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Re: VBAC revisitedFrom: Cheri Van Hoover (cherivh@xdcr.com)Sat Jul 5 11:50:04 2003
Robert J. Carpenter, Jr. MD wrote: > I am not much of a rabble rouser (sic); however it would appear that what is needed > is appropriate region/area wide information on the origins for the decisions that have > been made by the three hospitals in the area. That would likely include information > which is produced and given to the women in the office, newspaper and other media > presentations really focusing in on the roots of the problem. I, on the other hand, have been considered a bit of a rabble rouser in my time. I appreciate Dr. Carpenter's comments on this very complex and troubling issue, and would like to raise a few other concerns of my own. I am in sympathy with those who feel that they can not safely perform VBACs in their communities. I know that I have been privileged (in some ways, anyway - no place is Nirvana) to always work in areas where in-house anesthesia, blood bank, and physician coverage has been available. But the inability of women to choose to receive a type of medical care that is within the bounds of obstetrical safety simply because they live in a community where there are fewer resources made available to them is both sad and frustrating. Repeat C/S is not without its own risks. The rate of surgical complications during a repeat C/S is higher than that at a primary. So these women are being forced to undergo a possibly (probably?) unnecessary major surgery fraught with attendant risks (anesthesia, blood loss, injury to other organs, infection, etc.) because the hospitals in their area have not joined together to create a system whereby appropriate coverage could be provided to allow these women to make their own informed choices about which risks they would prefer to take. Our institution recently provided care for a woman from Northern California who actually moved to San Francisco for 3 weeks to await labor so she could have her second successful VBAC. I attended her in labor. This woman and her husband incurred considerable expense to get the birth experience they felt was safer. They pointed out that most women in their community (where the total C/S rate, they said, is 30%) do not have the financial resources to be able to do what they did. They reported that some of their acquaintances are driving to hospitals in other areas where they arrive in labor without records so they can VBAC. They also told me that there has been no widespread community awareness of this situation. They learned only in early pregnancy that they would be unable to attempt VBAC in their local hospitals with the doctor she knew and trusted. The same day this woman delivered (NSVD, intact perineum, healthy baby) our team did a repeat C/S on another woman who had extensive adhesions, anatomic distortion, and serious bleeding. This woman had to be transfused with 2 units before leaving the OR. The surgery took over 2 hours. She was advised not to attempt further pregnancies. It seems to me that it is only a matter of time before some woman who has been coerced into having a surgery she didn't want and probably didn't need because of lack of hospital support will suffer surgical complications and sue the hospital and the physician for a bundle. I think it would be an ultimately cheaper and certainly more ethical solution to look for ways smaller hospitals in less heavily populated areas could coordinate their resources to provide appropriate obstetrical care, including VBAC.
-- Cheri Van Hoover, CNM, MS Faculty OB/GYN Group University of California, San Francisco
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