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Re: VBAC, immediate availabilityFrom: ainsron@msn.comThu Feb 15 09:55:57 2001
At Thu, 15 Feb 2001, art fougner, md wrote: > >to paraphrase johnnie cochrane - "if they can't do it, they must quit!" > >just my opinion - i could be wrong. > >art I think you are wrong. This is another excerpt from Flamm's commentary, and I think it places a needed perspective on the whole argument. The Appropriate-Hospital Controversy The literature documents thousands on thousands of VBACs with almost uniformly good outcomes, but most of these labors took place in hospitals in which obstetricians, anesthesiologists, and operating room nurses were immediately available.(6, 7) In some settings, it may not be possible to perform a "crash" cesarean within 10-15 minutes of the onset of an ominous fetal monitor pattern. It is tempting for those of us who practice in large medical centers to conclude that hospitals without round-the-clock in-house cesarean teams are not appropriate for VBAC. However, that logic also would lead to the conclusion that such hospitals are not equipped to handle any obstetric cases. Sudden obstetric emergencies such as placental abruption, cord prolapse, and unexplained severe FHR decelerations can occur in parturients with no previous cesarean, and the incidence of each of these complications is similar to the incidence of uterine rupture. Therefore, although it may be reasonable to refer VBAC patients to centers with immediate cesarean capabilities, it does not seem logical to mandate such referrals. This is especially true in rural areas where a patient might opt for home birth if her only alternative involved extensive travel to an urban medical center. This also raises the question of whether it is appropriate to single out VBAC patients to sign a document acknowledging that it might not be possible to perform a cesarean quickly enough to prevent fetal brain damage. Should all women at hospitals without full-time in-house cesarean teams be given this same informed consent and be offered the opportunity to seek obstetric care elsewhere? A more reasonable approach would be to strive to improve response times for emergency cesarean operations at all hospitals. This will not be an easy task in some settings, but there are few more worthy goals. Conclusion As we approach the end of the 20th century, the definition of the "appropriate" cesarean rate remains elusive and the place of VBAC remains controversial. The issue of what constitutes appropriate informed consent for VBAC continues to be debated. Discussion of even a small risk of potential fetal brain damage certainly will dissuade most women from attempting VBAC. Is this good medicine or just a misguided attempt at risk management? Is it appropriate to inform patients of each and every conceivable risk of a given treatment option? Where do we draw the line? The risk of an infant being neurologically impaired when delivered by cesarean performed to salvage a fetus at 25 weeks' gestation is at least a hundred times greater than the risk faced by a term infant in a woman attempting a VBAC. Yet, we do not insist that women with extremely premature infants sign consent forms stating that if they decide to proceed with a cesarean they may end up with a neurologically impaired child. Clearly, there are risks to VBAC, but the aforementioned consent forms vastly overstate them. A woman with a prior cesarean is at increased risk regardless of her mode of birth, and eliminating VBAC will not eliminate the risks. Vigilance with respect to primary cesarean delivery is the only way to avoid this dilemma. The young woman delivered by primary cesarean for "lack of progress" in the latent phase of labor will have a permanently scarred uterus and will be at some increased risk during any and all future pregnancies. For the moment, at least in some parts of the country, the pendulum seems to be swinging back toward routine repeat cesarean. This may cause the national cesarean rate, which has been stable at approximately 22% for several years, to once again begin to climb. As the next century comes to a close, our descendants will no doubt look back at our current cesarean rates and smile. The question is, Will they find our current rates ridiculously high or ridiculously low?
-- Ronald E. Ainsworth, MD
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