VBAC Bans and Court Ordered Cesareans


Arizona Mother Joy Szabo

All around the country we are starting to hear stories just like the
one of Joy Szabo, threatened by a court order for a cesarean section if
she was to show up at her local hospital Page Hospital of Lake Powell,
AZ. in labor attempting to have a VBAC.
Now, lets get into the history of Joy’s pregnancies. She had a healthy
vaginal birth with her first child, and then with her second child she
had an emergency cesarean section for a placental eruption, which was
followed by a healthy and safe VBAC with her third child. For those not
familiar with the term VBAC it means Vaginal Birth after a Cesarean
Section.
So what is the problem with Page Hospital?
Recently in June, the hospital decided they would no longer allow VBAC,
because of staffing problems they are having. Stating that they would
not be able to urgently deliver a baby if there is a problem with a
VBAC. But then comes the question about other moms who may need an
emergency cesarean section who have not had a previous cesarean
section. How are they able to deliver those babies under an emergent
situation, but not a mother who is having a VBAC?
Sorry but if you can’t handle one emergency, you can’t handle any and shouldn’t be delivering babies at all.
It is a cheap cop out.

Unfortunately we are seeing this trend across the country. Women
being denied VBAC for the same reasons stated above, or because Doctors
simply do not do them.

For more information on VBAC bans across the country visit http://ican-online.org/vbac-ban-info

To speak out against this human rights violation, contact Page
Hospital President and CEO Peter Fine at peter.fine@bannerhealth.com
Or visit their Facebook page and inform them of your outrage.

http://www.facebook.com/home.php#/BannerHealth?ref=ts

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To schedule an interview with CTBirthAdvocate please contact Communications Director Rachel Perrone at rachel@rhrealitycheck.org.

  • eamd

    I’m a medical student. I believe it is and will be my role to help women deliver their babies in ways they find safe and positive, and I find "court-ordered caesareans" to be completely abhorrent. However, I also do not think it is appropriate to characterize Page Hospital’s policy as a "cheap cop out" or something which results from a lack of respect for human rights–my guess is the reasons are more economic. OB/GYNs pay through the nose for malpractice insurance, and while the risk of VBAC-related complications is low, it is still considerably higher compared to vaginal births before c-sections (regardless of how skilled the provider is). Page Hospital should do its best to rectify the "staffing problems" it is having in order to expand the options they can offer women, and fear of malpractice isn’t an excuse to fail to provide care, but to run this article without mentioning the lawsuits which frequently follow bad outcomes of VBACs fails to tell the whole story.

  • ctbirthadvocate

    VBAC is proven to be safer for low risk women, especially with previous successful VBAC’s. There is absolutely NO reason for this woman to be subject to a completely unnecessary surgery.

    Not only that, but if this hospital does not have "adequet" staffing for a VBAC emergency, they should not be doing ANY birth because an emergency can happen at ANY time, not JUST during a VBAC. Simple as that.

  • lineline

    However then it should also be mentioned the reasons that VBACs CAN have higher complication rates, and look at VBACs with OBGYNS vs. VBACS with midwifes (who can do them legally in some states). By reasons, I mean what happened during the birth (was she INDUCED, which has been shown to be a major cause of complications), and what type of incision was used during the previous section. Uterine rupture is one of the most popular complications, and is at least correlated with, if not caused by overuse of inductions. Fear of lawsuits is an issue with all kids of obgyn care…

  • ctbirthadvocate

    lineline, please read the piece. This is a mother who has already had one successful VBAC, meaning her "risks" for anything happening to her are even greatly lowered.
    The hospital’s excuse was their facility is not properly staffed in case of an emergency, which raises the question of how they are properly staffed to handle any kind of obstetric emergency.

    Midwives can attend a VBAC in all states legally in a hospital.

  • drdredd

    All it takes is for one disaster to happen during a VBAC, and the lawyers will be flocking like vultures.  At this point, VBACs aren’t standard of care in most hospitals.  (What kind of hospital is Page Hospital?  Is it a small, county hospital or large, tertiary care hospital?  Does it have an adequate NICU?  Are the medical staff experienced with VBACs?  You’d better believe all of those questions would be asked during a malpractice suit.)

     

    The threat of being sued is quite high for most specialties, but ob/gyns are particularly affected.  Unless tort reform is on the table, I can’t blame them for wanting to avoid high risk situations.  And trying to force a doctor to do a procedure he/she does not want to or does not feel comfortable doing is also unjustifiable coercion.

  • ctbirthadvocate

    Who sets what the “Standard of Care” is today? ACOG? Hospital Administration?

    It shouldn’t matter. Women should have the choice to have a natural birth after a cesarean, they should not be forced to have a RISKY surgery that studies prove is more dangerous for the baby.

    http://www.uch.edu/about/news/2009/repeat-cesareans-babies-at-risk.aspx

  • meghan

    Page is a tiny community hospital. It has two obstetricians and one anesthesiologist. It has one OR. It has 25 beds. It does not meet in any way the criteria for VBAC, unless the OB and anesthesiologist are able and willing to be present in the hospital throughout this woman’s labor.

    Her having a tested scar is not really the point. Permitting VBAC for her requires that the hospital take on the liability of attending VBAC in a setting where they cannot possibly meet standard of care to do so. You really expect a hospital to take on a service they cannot safely provide? How is that different from her demanding a heart transplant from a hospital without a transplant service?

    As a CNM and a woman who has had two cesareans, I believe in VBAC. I believe in VBAC as a safe alternative — when it’s in an environment that can provide it safely. Joy chose to live in a tiny rural community with a small local hospital.

    Realistically, if she had said nothing about her plans for VBAC, she cannot be forced to have a cesarean. She would have come in in labor, been admitted under EMTALA, and declined cesarean. There would have been no time to seek a court order, and the issue would have been moot.

  • meghan

    Standard of care is a nebulous concept, because it involves as much liability as it does evidence-based practice.  But whether it should or shouldn’t matter, it damn well does.  Welcome to the real world.

     

    Also, women do have the right to decline a cesarean.  However, if they’re smart, they don’t announce their plans in advance to a hospital that does not provide VBAC and needs to cover their asses.  It’s not irrational.  Women have sued because they claimed they were not thoroughly consented to the risks of VBAC.  Why would a hospital knowingly take on that risk, given that they are not meeting the standard of care in doing so since they cannot provide an emergent section?   

  • ctbirthadvocate

    If that is the case, they are not equipped to hand ANY birth emergency and should simply not be doing births.

  • meghan

    Realistically, birth emergencies have warning signs long before they truly arrive.  Those that don’t (cord prolapse, for example) a) generally have risk factors, and b) are vanishingly rare.  You really expect a hospital to contravene standard of care and leave themselves wide open legally speaking over a known increased risk of uterine rupture? Seriously?  Particularly when having the VBAC isn’t the issue — it’s that Joy announced she wanted one, backed the hospital into a corner and expected that her refusal would change policy.  She could always refuse a cesarean.  By announcing she wanted a VBAC ahead of time, she opened the door for the hospital to seek a court order. 

  • ctbirthadvocate

    But studies show that elective repeat cesareans have MORE emergencies and complications for moms and babies than VBAC. This woman has a less than 1% chance, especially after already having ONE VBAC successfully, IN THIS SAME HOSPITAL.

    Seriously? There is no argument here.
    Good for this woman that she is going else where now, I hope she sends the bill for all her traveling expenses to Page Hospital.

  • drdredd

    Again, not true.  All emergencies are not alike.  It’s like saying a hospital shouldn’t do any bypass surgeries if they’re not equipped to deal with a problem related to pacemakers.  The two don’t necessarily relate to each other.

     

    Besides, if Page is indeed a small hospital, it’s probably the only one in the area.  Do you really want it to "not do births"?  What are you going to do, tell a pregnant woman to go elsewhere because the hospital just doesn’t do obstetrics at all?

  • bennean7

    Seems doctors and hospitals want it both ways. They want to be able to say *do it my way or your baby will die* (which implies it won’t if you do it their way) and then not be sued when inevitably as happens in birth something goes wrong.

    There is increased risk of rupture in VBAC over repeat c/sec. Did you know that even repeat c/sec has an increased risk of rupture over hysterectomy? Should we therefore recommend hysterectomies for all women who have had c/secs because doctors are increasingly wary of rupture? I hope not.

    Let’s talk about this rationally. Risk of uterine rupture in a first time VBAC with no induction or augmentation and no prior vaginal births is generally considered to be about 0.4% to 0.5%. Risk of miscarriage during amniocentesis or premature birth(recommended and accepted risk by many physicians) is generally considered to be 1% (that’s twice as high as rupture in VBAC, thank you). Risk of cord prolapse in ANY pregnancy is generally considered to be approximately 1%. Risk of any other emergent condition in any pregnancy (placenta abruption, accreta, precreta, previa, etc.) is generally considered to be between 1% – 3%. Outcomes from prolapse and placental issues are typically every bit as devastating as outcomes from rupture, IF NOT MORE SO. (Often something termed a *rupture* is not catastrophic, but a slight window or dihesence in the scar). Moreover, there are increasing ruptures in women with no previous scar, due to misuse of drugs for induction. So this argument that VBAC is so risky holds no water for me…if VBAC is too dangerous, then pregnancy itself is too dangerous, and to me it’s time to get out of obstetrics if you think this way.

    And, since when do we put concern for the state of the doctor’s pocketbook above concern for women and babies? We can’t do VBAC (which, btw, is the natural outcome of a post-cesarean pregnancy) because there might be lawsuits (I’d love to see lawsuit statistics between people who *choose* VBACs, versus people who are coerced into them as often happened in the 1990s…generally people who choose a path tend not to sue unless treatment is egregiously horrible…but people who are coerced into something will be more likely to sue). BUT, we can expose mothers *and babies* to higher likelihood of risk of death, morbidity, and NICU and ICU stays by performing repeat c/secs? Have you all seen the recent studies that indicate babies are 2-3 times more likely to end up in the NICU (and I think die even but can’t remember for sure if that was the conclusion) if born by repeast c/sec than by VBAC???? How is it justifiable to defend a doctor’s decision not to do something that is statistically healthier for both his patients, in order to protect his pocketbook? What happened to first do no harm???

    I find many ofthe comments to this article sickening. As a woman, I see my place. I have none. My life, my health, and even my babies’ lives and health are nothing compared to the almighty doctors’ pocketbook. Great to be living in the early 2000s, when we have our priorities really straight.

  • jayn

    Liability issues aside (from what I’ve heard, the situation just plain sucks for all parties), the arguments behind the hospital’s POV don’t really make sense to me. This woman has to have a VBAC or a repeat C-section. There are no other options. By refusing to attend the VBAC, it seems to me that the hospital is forcing this woman to agree to more/different risks than she is comfortable with taking. I’m not sure what standard of care includes ‘ignore the patient’s wishes’ or ‘she’s on her own–we don’t want to deal with her’.

  • meghan

    They cannot force her to have a cesarean.  SHe can decline.  I have had patients decline.  They’re not forcing her to have a c-section: by announcing her intent, she’s forcing them to take action or risk liability.

  • meghan

    Cord prolapse has risk factors but no warning.  UR, by contrast, has been validated in the research to have early changes in FHR.  So you are proposing that it’s ethical for a hospital to monitor a labor, known to be at elevated risk of not only UR but also placenta accreta and abruption, because of the prior scar, and be unable to intervene?  Wishful thinking does not erase a cesarean scar.  VBAC is not the same as labor with an intact uterus.  Is it dangerous? Not particularly, when monitored and able to intervene as needed.  But it is not a "low-risk" labor.

  • meghan

    I don’t agree that ERCS is riskier than VBAC.  One of the morbidities included in most studies is TTNB, transient tachypnea of the newborn, which is more common in CS, including ERCS.  But in magnitude of problem, do you really want to compare a relatively common but benign condition like TTNB with uterine rupture, which is rare but devastating?

  • phylosopher

    and gee, what was that about a delivery team, and a medical team, and the doctor as partner in healthcare.  Unfortunately, all those cheerleaders now want the QB to be reading from a secret playbook.  Sorry Meghan, but your advice is pretty appalling.  I’m applauding this woman for taking a stand. Being pro-choice and fighting for that right doesn’t stop with deciding to have the child, you know.

  • smjesq

    A couple of points should be added here:

    1. I understand Joy had her first vbac at this very same hospital, which was in the same location and had the same number of beds. So, why won’t the hospital “permit” vbac now?
    2. The so-called ‘standard of care’ that the hospital is citing is an ACOG guideline that was amended a few years ago so that it now calls for hospitals where vbacs take place to have an in-house anesthesiologist and OB standing by. ACOG has admitted that this new version of the guideline is based upon concerns about lawsuits, NOT upon concern for the welfare of the patient. The guideline is acknowledged by most authorities as lacking good scientific evidence to support it. Medical standards and guidelines should be based upon evidence, not economic concerns such as liability exposure. Numerous studies have been published over the past few years by respected authors — many in ACOG’s own medical journal — supporting the relative safety of vbac over elective repeat c-section. ACOG has refused to follow the evidence and change its guidelines, however.

    3. The fact is that a hospital that considers itself unable to handle a vbac should definitely NOT hold itself out as being able to handle ANY OB emergency. The general standard for emergencies in obstetrics is 30 minutes “decision to incision” — which means the ability to begin a c-section within 30 minutes after an emergency that requires a c-section has been identified. This same standard — which used to be the ACOG guideline for c-sections also — should apply for patients who vbac.

    4. I also understand that Joy has been told that the hospital will try to get a court order to force her to submit to a c-section if she presents there in labor and refuses to consent to cesarean surgery. Which is major abdominal surgery. Can you imagine what it would be like to be forced to undergo surgery against your will? Judges in some states have made such orders. Although appellate courts have held such orders unconstitutional, it won’t help Joy much to have the Supreme Court someday overrule that order months or years from now, will it? No one should be forced to endure unwanted surgery — such an order would be a violation of our basic human and constitutional right to bodily integrity.

  • smjesq

    The hospital has threatened to get a court order to force Joy to submit to surgery if she goes into labor, presents at the hospital, and refuses to consent to surgery.  How would you like to be in that position, Megan?  What’s her alternative?  The nearest vbac-friendly hospital in a several-hours’ drive.  Is it safer for Joy to travel by car for hours to another city while she’s in labor than to give birth vaginally in her own home town?  She is unlikely to have an OB and anesthesiologist in the backseat for the trip.

    According to many recent medical studies, the incidence of maternal death is four time higher with c-sections than with vaginal births.  Neonatal death is approximately 3 times higher.  Maternal and infant morbidity (injury or other adverse outcomes) are much higher for c-section patients in reported studies. Whose safety is the hospital protecting?

     

  • stdrcox

    I hope to be an OBGYN when I finally graduate and go through residency, and this would be my thought on it.  If there are only 2 OBGYN in this community and neither of them is comfortable in allowing the women to have a VBAC I would have to respect what their wishes are, that being said I would not want to force this women into have a c-section either.  This is a horrible problem and I am sure that there are many areas of the country that are rural that are affected by a lack of providers to provide need services.  At the same time this women needs to ask if the Dr’s aren’t comfortable with it does she want them to deliver her?  I would hope that this is not just motivated by money but concern for the patient.  This is a really hard spot to be in, I don’t know that there is a good solution to this problem.

  • ctbirthadvocate

    The issue is the hospital, her OB/GYN is fine with her having a VBAC and delivered her last child in the same hospital Via VBAC.

  • crowepps

    You might want to read this over carefully, because as I understand the situation, the doctor IS okay with it and the hospital is not willing to let the doctor and patient make the choices but instead ‘hospital policy’. This is really something that might affect you in the future, because you will be REQUIRED to knuckle under to ‘hospital policy’ in order to keep your privileges.

  • meghan

    If you want a provider who is a partner in your health care, then treat them that way: as a professional whose opinion you seek, but the decision remains your own.  As it is, OB providers are either held responsible for poor outcome or expected to provide care they believe to be unsafe. 

  • meghan

    She chose that town.  Not all services are available in all areas. I grew up in the West.  I understand that.  But that is one of the things that one gives up by choosing a small town: not all services will be available. The alternative is — what?  Requiring a hospital to provide services that leave them open to litigation?  What purpose will be served if the hospital then has to close?

  • meghan

    The issue is that she announced her decision ahead of time.  This is not a VBAC-friendly climate currently.  She could have had a VBAC by arriving at the hospital in labor and declining a section.

     

    There is taking a stand, and then there is complaining because one does not receive a positive response from the power structure to taking a stand.  The most generous and charitable assessment would be that Joy has a tragic level of naivete.