Sunday, June 24, 2018
Health

Tampa ob-gyn: VBACs may not be a risk worth taking

The Tampa Bay Times recently reported on the VBAC debate, the vaginal birth after caesarean section, a complex topic on many fronts. Patients, physicians, insurers and policymakers are all concerned about the high rate of caesarean births. So it's not surprising that many are interested in reversing this trend, both for women having their first child, and for those who want to attempt a vaginal birth after a caesarean.

The Times article pointed out that many local obstetricians don't offer patients the alternative of VBAC, and raised the question of why this should be, given the low rate of complications — about 1 percent among women who are appropriately screened.

As a practicing obstetrician-gynecologist in Tampa for 20 years, I have practiced on both sides of the VBAC debate. But my division's partners and I stopped offering this option in 2004 after lengthy, thoughtful discussions.

Why? Not out of fear of litigation, or because it's more convenient to schedule a c-section, and certainly not because we didn't accept the latest safety data on VBACs. Our decision came down to this: Even though the risks are small, they are so unpredictable and potentially so devastating, we could not justify continuing to offer the option.

A little background: In 2010, the American College of Obstetrics and Gynecology broadened its endorsement for VBAC, stating that for women in good health who have had one or sometimes two caesarean deliveries, a trial of labor in the next pregnancy could be justified.

The biggest danger for these women would be rupturing the c-section scar in their uterus. As VBACs became more popular in the 1980s and 1990s, enough data could be collected to show that this is a rare event, occurring perhaps once in 100 attempts.

That statistic has been published in respected journals and is widely accepted. It's a key piece of information that physicians give patients seeking VBAC as part of the informed consent process. Patients also are told that VBAC is appropriate only for women whose medical history puts them at low risk of complications.

But even among women who fit these criteria, it's just about impossible for a physician to predict who might be part of the unfortunate 1 percent.

If a woman does suffer a rupture, an emergency c-section must be performed immediately to save the baby's life and the mother's uterus — even the mother's life if there is a great deal of blood loss.

In such a case, there is no time to lose. That's why VBACs must always be offered in an appropriately staffed hospital setting. Even so, with all precautions taken, success is not guaranteed if blood loss is rapid or the uterine rupture is not immediately evident.

Physicians must explain all of these risks, however rare, to patients. And all of us grapple with this question: How do we know when an expectant mother, her partner and family are truly informed? How can anyone know how they will feel if the worst-case scenario — however rare — happens to them?

As physicians we are charged with providing safe, excellent patient care. And just like our patients, we physicians are the products of our experiences and those of our colleagues. Let me pose a few hypotheticals, based in reality but changed to retain anonymity:

• If Dr. X, an excellent ob-gyn, diagnoses a uterine rupture, and does all she can and still loses the mother or child, what happens with the next patient seeking a VBAC? Should Dr. X change her method of informed consent for the well-being of future patients?

• If Mrs. Y attempts VBAC, sustains a uterine rupture but her physician does an emergency c-section in time to save both Mrs. Y and her baby, should she be a proponent for the safety of VBAC?

• What of Mr. Z, whose wife lost her uterus from uncontrollable hemorrhage and whose baby has cerebral palsy, the result of uterine rupture on her way to the hospital while in early labor? Will he simply accept what happened as bad luck, given that his wife had given her fully informed consent?

• What of the overwhelming majority of VBAC patients blessed with the successful outcome everyone so desperately desired? Should their voices be more important than Dr. X, Mrs. Y or Mr. Z?

There, I believe, lies the true significance of "less than 1 percent." Who decides which side of the statistic should dictate policy?

Dr. David Minton is a partner in Partners in Ob/Gyn, a division of Women's Care Florida in Tampa. He is board certified by the American Board of Obstetrics and Gynecology, and a Fellow of the American College of Obstetricians and Gynecologists.

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