Recently, I participated in a minor uproar on Twitter regarding VBAC.

The discussion arose from a story on CNN regarding Joy Szabo. The story detailed the fact that Ms. Szabo had been told that she could not have a VBAC at the hospital where she planned to deliver. As a result, she ultimately moved nearly six hours away from their home in Page, Arizona, to Phoenix to give birth at a hospital that does permit women to have VBACs.

And, thus, one woman’s quest for a vaginal birth after a cesarean became national news. How did it come to this? The fact that hospitals are refusing to even offer the option of a VBAC (with apparently no discussion of options or alternatives) is striking to me.

But, then again, I completed my OBGYN residency in the mid 90s when VBACs were at their peak. “The Golden Age of VBACs”. I also had the honor to work with the Midwifery Service at North Central Bronx Hospital after finishing my fellowship. In 1998 (when I finished my fellowship) the Obstetrics service at NCB boasted a C-section rate of 7-10% for first time mothers. Also, over 90% of women with a previous Cesarean had trials of labor and the vast majority had successful VBACs. Interestingly, I never experienced a uterine rupture during a VBAC attempt at NCB.

The conversation that developed around the case of Szabo spawned a number of tweets (and retweets) as well as lively blog posts by Nick Fogelson (@academicobgyn) and the blog Mom’s Tinfoil Hat . One of the thing that everyone agreed about was that in order to reduce the number of repeat cesarean deliveries, it would be important to decrease the number of first time cesareans. But how can that be done? and what is an unnecessary cesarean?

A quick story should provide some context. When I was a chief resident at Harlem Hospital, the team of physicians reviewed a fetal heart rate strip with clear evidence of fetal distress and decided to proceed with a cesarean section. As we prepared for the case, we sent the intern to the room to get consent from the patient for surgery. Several minutes later, the intern returned to tell us that the patient had refused the cesarean. The response from myself and other physicians was unanimous and immediate. “Nonsense. She *can’t* refuse a cesarean. Obviously the intern did not know how to “counsel” the patient regarding her “options”. I went to the room, spoke to the patient and within 2 minutes the consent was signed and the patient was on her way to the OR for the cesarean.

I use this story to remind people of the awesome power that a physician wields where an unborn child is concerned. Patient’s trust physicians to make tough calls by virtue of our expertise, training and because they believe that we want what is best for them. My fear is that physicians risk losing the trust and goodwill we have with patients if we steer them away from safe vaginal deliveries toward unnecessary cesarean deliveries for questionable reasons. The current trend towards not offering VBAC may have begun due to concerns regarding safety or even medico-legal exposure; however at present, it has metaststatized to inordinant levels that I have referred to as PVH (physician-VBAC-hysteria).

The reversals in the rate of VBAC have clearly increased the Cesarean rate in the US, but have not (in any definable way) improved maternal or fetal outcomes. Therefore, presented for your review is my most recent slideset on practical ways that patients can avoid some of the pitfalls which may result in an unnecessary cesarean delivery.

Enjoy.

Posted via web from onyeije’s posterous