November 30, 2004
VBAC Under Attack
On another obstetrical front, The New York Times on Monday ran a story about hospitals that have prohibited obstetricians from performing vaginal deliveries for women who have previously had Caesarean sections. Although the recent shift in attitude is explained early in the article by reference to recent studies that have increased the predicted rate of uterine rupture and catastrophic blood loss from 0.5 percent to 1 percent, "[s]ome doctors and hospitals freely acknowledge that fear of being sued has driven their decisions," in addition to "concern for patients' safety":
Hospitals say they cannot comply with guidelines issued in 1999 by the American College of Obstetricians and Gynecologists, which call for a doctor to be available "immediately" throughout active labor during such a birth, to perform an emergency Caesarean if needed. Previous guidelines had called for them to be "readily" available.
I guess they can call this a liability question if they want, but if the leading accrediting college for OBs has had this as a standard of care for the past 5 years, does "risk management" add anything to the debate (unless ACOG's standard was driven by liability concerns and not by science)? The article does not tar ACOG with that brush:
Dr. Charles Lockwood, chairman of the department of obstetrics, gynecology and reproductive sciences at Yale and an author of VBAC guidelines issued by the American College of Obstetrics and Gynecology, said alarms began to sound in the late 1990's.
"What precipitated this were reports in the literature and reports that came to the college itself about women who had ruptured their uterus, particularly in rural settings, with no doctor and no anesthesiologist around," Dr. Lockwood said. "Babies died, and women lost the uterus in some cases."
That prompted the obstetrics college to change its formal recommendations for vaginal births after Caesareans in 1999, saying a doctor should be immediately available during labor to perform an emergency Caesarean.
And yet the med-mal demon immediately reappears in the article:
"[The ACOG standard] had a chilling effect," Dr. Lockwood said, particularly on hospitals in rural areas that did not have anesthesiologists available around the clock, and on doctors in solo practices who could not stay with a patient throughout her labor.
"I think the real death knell to VBAC's was the malpractice crisis," Dr. Lockwood said.
November 30, 2004 | Permalink
You and your readers might be interested in a statement by the American College of Nurse-Midwives in response to the recent VBAC developments. The statement is available online at http://www.midwife.org/press/display.cfm?id=445.
Another item might be what we consider the most systematic review of the literature on cesarean section, also available online at http://www.maternitywise.org/mw/topics/cesarean/booklet.html.
Keep up the great work.
Posted by: Tim Clarke | Dec 1, 2004 1:34:20 PM