Friday, March 19, 2010

VBACs, C-Sections, and Pregnant Patient's Rights, Part One

As we get closer to our daughter's due date, medical appointments, tests, and filling out hospital policy forms are kicking into high gear.  This is especially true since this birth is a planned as a vaginal birth after cesarean, or VBAC. 

On one hand, we're lucky to have a hospital within a workable distance of our home that permits VBACs.  On the other, the hospital is an hour away.  There are four other hospitals less than half that distance from our home.  However, they each have a ban on VBACs.  In order to deliver at this more enlightened hospital, I had to switch midwife practices, and accept driving an hour each way for each prenatal appointment, test and ultrasound.  This also meant lots of extra time and fuel, and some extra nerves trying to make sure I'd be back home in time for my husband to get to work on time.  There were several times, involving tests and ultrasounds, that he had to request time off because there was no way to get there and back in time.

Of course, I did have the option of sticking with my first choice midwife, and either going in for a sceduled c-section with her back-up surgeon, or to fight the policy while in labor.  After dealing with a cruel and sadistic hospital staff (probably the result of the nurses being understaffed and undervalued, and a doctor who did not provide me with enough information to make a truly informed decision) during the birth of our son, I wasn't up for another patient rights fight in the middle of labor again.  Perhaps, if I were 10 years younger, I may have taken on the fight.  This time around, I just want a supportive hospital staff without all the tension.

Some folks may ask what the big deal is about a hospital policy that requires a woman that has had a prior c-section to deliver all future babies by c-section.  The reason often cited for repeat c-sections is to prevent a uterine rupture, which could result in severe trauma to both mom and baby, including death. 

That sounds pretty scary, until you look at the frequency of such complications.  For women with a low, transverse scar, a uterine rupture occurs in fewer than 1% of women attempted a VBAC.  This means the risk of a uterine tear is about the same as it is for a woman with an untested uterus- in otherwords, all first-time moms!  And, we certainly do not require all first-time moms to deliver by c-section.

C-sections are common.  But, just because they are common, "common" doesn't equal "safe".   A c-section is a major abdominal surgery.  The manner in which the placenta separates from the uterus is different than in a vaginal birth.  In a c-section, the placenta separating leaves scarring that can endanger future pregnancies.  That same scar tissue also increases the mother's risk for uterine cancer later on.  In a vaginal birth, the placenta seperates leaving no scar tissue.

The risks do not end there.  There can be complications from anesthesia, including paralysis and death.  There is a risk of the surgeon accidentally cutting unintended organs and tissue.  The risk for hemmorhage increases the likelihood of a hysterectomy.  There is also added risk of major infection, pulmonary embolism, and stroke.  Any of these c-section risks may lead to death.

Of course, there are times when c-sections are life-saving procedures.  I am not referring to those kinds of emergency c-sections.  All too often, unfortunately, they are performed for convenience or out of fear.  Some women, who only have media images of birth for their prior birth experience, are afraid of the pain of a vaginal birth.  Television and movies show a completely distorted image of birth, usually of a woman who goes from saying "my water just broke" to saying "the baby is coming" in 2.2 seconds.  Usually she screams through the ever so brief labor, looking completely out of control, and then deliviers in the back of a taxi, or in the best of circumstances, barely makes it into the hospital.  If it is a hospital scene from the beginning, the woman will still be depicted as out of control and screaming, but this time screaming for pain medication. 

That simply isn't how labor is.  While there will always be an exception to every rule, and a precious few women will have a labor that is too quick to get to the hospital, that really only happens on tv or in the movies.  Labor typically lasts for hours, and most of that time, the contractions are very manageable.  For those women who schedule c-sections out of fear, please know this: recovery from a c-section is much longer and more painful than a vaginal birth.

Some women may schedule c-sections because they want to plan exactly when the baby will be born to accomodate a work schedule, vacation plans, or some other event.  This is a case of a major elective surgery that is totally unnecessary.  Perhaps this is born out of the "common" equals "safe" misunderstanding.  But very often, ob-gyns do not adequately explain the risks associated with c-sections.  When a woman expresses her desire to have a c-section, it isn't questioned.  Of course, the c-section will result in a higher fee for both the doctor and the hospital, so why would it be questioned?

There is another circumstance where c-sections happen for convenience, and this is the most reprehensible circumstance- convenience for the surgeon.  Unfortunately, pregnant women are often seen as unreasonable, written off as being "hormonal", and are forced to advocate for themselves while in the middle of labor, which is next to impossible.  If the birth is not a sceduled c-section, the mom has no guarantee that she will have her own ob-gyn attend the delivery.  Usually, she will be at the mercy of whoever is on call at the time she goes into labor.  All too often, doctors are quick to recommend c-sections, especially if the patient is perceived as "difficult", just so that the doctor doesn't have to deal with a mother who actually insists on being treated like a human being with respect.

Clearly, some c-sections are absolutely necessary.  C-sections, however, are the most common surgery women receive in this country, with the percentages climbing every year.  Many hospitals have c-section rates as high as 35-40%.  Compared to deliveries with midwives (either at home or in a hospital/birth center environment) of closer to 5-10% resulting in a c-section. 

This is a highly-charged subject. As such, it will be handled in multiple blog entries. There is much more to cover, including why some hospitals ban VBACs, are such bans enforceable, homebirths, and the quality of women's health care in general in the US. 

Live better, a little every day.

No comments:

Post a Comment