Anatomy and Physiology of a VBAC Ban

I’m doing research for an upcoming presentation for Happy Mama regarding VBAC Bans.  We’re finally at the point in my community where this issue has to be addressed head on.  VBACs aren’t actually banned in Missoula at Community Medical Center, but they are rare because of the criteria in place discouraging women from having a vaginal birth after one or more cesareans.  This is NOT an evidence-based practice – to obstruct women’s access to natural birth.  What is more concerning regarding the medical climate in Missoula is that the cesarean rate is above 31% and therefore on par with the national average which is already twice the rate recommended by the World Health Organization.  According the the CMC website:

More babies are born at Community Medical Center than any other hospital in Montana. CMC is the hospital of choice for many families because family-centered care is accentuated in obstetric and newborn services.

All the more reason to ensure that CMC is providing the highest level of ethical, supportive, and evidence-based care.  First, I will contact Tracey Thompson, the Director of Women’s & Children’s Services at the hospital.  I’ve talked with her before, but when I called in a more formal capacity as an ICAN leader, she didn’t return my call.  If I do not receive what I need from her, I’ll call and talk with a labor & delivery nurse.  Depending on what I find out, I will contact the hospital’s Board of Directors and the President & CEO, Steve Carlson.

I am investigating discrepancies that have been reported regarding Community’s VBAC policy.  I have been told that the OB must be bed-side when overseeing a VBAC.  (Not great for mom; not great for the doc; not great for the doc’s other patients.)  I have been told that the OB must be on campus when a VBAC patient is in labor.  This has been particularly problematic for Dr. Lynn Montgomery’s practice, since his birth center is about 3 whole minutes from the hospital and therefore NOT on campus.  [Lynn Montgomery died from a massive heart attack at age 51.  I do need to write about him.  He is sorely missed in our community.]  Since Dr. Montgomery’s death, his CNMs have lost their privileges at the hospital.  Isn’t that horrible?  And it is my understanding that area OBs are more than happy to take business away from the birth center (sure we’ll take your clients) but won’t back up the CNMs at the hospital or donate their services temporarily to help keep the Birth Center in business.  More on that later.

Here are excellent resources to consult when you have questions about VBAC Bans:

• ICAN of Portland’s VBAC Ban FAQ
• Enforcing and Promoting the Rights of Women Seeking VBACs (Katherine Prown, PhD)
• 50 Ways to Protest a VBAC Ban, by Barbara Stratton
• ICAN’s VBAC Ban info (including a searchable database)
• Henci Goer’s article, Spin-Doctoring the Research (pdf)
• VBAC Ban Information for NW Arkansas (we need one of these for every state!)

VBAC Ban Stories & News

• Tina Cassidy – The Birth Book Blog: VBAC Ban
• VBAC Backlash, Slate (2004)
• VBAC Ban in Oklahoma (Yahoo Answers)
• VBAC Facts post – A letter from a hospital explaining its ban
• A letter from a concerned mom to a hospital CEO (good one to use as a template!)
• VBAC Ban at Santa Barbara’s Cottage Hospital (VBAC Facts)
• VBAC ban is a loss of choice in women’s health
• ACOG Responds Regarding VBACs, I Respond Back (BOBB Blog)
• The VBAC Ban Almost Got Me (by ICAN’s Claudia Villeneuve)
• Sample VBAC Ban Protest Letter

Google search: “VBAC ban” petition

Additional Resources

• International Cesarean Awareness Network (ICAN)
• The Rights of Childbearing Women (Childbirth Connection)
• VBAC or Repeat Cesarean (Childbirth Connection)

Blogged with the Flock Browser

Tags: VBACban, Henci Goer, Barbara Stratton, Katherine Prown, Community Medical Center, obstetrics, petition, rights of childbearing women, cesarean awareness, women’s health, advocacy

RPL Update Number I Lose Count

I started writing up a big post about the more recent developments in my journey through recurrent pregnancy loss.  I still need to finish it up, but in the meantime, he’s a quick update:

1. In August I had a hysteroscopic myomectomy done in Denver.  The idea was to hopefully remove a fibroid that was bulging into my uterus.  Instead of a fibroid, the surgeon found an adenomyoma located directly above my cesarean scar.  I have to review my records from my 1 successful pregnancy to determine whether or not the fibroid that was present during that pregnancy changed into this adenomyoma.  Otherwise, it is likely a lovely by-product of the 2004 cesarean section that was performed on me and my daughter.
2. I have a substantial progesterone deficiency.  Progesterone levels should not drop below 8-10 in 2nd luteal phase draw, and mine dropped to 3.  I will have to have HCG shots during the luteal phase and progesterone shots during the first trimester to support the corpus luteum and developing baby.  It makes me INSANE that the last OB I asked to test my progesterone outright refused.  I lost that baby, obviously.
3. I have to wait until November to have an ultrasound performed to let me know if my uterus and endometrium have repaired from the surgery.  Then we can talk about ttc.

That’s my nutshell.

Anomaly

Anomoly.  Congenital.  Rare – in my case occurring in 0.1-0.5% of women or possibly as high as 10% in women with recurrent pregnancy loss[1].

On Monday I had a hysterosalpinogram (HSG) done to check the lining of my uterus for abnormalities potentially caused by a cesarean section in 2004.  My doctors and I are not finding good reasons for repeat pregnancy loss.  My lupus anticoagulant panel came back clean, and the only test left to do in my current OB’s mind is an ANA.

As a result of the HSG, I was diagnosed with uterus didelphys, one of several Mullerian Anomalies.  The OB is certain that this is the cause of my recurrent losses though still recommends the ANA blood draw.  He doesn’t think I need to proceed with a thrombophilia panel.  He didn’t offer any course of action for this issue, suggesting that we should just “keep trying.”  He was surprised that this hadn’t been diagnosed sooner.

Of course, being the curious person that I am, I performed internet searches for “double uterus,” “didelphic uterus,” and “uterus didelphys.”  I also chatted with an internet friend who put me in touch with a couple of other people who have been diagnosed with anomalies.  I have joined a yahoo group that deals specifically with these anomalies.  Even a couple of hours after the procedure, having looked at many pictures on the internet, I began to have doubts about my diagnosis.

I will obtain a copy of my HSG “picture” hopefully today from the radiology lab.  When I compare what I remember seeing on the screen at the hospital with what I see on the internet, I think it’s more likely that my uterus is bicornuate (heart shaped) and/or possibly contains an uterine septum.  A septum would be most problematic for maintaining a pregnancy because if the baby implants on the septum, it will not have enough vascular support to grow.  (This just breaks my heart.)

What next?  I am going to be in Denver for a couple of months studying vocology (vocal science).  (I need a calculator and to remember my college physics class from 1990, eek.) I am looking for a reproductive specialist there who will do a thorough investigation of immunological, endocrine, and structural causes for my losses.  It is possible that the immunological path has been exhausted, but with my mother’s history of autoimmune disease, I’m not so sure.  Endocrine/hormone issues haven’t been addressed to my satisfaction.  Neither OB group I have worked with in town believe in progesterone deficiency.

So, that’s my story in a nutshell for now.

[1] Müllerian duct anomalies are estimated to occur in 0.1-0.5% of women. The true prevalence is unknown because the anomalies usually are discovered in patients presenting with infertility. Some women carry babies to term with anomalies, so it could be more common, possibly as high as 3% of all women.  Sources: http://www.emedicine.com/Radio/topic738.htm; http://www.seattlefertility.com/treatmentOps_UterineAnomalies.htm

Upcoming Interview

In about an hour I will be interviewed for a local news station regarding Montana’s cesarean rate.  I don’t know much more than that.  The reporter has a young child.  The reporter is supposed to be meeting with a local hospital official.  Other than that, who knows what her focus will be.  In anticipation of this interview, I decided to review some things that I have read and wrote regarding cesarean rates.

With regard to rates, it is important to consider that the US cesarean rate (2006, preliminary) is 31.1%.  The rate has increased by 50% since 1996.  The rate recommended by the World Health Organization is 10-15%.  Once the cesarean rate exceeds 15%, the risks (statistically speaking) outweigh the benefits.  The Montana cesarean rate (2006, preliminary) is 28%, nearly a 3% increase from the year prior.  According to a source at the local hospital, our local rate is around 31%.  I was told that only 16 VBACs took place in 2006 at my hospital.  (A local CNM questioned the accuracy of the VBAC figure, suggesting that VBACs were under-reported.)

I can list many contributing factors to the continued increase in the cesarean rate:

• Medico-legal concerns on the part of doctors, hospitals, and insurance providers (it’s HUGE, actually)
• “So and so had a cesarean . . .”
• Hollywood stars having elective cesareans
• Young and underpriviledged mothers are more at risk for cesarean surgery
• An unchecked trust in care providers – most women do not seek second opinions when it comes to maternity services
• Sensationalization of birth – Baby Story and OR Live come to mind
• Society – our view of birth has changed; the culture of fear has spread to childbirth
• Cesareans ARE more safe now than they ever have been

Of course I’ll direct the reporter to resources such as:

• ICAN
• The Mother-Friendly Childbirth Initiative
• Childbirth Connection
• Conscious Woman

The Cost of Miscarriage

It’s been a while since I posted last.  I guess it’s that time in the semester where I’m so busy teaching, advising, and attending events that I have no time for anything else!  Plus, I had a major job during a “Super Regional” conference that took place in my town last weekend.

I have received a couple of bills from my 2/23/08 miscarriage:

LEVEL 4 HOSPITAL SERVICE

• Recovery phase 1 lvl 2 per hr $419.25
• Path group 3 122.00
• Venipuncture x 2 26
• ABO group 38.50 (they had access to this info)
• RH type 31.25 (I told them I was RH+)
• Antibody screen 83.50 (???)
• CBC 48.25 (narrowly avoided a transfusion!)
• surgery major 1 1207.00
• set up for surgery 641.50
• anesthetic 42.50
• propofol 80.11 (damn, that had better have been good stuff!)
• lidocaine 7.50
• sevoflurane 231.20 (now, THAT better be good stuff)
• metoclophramidercar (say that 3 times fast) 16.38
• dexamethasone 16.38
• fentanyl 16.38
• hydromorphone 16.38
• ondansertron x 2 32.76
• fentanyl 16.38 (again?)
• recovery/observation 75.00
  GRAND TOTAL: $3168.22

That’s what a curettage (following/during miscarriage) costs you (or more).  When it’s all said and done I’ll owe $650.29, plus I received a $97.00 bill for the follow-up with the OB.  It should have been a $15.00 copay, but since they coded it maternity, my insurance company isn’t paying for it, claiming that it’s covered under my global (maternity) copay.  THANKS FOR THAT NICE SWIFT KICK TO MY BROKEN UTERUS.

Still, nearly every moment of every day I remember what I have lost this past year.  And there’s no hope yet of moving past it.  There’s always tomorrow . . .

Sharing Cesarean Awareness

I found this on ICAN’s eNews (www.ican-online.org/community/eNews/) and want to share it with those who maybe aren’t (yet) subscribers!

Cesareans Affect Lives. Real women, real babies. Lives changed.

How has your cesarean impacted you? Come to www.ican-online.org and blog about your experiences in 100 words or less, tell us your story.

Cesarean Awareness:
is not only about the “bad” cesarean and recovery
is not about guilt for not succeeding at VBAC
is not about not attempting VBAC
is a state of being, whatever that may be for you or me – hope, fear, acceptance, sadness, depression, thankfulness
is about doing the research to understand the reality of the risks taken on every time another mother has another surgery

ICAN is about all birthing women having access to that information.  Cesarean Awareness Month is about encouraging the spread of that information.  We want to encourage you to find a way to spread the awareness in your community. Wear your ribbon. Write on your car. Buy brochures to drop off in the library. Put up a poster at your work. This is about open communication about the health of our women, babies and families.