Re: vbac policy, I really need opinions regarding this man's actions in defiance of hospital policy.

From: ainsron@msn.com
Tue Jan 25 10:16:30 2000

Not to beat a dead horse, but the argument regarding VBAC and how at risk we place ourselves if we continue to perform it without in-house anesthesia comes down to the last two paragraphs of the ACOG practice guideline: "The following recommendations are based primarily on consensus and expert opinion (Level C): 1) Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians readily available to provide emergency care. 2) After thorough counseling that weighs the individual benefits and risks of VBAC, the ultimate decision to attempt this procedure or undergo a repeat cesarean delivery should be made by the patient and her physician."

As far as I am concerned, both statements are of equal importance. And please note, they are level C recommendations, based on consensus and expert opinion. I think for now, I will weigh in on the side of patient autonomy and education. I am just as opposed to a mandatory requirement for repeat cesarean section by my hospital as I am towards the mandatory requirement of VBAC which some insurance entities which was proposed in the past and vigorously opposed by all of us.

A hospital, such as the one I practice in, with three obs and three anesthesiologists cannot realisticly provide 24 hour in house anesthesia and obstetrical presence. We provide the best care we can under the realities of our situation. To expect patients who request VBAC to drive 90 miles to the nearest tertiary care center or send them by ambulance would be ridiculous. It would also be hard to explain to a patient who has had a previous C/S and previous uneventful VBAC, that it is now too dangerous for her to have another vaginal birth at our hospital because of a change of ACOG's policy on VBAC.

>>Question is, why can't the hospital perform VBAC's?? They are high risk along with diabetes, hypertension, placenta previa, etc etc. Does the hospital refer high risk patients elsewhere or *only* VBAC's.
>If your hospital can not comply with the VBAC's guidelines because of
>some non remediable factor, such as no anesthesiologist in house
>possible during a VBAC because let's say there is only one
>anesthesiologist in the region, then the hospital is correct in not
>allowing VBAC's. Certainly if you can not comply with ACOG you and your
>patient are both better off with a C/S.
>If however, it can be corrected then the physician might be correct in
>pushing the hospital into complying with the guidelines. At the
>hosspital where Dr. Efrain Ramirez and I work, anesthesia didn't want
>because it would cost them money. But they were forced by our pressure,
>now they are in-house all the time. Placenta previa, prolapsed cord,
>severe fetal distress all require it in addittion to VBAC's. Five or
>ten minutes away from hospital is not enough.
>
>I know he will be suspended, but it would be good to know if the
>hospital can comply with the guidelines of ACOG and doesn't because it's
>not *economically* feasible or for some other correctable reason.
>
>My two cents, we now have the anesthesia, and are working on
>drills and logistics to have an open OR or a L&D room for VBACS with C/S
>capabilities. Of course, it costs money. But good medicine isn't
>always cheap nor is it the easiest.
>
>Carlos

--
Ronald E. Ainsworth, MD



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