutes by the nursing staff, as well as, anyone else who walked into that room.

Worst part is if this actually makes it to trial (which it shouldn't) he will likely lose, as juries on the whole do not side with the "rich, greedy, doctors."

 

[Veneficus]

Probably not. But there was also no malpractice on the part of the attending, he did everything he could to try and get this person to let him intervene earlier (essentially from the moment they came in), likely when the fetus still had a good chance. She was never incapacitated, refused all drugs, and vehemently refused care other than a nurse being in there to help coaching thru contractions with husband. Not to mention that she was reminded of the risk she was taking every few minutes by the nursing staff, as well as, anyone else who walked into that room.[/QUOTE]

You cannot reason with stupid. They already know more than everyone else.

http://en.wikipedia.org/wiki/Dunning–Kruger_effect

Worst part is if this actually makes it to trial (which it shouldn't) he will likely lose, as juries on the whole do not side with the "rich, greedy, doctors."

No offense, but the US medical system does invte a lot of this.

From EMS to concierge, when you price yourself out of the market, somebody is going to sue to get out of the bill. It is just a question of who is going to get sued.

I have seen it from MVA victims when they get the ambulance bill all the way up to inpatients.

But in my not expert legal opinion, the solution isn't defensive medicine, the solution is to hire your own better lawyers.

Sure it will have a higher up front cost, but I think in the long run if every personal injury lawyer knew that suing a doctor meant going the distance every time, the effort to payoff would make them much more reluctant.

 

[OODAsquirrel]

The US OB system is really screwed. If there is a single book I think every woman of childbirthing age in the US should read it is Pushed by Jennifer Block. The US has one of the highest c-section rates in the industrialized world and along with frighteningly high mortality and morbidity rates for mom and baby.

The push for moms to have c-sections and induce and accept other medical interventions is overwhelming.

Women (myself included) have to guard their deliveries like a hawk and, yes, sometimes that means moms overdo it because they simply do not trust the medical community not to trick them into an unnecessary procedure because of convinience or whatever.

Either way the idea that a woman MUST have c-sections after her first is way over stated and simply not true MOST of the time.

 

[Veneficus]

The US Medical system is really screwed.

Fixed it for you

http://www.nejm.org/doi/full/10.1056/NEJMp0910064

and sliding...

 

[Flight-LP]

Just finished 8 weeks of OB and we TOLAC (Trail of Labor After C-section, VBAC isn't used much anymore) nearly everyone...the risk of rupture is around 1%. There had to be a very compelling reason to section a patient if the only "indication" was previous section.

Interesting. Can you post some updated research to substantiate this?

Being on the largest dedicated HROB transport team in Houston, I have never heard this statistic. We (meaning staff MD's / L&D / Post & Ante Partum personnel) routinely use and document VBAC.

We transport a few of these VBAC patients that outlying OB's relunctantly agree to try another round using the natural canal. What we find is that many of them need to remain assertive in their knowledge and practice that the aforementioned adverse effects are very real. They also need to be mindful that the level of care potentially needed for an ubrupted or ruptured patient has to supercede the usual cosmetic or personal request of the mother. Far too often I have seen these risks underestimated and with severely negative outcomes (i.e. I shouldn't have to be hanging FFP and Plasma and hitting 3rd round hemmorhage meds).

All factors have to be taken into account.

I'm all for trying to balance nature, but a little common sense can go a long way. I guess that is lacking Southeast Texas with some OB's.

Good topic!

 

[Dwindlin]

Post #11 has a link to an article. You can use that to track other citations you may find relevant.

 

[abckidsmom]

Interesting. Can you post some updated research to substantiate this?

Being on the largest dedicated HROB transport team in Houston, I have never heard this statistic. We (meaning staff MD's / L&D / Post & Ante Partum personnel) routinely use and document VBAC.

We transport a few of these VBAC patients that outlying OB's relunctantly agree to try another round using the natural canal.

Please, please respect women enough to use the real terminology: trial of vaginal birth. I know the difference is subtle, but when you're dealing with such a touchy subject, it makes a big difference. Women for whom this is a problem are really sensitive about any euphamisms.

What we find is that many of them need to remain assertive in their knowledge and practice that the aforementioned adverse effects are very real. They also need to be mindful that the level of care potentially needed for an ubrupted or ruptured patient has to supercede the usual cosmetic or personal request of the mother. Far too often I have seen these risks underestimated and with severely negative outcomes (i.e. I shouldn't have to be hanging FFP and Plasma and hitting 3rd round hemmorhage meds).

The risks are underestimated and the fool OBs hang pitocin on a previously sectioned uterus. Patience is the real thing that people lack in the situation. Ever hear of a FTP (Failure to Progress)? Many people call that Failure to be Patient.

All factors have to be taken into account.

Yep. They sure do. And sometimes, OBs with blinders on make decisions for their golf games or their family holidays and not necessarily their patients. Just throwing that out there. When you get in a hurry for a baby to get born, that starts a lot of trouble.

 

[FLdoc2011]

Please, please respect women enough to use the real terminology: trial of vaginal birth. I know the difference is subtle, but when you're dealing with such a touchy subject, it makes a big difference. Women for whom this is a problem are really sensitive about any euphamisms.

I'm not sure I'm follow here. Euphemism? VBAC is an accepted medical term, one which ACOG uses.

 

[abckidsmom]

I'm not sure I'm follow here. Euphemism? VBAC is an accepted medical term, one which ACOG uses.

"natural canal"

 

[Veneficus]

It has been my observation that many women think they actually know more than they do about their bodies by virtue of being women.

I find it strangely ironic being a man and explaining menstruation and breast development to them.

More still childbirth.

 

[jwk]

The US OB system is really screwed. If there is a single book I think every woman of childbirthing age in the US should read it is Pushed by Jennifer Block. The US has one of the highest c-section rates in the industrialized world and along with frighteningly high mortality and morbidity rates for mom and baby.

We don't have "frighteningly high" M&M rates for mom and baby". Perhaps higher than they should be, but to think it's due to too many C-Sections means assuming that what you read in some women's magazines or from a woman who had a bad experience is the gospel truth. An absolutely HUGE reason for continued M&M is mothers who abuse drugs and baby's who are born addicted. Save some of your outrage for those moms - they're the same ones, along with many others, who never, ever, go for pre-natal care when it's available free (even for illegal aliens) and then have a lawyer on speed-dial if something goes wrong. [/QUOTE]

The push for moms to have c-sections and induce and accept other medical interventions is overwhelming.

The high C-Section rate in this country is LARGELY due to the malpractice climate in the US. OB docs have among the highest malpractice rates in the country. Parents, on behalf of their children, have an 18 year window to sue for "injuries at birth", which has NO legal definition. It can be anything from death to "learning disabilities", which surely must be the cause of someone's child not getting into Harvard since everyone else in the family went there. Are there legitimate causes of malpractice with OB? Absolutely. Are there far more nuisance suits where patients (and of course their attorneys) hope to make $50-100k in a quick settlement? You bet!

Women (myself included) have to guard their deliveries like a hawk and, yes, sometimes that means moms overdo it because they simply do not trust the medical community not to trick them into an unnecessary procedure because of convinience or whatever.

If you don't trust your doctor, GO TO SOMEONE ELSE!!!! It's that simple. Docs want the same thing you do - healthy mom, healthy baby. If they err, 99.9% of the time they do it on the side of caution. I work with a couple hundred OB docs - they all have different levels of expertise, but there isn't one of them that doesn't care deeply about doing everything they possible can to insure a good outcome.

"Sometimes moms overdo it." Seriously? I see women come in with 10 page "birth plans" full of expectations and demands. Some are easy - some are absolutely ludicrous. Look, if you want an intervention free delivery, fine. Do it at home with a lay midwife and roll the dice. Thankfully, most deliveries are complication free. Some are not. If you're at home with a lay midwife, or at a "birthing center", it can be a crap shoot. When something goes wrong there, your baby and you could both wind up dead. And that's not exaggeration or scare tactic.

Either way the idea that a woman MUST have c-sections after her first is way over stated and simply not true MOST of the time.

Again - too many women's magazines. There are plenty of OB docs out there that will do VBAC's. And some that won't. Any woman who cares that much one way or another should have the intelligence and common sense to seek out a doctor that shares their concern.

And here's another tidbit for you - we now have to turn women down who WANT a C-Section. We have women ask for primary C-Sections for their first baby. We have women who want to be induced the last couple days of December if they're within a month of their due-date so they can get the tax deduction. We have women that want to be induced in the middle of the day on 12/31 so they can have a New Years' baby, maybe even get the "First Baby of the New Year" designation and get their picture in the paper. And we have TONS of women who, once they've had that first C-Section and especially after having labored and had to end up with a C-Section, ALWAYS want their subsequent births to be by C-Section. Why? Because they can avoid labor and the pain that goes with it, AND, they can pre-schedule it at a time that is convenient for them.

And here's one more tidbit - a surgically scarred uterus does indeed have a higher risk of rupture. Every time this happens, whether from a C-Section or other gynecologic surgery, the chance of complications increases. We now see women having 3,4 or even 5 C-Sections. We have also seen a drastic increase in placental malplantations - previas, accretas, percretas. These are nightmare deliveries with a high M&M rate.

ACOG actually has guidelines and indications for C-Sections. New data has shown that babies benefit from staying in utero as close to the due date as possible. 39+ weeks is better than 36-37 weeks - a few years ago, most didn't think it made any difference except for growth. Any that are done at my hospital prior to 39 weeks require valid indications, and convenience or desire of the mother is not on the list.

 

[Veneficus]

We don't have "frighteningly high" M&M rates for mom and baby". Perhaps higher than they should be, but to think it's due to too many C-Sections means assuming that what you read in some women's magazines or from a woman who had a bad experience is the gospel truth. An absolutely HUGE reason for continued M&M is mothers who abuse drugs and baby's who are born addicted. Save some of your outrage for those moms - they're the same ones, along with many others, who never, ever, go for pre-natal care when it's available free (even for illegal aliens) and then have a lawyer on speed-dial if something goes wrong.

Actually, there is a large "homebirth" or non medically assisted movement that inflates these statistics as well.

However, it is important to also realize that infant mortality is measured by 2nd year death rates, not by deaths during birth.

Despite massive spending, the trend in the article I sighted continues to show the US healthcare system in decline compared to the same measurements everyone else uses.

Of interesting note on Women's magazines and other webbrowsing, etc. I sat in a seminar on psychology of women in my undergrad days, and one of the things pointed out was women seek consensus and when soliciting information, all opinions carry equal weight.

Having a kid does not make anyone an expert on childbirth. Some of the biggest morons on Earth have more kids than anyone else. You must weigh the advice of a healthcare provider more. Even they are not all at the same level of knowldge and ability.

However equating these M&M of infants ad mothers with drug using neglectful women sounds more like political villianization of a minority group than actual fact.

Since US second year death rates are worse than Russia and China, where many have no healthcare and in the former a more significant drug and alcohol problem than the US, I have to call BS on the undesirable mother propaganda.

The high C-Section rate in this country is LARGELY due to the malpractice climate in the US. OB docs have among the highest malpractice rates in the country. Parents, on behalf of their children, have an 18 year window to sue for "injuries at birth", which has NO legal definition. It can be anything from death to "learning disabilities", which surely must be the cause of someone's child not getting into Harvard since everyone else in the family went there. Are there legitimate causes of malpractice with OB? Absolutely. Are there far more nuisance suits where patients (and of course their attorneys) hope to make $50-100k in a quick settlement? You bet!.

This I agree with.

If you don't trust your doctor, GO TO SOMEONE ELSE!!!! It's that simple. Docs want the same thing you do - healthy mom, healthy baby. If they err, 99.9% of the time they do it on the side of caution. I work with a couple hundred OB docs - they all have different levels of expertise, but there isn't one of them that doesn't care deeply about doing everything they possible can to insure a good outcome.

The toruble with this is layperson ignorance. I can spot a good OB a mile away, a bad one even easier, but the general populous of any country I have been to can't tell a good doctor from a bad.

The recordable statistics are of no actual use. You ever see the numbers on a trauma surgeon compared to a private practice surgeon who excludes everything but easy patients?

OB is the same way. You cannot compare one operating in a rural or inner city area compared to an upper class suburbanite.

"Sometimes moms overdo it." Seriously? I see women come in with 10 page "birth plans" full of expectations and demands. Some are easy - some are absolutely ludicrous. Look, if you want an intervention free delivery, fine. Do it at home with a lay midwife and roll the dice. Thankfully, most deliveries are complication free. Some are not. If you're at home with a lay midwife, or at a "birthing center", it can be a crap shoot. When something goes wrong there, your baby and you could both wind up dead. And that's not exaggeration or scare tactic.

Absolutely spot on.

While some birthing complications are known from prescreening, some happen spontaneously, for a variety of reasons. If personal anecdote is your thing, when my daughter was born my wife had an artery spontaneously rupture. There was no way to predict that, it just happened. (picking the best OB/Gyn in the region to oversee the birth was not an accident though)

Plan worst case, set yourself up for success, is my advice for all of life.

ALWAYS want their subsequent births to be by C-Section. Why? Because they can avoid labor and the pain that goes with it, AND, they can pre-schedule it at a time that is convenient for them.

Meperidine is seriously under-used in the States.

But for other cost reasons, it is far cheaper to go to Europe for childbirth, I would never want to have a baby in the US. It just costs too much and is far too complicated.

And here's one more tidbit - a surgically scarred uterus does indeed have a higher risk of rupture. Every time this happens, whether from a C-Section or other gynecologic surgery, the chance of complications increases. We now see women having 3,4 or even 5 C-Sections. We have also seen a drastic increase in placental malplantations - previas, accretas, percretas. These are nightmare deliveries with a high M&M rate.

A buchered, scarred uterus with large amounts of complications. Sounds...Predictable.

Part of the problem with McMedicine, people were not meant to be cut open with a blade and altered. When you are, you are accepting the risk and future complications is worth the intervention of the moment.

"Elective C-section" is on the list of most stupid things I have ever heard. Doctors who agree to them are foolish and while probably not deserving, should expect to get sued sooner or later when something goes wrong, including on subsequent deliveries or 18 years later.

ACOG actually has guidelines and indications for C-Sections. New data has shown that babies benefit from staying in utero as close to the due date as possible. 39+ weeks is better than 36-37 weeks - a few years ago, most didn't think it made any difference except for growth. Any that are done at my hospital prior to 39 weeks require valid indications, and convenience or desire of the mother is not on the list.

This is just amazing to me. The fact that people need scientific data to adopt a position that medical/surgical altercation of a biologicial process that doesn't cause pathology is worse than no intervention.

What could I possibly say...