I have a few questions. I’ll preface them with a hypothetical situation.
A woman has a baby in 2005 by cesarean. She hopes to avoid another surgery while pregnant in 2007, but her doctor tells her horror stories of how VBAC kills babies and she should reconsider her plans. She schedules a repeat cesarean.
Now it’s 2010 and the same woman is expecting her third child. She walks into an obstetrician’s office and is told that VBAC is a safe and appropriate choice. The woman asks if there was new research conducted that would have led to this 180 degree change in practice and is informed that, no, the evidence predated her repeat cesarean.
How will this impact the trust that patients like this woman (and those affected by the astronomical primary cesarean rates around the country) have in their doctors or in the U.S. health care system in general? I assume that there are a lot of people banking on the chance that people will be dancing in the streets about the less-restrictive guidelines and crossing their fingers that few will question how VBAC just—POOF!—became “a safe and appropriate choice” again.
I am very curious about how this will play out. Some doctors are forthright with their patients if they cannot offer them anything but a repeat cesarean for reasons that have nothing to do with the actual patient—hospital policy, ACOG’s “immediately available” guideline, not wanting to be dropped by their malpractice insurer, experienced a bad outcome and are not willing to live through that again with another family, experience with having been sued in the past, staff shortage, etc. Are many or most doctors this honest with their patients?
We’ve all heard from nurses and patients about the VBAC bait-and-switch which involves an initial openness to a trial of labor. As the pregnancy progresses, the doctor starts expressing concern for the baby’s wellbeing through the use of disingenuous scare tactics and offering reasons why the prospect of a trial of labor is becoming more and more dangerous for this particular patient with the hope that the patient will finally just consent to a planned (and “elective”) cesarean. Just ask an OB friend about it and you’ll probably get the low-down on a few colleagues who promote their practice as VBAC-friendly but are really not.
I want to know how in the world this will be dealt with from a public relations standpoint. ACOG took the first step and issued a press release. At the press level, it would be easy to say the same things that have already been said about defensive medicine and the fear of being sued ultimately hurting patients. However, it won’t backfill the decade or more of doctor-patient conversations that pitched the repeat cesarean as the only safe and reasonable option and framed VBAC as highly irresponsible and dangerous. We can all talk generally about the fear of VBAC lawsuits until we’re blue in the face, but until we acknowledge the manner in which this fear actually trickles down to the actual prenatal visit or labor and delivery, we’re merely scratching the surface.
Like many people, I’ll be observing this as it unravels. Will it change anything for those for whom the mistrust of scarred uteri is so entrenched that they ponder why there are any VBACs at all (see comment #7)? Or for those who would like to see VBAC go the way of the dodo like breech birth did in the United States?
How will this cultural shift occur? How does ACOG, as the primary mouthpiece of OB-GYNs in the United States, plan to address the years that have gone by and the thousands and thousands of women that were told that VBAC is too dangerous in spite of ample evidence that it is not? Can they save face or will this provoke too much critical thinking on the part of patients? If so many of the people that we trust with our bodies and our births have been willing to tell women to their faces that VBAC is not a safe option for them in spite of evidence, is anyone concerned that the public might be wondering what other practice bulletins need an overhaul?
I need to get back to dancing in the street, so please let me know how you think this all might pan out.
From my feedreader in reverse chronological order:
New VBAC Guidelines (Birth Activist)
Sunday News Round-Up: *Why* Is It Sunday Already? Edition (Women’s Health News)
New Guidelines OK Vaginal Birth After Cesarean (VBAC) (Medical News Today)
About Damn Time: Good News for Vaginal Birth After Multiple Cesarean! (Well-Rounded Mama)
ACOG’s VBAC Change of Heart - The What and Why (Keyboard Revolutionary)
VBAC in rural hospitals (VBAC Facts)
ACOG’s New VBAC Guidelines: Making (and Seeing) the Difference (Birthing Beautiful Ideas)
ACOG Says Yes to VBACs (RH Reality Check)
Did ACOG (finally!) Take Their Meds? (Navelgazing Midwife)
ACOG issues less restrictive VBAC guidelines (Stand and Deliver)
Progress not perfection, right? Thanks, ACOG. (Cross-posted on VBAC). (Unnecesarean Fan Page)
ACOG issues less restrictive VBAC guidelines (VBAC Facts)
Ob-Gyns Issue Less Restrictive VBAC Guidelines (ACOG News Releases)