Update on one March homebirth death and report of a second death

Homebirth Russian Roulette

Homebirth advocates exult that the proportion of planned homebirths in the US has been rising from miniscule to slightly more than miniscule. Too bad they never point out the endless stream of preventable homebirth deaths that result.

I noted earlier this month that there are so many homebirth deaths that I can barely keep track. There was an additional homebirth death just this past weekend.

First, though, I’d like to update the information on a death that I mentioned in the above post:

A baby who died in Phoenix last week whose mother, a doula, had a previous HBAC. I have not been able to establish whether the caregiver knew that the baby was dead before birth or was not expecting it.

It turns out that I had written about the mother before. She runs the Big Baby Project, which I wrote about here.

In a bio for a this piece and the follow up piece she wrote for a birth website, Cherise Sant is described as:

…Mother, Doula, Childbirth Educator, Placenta Crafter, and Creator of the marvelous “Big Baby Project” (a website full of empowering vaginal births of babies 9 lbs and over).

Sant is a purveyor of the standard homebirth trope.

Disappointment with her first birth:

I had resisted an induction but eventually caved to the pressure I was receiving from my obstetrician. The ultimate result was a healthy baby boy born via cesarean and my broken heart and body.

A successful hospital VBAC:

My second birth was an empowering vaginal birth in the hospital, but I was met with mistrust, abandonment and even violence though I had carefully chosen my provider and a “natural birth friendly” hospital.

Then the successful HBAC and total lack of awareness that the baby was possibly borderline IUGR:

We had a boy! As I’d pulled him up, I immediately could tell that he was little!! My smallest baby for sure, and yes he weighed in at 5 pounds, 15.9 oz. Later I would marvel that I changed course on a path to VBAC and didn’t have planned cesareans at 39 weeks. I couldn’t imagine how small and fragile he would have been 2 ½ weeks prior.

But if he was IUGR, he was not getting stronger in the two weeks after 39 weeks. He was struggling to survive despite a placenta that was depriving him of adequate oxygen and nutrients.

Sant had dodged a bullet, but she didn’t realize it.

This time around she was not so lucky. This baby was stillborn.

According to a post left on the Big Baby Project Facebook page, the baby died during labor:

This wonderful woman, Cherise Sant, who has been a support and strength to many, including this community, recently lost her sweet babe during childbirth. Please help them if you can. Look at her photos and let their story touch you. Spread the love!

Cherise Sant is a doula who headed up the Big Baby Project though she hadn’t had a big baby herself, she spent countless hours helping all women to have a wonderful birthing experience, no matter how big their baby was measuring.

She is very involved in the birthing and natural living communities.

She has been a strength and inspiration. I hope we can reach out to her now!

In other words, she inspired other women to play Russian Roulette by holding a figurative gun to their babies’ heads just like she did.

Inevitably, there is the obligatory plea for money accompanied by a heartbreakingly beautiful picture of a stillborn baby.

This baby lost his mother’s game of Russian Roulette. Perhaps his death may serve as an inspiration to women contemplating homebirth not to play Russian roulette with their babies’ lives.

*****

But, tragically that’s not all for March.

A Connecticut mother played Russian Roulette and her baby lost, too.

March homebirth death CT

She was laboring at home at 41 1/2 weeks.

Her uterus ruptured and the baby died. The mother survived.

Her “midwives” are a CPM and a lay midwife.

This will be yet another opportunity for CPMs to practice “letting go.” It couldn’t be letting go of babies lives could it? It could.

As Lana Muniz writes:

Homebirth midwives “value the art of letting go.” Letting go of what, exactly? The lives of babies born at homebirths.

We know this because it’s written in the MANA Statement of Values and Ethics right on their website,

“… We value the art of letting go and acknowledge death and loss as possible outcomes of pregnancy and birth.”

It’s a disturbing statement coming from an organization that claims homebirth is safe, even though it’s 4 times more deadly than hospital birth.

Muniz provided chilling quotes from Professional Ethics in Midwifery Practice by Illysa Foster and Jon Lasser:

We value the acceptance of death as a possible outcome of birth. We value our focus as supporting life rather than avoiding death…

We place the emphasis of our care on supporting life (preventive measures, good nutrition, emotional health, etc.) and not pathology, diagnosis, treatment of problems, and heroic solutions in an attempt to preserve life at any cost of quality.

In other words, they place the emphasis on what they can provide (and bill for) and NOT diagnosis, NOT treatment of problems, NOT heroic solutions (all things they cannot provide and therefore cannot profit from).

They can provide preventive measures for playing Russian Roulette (nutrition, emotional health), but if you’re the unlucky mother with a bullet in the chamber when she figuratively fires into her baby, they not only can’t fix it, but, apparently, they don’t even think it is worth trying.

This is what “ethics” looks like in the world of homebirth midwifery. It’s a farce, just as their education and training is a farce.

*****

If you’re a mother thinking about homebirth, think again.

Do you really want to play Russian Roulette with your baby’s life? No doubt you think this couldn’t happen to you, but, then these mothers thought that too and now they are burying their babies.

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  • Jon

    My name is Jon Lasser and I’m a co-author of Professional Ethics in Midwifery Practice (Jones & Bartlett, 2010). You noted that Lana Muniz (for whom I can find no contact information) provided “chilling quotes” from our book.

    To be clear, our book has appendices that reproduce ethical codes and statements from professional organizations. The “chilling quotes” are not our words, but rather statements developed by professional organizations that appear in the appendices. The main body of our book was not quoted by Muniz. It’s important to be clear when quoting MANA rather than Foster and Lasser.

    If you’re in touch with Ms. Muniz, please share with her.

    Sincerely,
    Jon

    • Amy Tuteur, MD

      Thank you for the clarification!

    • Lana Muniz

      I have edited the post.

  • sdsures

    “The ultimate result was a healthy baby boy born via cesarean and my broken heart and body.”

    Awww, poor poor narcissist.

  • Jetset

    Clearly a painful subject but I was further saddened to see on the “donation page” for your first subject, there was yet another person with a Home Birth After Cesarean with a death. This seems like a subject that should really be more prominently highlighted in the news. Homebirth certainly has killed more than measles this year.

    Dhanya Bramhall-Smith · Phillipston, Massachusetts
    So sorry for the loss of your beautiful baby. Losing my middle son (hbac) was the worst thing that ever happened to me. Feel free to message me <4

  • Medwife

    Anyone else watched Trial of Labor yet?

    http://bit.ly/18gTwVB

    One of the women has a HBA2C (no hx vaginal birth) with Brenda Carpps. Spoiler: her baby does not die. The whole time the women talk about their c/s births, there’s this ominous tonal music in the background. Ugh.

    • CrownedMedwife

      Haven’t yet, but plan to when I have the wherewithal. Recent events have brought a prelabor dehiscence, acreta and Stage III PPH. I am in no mood to listen to a gathering of ideologues lament the travesty of previous Cesareans or disseminate a message of the ‘journeys back to trusting themselves or their bodies’ after previous Cesareans. Three mothers who would have had very different outcomes today had they taken that journey back to trusting themselves, their bodies or birth itself. I just can’t right now, but I know I eventually have to in order to understand and counsel the women who will eventually watch this film and bring it’s underlying premise into their care. Right now I’m just doing everything to process this subculture mentality to trust birth, to deny the fear. I fear death, I fear disability, therefore I cannot trust in birth without fear.

      • moto_librarian

        Jesus. So glad that these women had you and your colleagues to take care of them and their babies!

        • CrownedMedwife

          Yeah, I call that a really bad week. Then again, everyone involved provided stellar care and these are 3 mothers and four babies who won’t be making it to Dr. Amy’s inbox as more examples of preventable deaths…so that makes it a really good week. Hey, Birth, I really, really don’t trust you.

    • Mattie

      just a note, am currently watching this, there is definitely a healthy dose of NCB rhetoric BUT the woman who has the HBA2C was essentially forced into it because the hospitals wouldn’t ‘allow’ a TOL/VBAC/VBA2C. How is that allowed? Women have the right to make informed decisions about their care, how is forcing them into a decision informed choice? Yes it’s risky, yes you may disagree, but it’s not the doctor’s or hospital’s decision. She repeatedly states she wanted a hospital birth, the homebirth with the midwife was her last resort in order to have her choices respected, that is not ok.

      • Guest

        Because hospitals and doctors also have the right to not be forced into doing things they deem too risky. If someone needed a heart transplant and demanded that it be performed out of doors or while fully awake, the hospital and doctors are not forced to comply.

        • Mattie

          See, that just doesn’t happen in the UK…like if a woman refuses a c-section or insists on a VBAC she can’t be forced to have a section and she has to be supported in her decision, because she has the right to make that choice. Hospitals can’t turn away women because they don’t want to take the risk. If hospitals and doctors want to reduce the amount of women having home births with unqualified care providers, maybe they should actually allow women bodily autonomy and support them in their decisions in hospital (like the other doctor did with one of the other women in the documentary). By not giving women other options, they are being forced to seek help elsewhere, if something goes wrong in the end is the fault of the women having no option so ending up at home with a midwife that may be skilled or not, or the fault of the hospitals that turned their backs on her?

          • toni

            Are the doctors/midwives culpable for the inevitable bad outcome?

          • Mattie

            Obviously if something goes wrong in birth (not inevitable as that implies no possibility of a good outcome) then liability would obviously look at whether the doctor informed the woman of the risks, how often and whether the care given was the best within the limits of the woman’s right to choose. I do think though that forcing women out of hospital by refusing to work with them, should at the very least leave a bad taste in the doctor’s mouths.

          • Amazed

            Why? A HVBA2C is a very specific set of circumstances and risks. Something that many doctors and hospitals think contains an unreasonable amount of both in terms of maternal and fetal health. Should a cook who refuses to prepare a dish of unbaked, unboiled and generally uncooked in any way meat coming from a very dubious place have a bad taste in their mouth because the poor client will then eat the meat uncooked in their own house with no one around to call an ambulance should they feel so bad that they cannot do it themselves?

            A patient is not a client and I can’t see why a doctor should have fewer rights than a cook. A doctor should not cut a client’s arm just because the client really wishes it done professionally and wants it because they think an one-arm look suits them better in the first place.

          • toni

            I know not all VBA2Cs would result in a bad outcome but if enough bad candidates insisted on a TOL there would be one eventually.

          • toni

            And in the State’s I think the individual doctor would be held responsible and on the hook for a lot of compensation

          • Mattie

            Oh yeh, true. I would hope that if they were in hospitals then problems would be picked up sooner and steps could be taken to prevent the bad outcome (and in this documentary that did happen, with the women having sections after TOL)

          • Sarah

            Any culpability would generally be the relevant Trust’s, if they were found to be at fault. Care providers should act as the reasonable clinician would do in the circumstances.

          • Somewhereinthemiddle

            A agree with you here. It isn’t fair that women should be forced into seeking care outside of the hospital because they can’t find a care provider willing to take them.

          • The Bofa on the Sofa

            It isn’t fair that women should be forced into seeking care outside of
            the hospital because they can’t find a care provider willing to take
            them.

            That is crazy.

            I can’t go into a hospital and demand that they do whatever I want them to for me. Even if I am sick, I can’t demand they they treat me by doing something they are not capable of doing.

            Oh, it’s so unfair that I have to go to a different clinic to see the dermatologist!!!! I don’t care if the clinic I am in doesn’t have a dermatologist on staff or doesn’t have the equipment, they need to do my tattoo removal HERE!

            And it’s so unfair that I can’t find a care provider willing to do an arm transplant to give me a third arm.

            These are medical professionals who have to adhere to standards of practice.

          • Somewhereinthemiddle

            I do not agree with you at all and saying that it is unfair is absolutely not crazy. No one is suggesting that doctors do things that go against practice standards but even ACOG has stated that within certain parameters, that VBA2C can be considered. That is not crazy. Higher risk than other choices, yes, but not crazy. Do not twist my words with the ridiculous hyperbole that you break out whenever someone expresses a view with which you do not agree. My eyes are rolling right out of my head at your ridiculous comparison of asking for a third arm and asking for a TOLAC and at your !!!!!!!!!. Please, give me a break.

            Yes, there are practice standards and then there is the right a patient to informed consent and autonomy.

          • Amazed

            And how do we know that a particular woman or hospital fall within those certain parameters? That’s right, we don’t. If a woman goes from doctor to doctor and hospital to a hospital and no one wants to take her, perhaps there was something that was out of those “certain” parameters?

            There is a reason why real doctors don’t give advice on the internet. The ACOG recommendations are no exception. Care should be tailored case by case, not by applying the recommendation blindly.

          • Somewhereinthemiddle

            Obviously all cases do not fall under certain paramaters which is why I am confused as to why you guys are jumping my shit. No one said that *everyone* should be accepted, that would be stupid. But instead of having a constructive conversation, Bofa is acting like a dismissive and contrary jerk. And it *is* unfair that some hospitals and providers disallow VBACs out of hand. I’m sure some do it for legit reasons like not having anesthesia, but some have those resources available and still don’t allow them. That is where bodliy autonomy and informed consent come in.

            I stand by my statement.

          • Amazed

            That’s still no reason to make the more dangerous choice instead of find a hospital that does what you want. If the hospital isn’t going to do it, they won’t live with the consequences of your choice if it goes bad, you will.

            When the centre I went to didn’t offer any cast (and they really should, IMO, honestly), I dragged my sorry ass and broken foot to where they did offer it, uttering some not so kind words NOT under my breath as I did it, as if the doctor was supposed to wave her Harry Potter wand and magic a cast for me out of thin air. I didn’t go home and let my foot heal as best as it could just to make a point.

            Two wrongs don’t make a right. And the Rinat Dray case is an exception and not standard. As a rule, women don’t get a c-section when they show up in labour. So the majority of the HVBAC moms could have had their natural birth in a hospital – admittedly, in less than positive environment, maybe. They still chose homebirth and it wasn’t for the lack of options.

          • Somewhereinthemiddle

            Some women do not live within a reasonable distance from a hospital or a provider where they will take her. In the state where I live, there are lots of areas where women have to drive more than 100 miles to see a provider who will consider a vbac after even one CS even if that CS is for breech and with the next pregnancy she has a vertex baby. These women *want* to see someone closer to home, they don’t want to have to drive 2+ hours for prenatal appointments or drive 2+ hours in labor attempting a vbac or having to be induced (increases risk of rupture) to be sure to be at the hospital. But they do it, especially if they want a larger family and aren’t comfortable with having 4 or more cesareans. There are more women than you would think that fall into this type of category. The risk of a rupture (even prior to labor), accreta, and percreta increases with each cesarean and I could see how someone would want to avoid those risks. If we are talking about balancing risks and benefits, let’s not pretend like those don’t exist.

            I *don’t* think those types of scenarios are fair and some women *do* choose to stay home and hire a midwife. Yes, that is a poor decision but when faced with laboring for hours in a car to get to a facility where vbac is allowed and birthing at home with a midwife, I can see how and why women make it. Flame me all you want, but that just seems like a shitty situation to be in.

            That isn’t even to get into the insurance part of the equation where women don’t have insurance with a provider or a facility where they are allowed to attempt a TOLAC. That happens too and no, I don’t think it is fair to be either forced to undergo a cesarean or have to pay $15,000 or more out of pocket.

          • Amazed

            I see. You start with bemoaning the fact that TOLs aren’t available for every woman the moment she wants them, not bother to elaborate, and then, when people take your words to their logical conclusion, you start complaining that we’re “flaming” you.

            Please. No one is pretending that there are no risks to c-sections. What is being argued about is whether the mother is actually the most competent person to make risk assessment. And while c-sections do present with some unique risks of their own, sometimes the risks of a vaginal birth to a particular woman and her current baby are greater – something that you only mentioned in your last post.

          • Somewhereinthemiddle

            I wasn’t bemoaning, I said that it was unfair/ unethical. And it isn’t. Just because you made assumptions and incorrectly filled in those blanks for me doesn’t mean that I was wrong in my initial assertions. Nice try for turning it around on me though. And geez, I wasn’t complaining about you flaming but I don’t see how what Bofa said could be construed as anything other than flaming.

            The reason I didn’t elaborate is because I was on my way out the door to take me kids to the park and was hoping to come back to join the conversation. Only to come back to undeserved ridicule instead of reasonable debate.

            I *didn’t* say that the mother was the one who should assess if she was a reasonable candidate, you are making that assumption. There are doctors and facilities that don’t allow vbacs and sometimes women are in a tough position to have to chose between having a cs that she doesn’t want. Even according to ACOG some women should reasonably be a candidate for vbac but because of her goegraphical location and not being close to a hospital that allows vbac or insurance situation, is being forced to make an unsafe choice (drive for hours during labor) or an even more unsafe choice (giving birth at home). Either that or face a hostile hospital environment where her provider is actively against her wishes when even ACOG says that she might be a reasonable candidate. That *isn’t* ethical. Some doctors and some facilities don’t “do” vbac at all even if they have the resources to make it a reasonable option. How is that reasonable? If we are talking about personalizing medicine and tailoring to a case by case scenario, how is that going case by case?

            And oh, yes, we are having an ongoing discussion. How could I cover *all* possible information, opinions, and scenarios in one single post? It is a complex issue and one that has many possible scenarios and outcomes and ways of looking at risks and benefits.

            Just as I think women should have access to a CS, even when her provider has a different first choice in mind, I also think women should have access to VBAC within reasonable guidelines, even if her provider has a first different first preference in mind. What in the world is there to argue with that??

          • Amazed

            *What in the world is there to argue with that??”

            Well, I think your basic premise has much to offer in terms of argument. I’d like to know why does it matter so much if the hospital provider is against the mother’s wishes for a VBAC. We know that a forced c-section is an incredibly rare event. Odds are, a labouring woman won’t be forced into a c-section and she won’t be evicted from the hospital for not wanting to have one. This assured, the hostility you’re talking about is expressed in… what? What does it matter if the staff is not thrilled? They probably won’t cut her without her consent and I refuse to think that they’d intentionally let her or the baby come to harm to make their point. Now, if trying to get her to consent to a c-section is seen as unsupportive, I suppose you do have a point. But they cannot force her, so if she’s *strong* enough, she won’t “cave”. I don’t consider grumpy staff a solid enough reason to risk two lives or healths. Not that I consider it a good thing but certainly a smaller risk than homebirth.

          • Somewhereinthemiddle

            But why should she have to submit to threats and coersion? What is if someone did that to a mom planning a repeat CS but came in in labor and the staff was pro vbac and spent the entire time trying to convince her to vbac because their hospital was natural birth friendly? Is that any more acceptible? I sure don’t think it is.

          • Amazed

            I am not saying that she should. I am saying that grumpy staff is still a smaller risk than a planned homebirth because in the vast majority of cases, all the staff can do is talk. You’re going way overboard with the threats thing. What, doctors say, “Now, I’m cutting you?” with a grim smile? They don’t do so even here.

            The difference is that with a desired VBAC, doctors, midwives, nurses and everyone can talk until they’re blue in the face and not achieve anything. With a desired c-section, there’s no way to have it if the ones who have to provide it won’t lift their knives.

            It’s much easier to achieve a desired VBAC than a desired c-section when the staff isn’t supportive in either case.

          • Somewhereinthemiddle

            I don’t know why a patient should be expected to call a providers bluff. If someone tells a patient they aren’t going to do something, they are well advised to believe them. And the patient ends up giving up their autonomy if they gamble and lose.

            I’m not talking about being coddled, I’m talking about facing coersion and hostility. There is a BIG area between those two options that includes including patient autonomy.

          • Guesteleh

            It really screws the doctor, though. Patient is acting AMA but if something goes wrong, doc is still on the hook because they failed to convince the mother that that danger was real. Even if the mom signs a form saying I understand I’m placing my baby at increased risk of death she can still sue and win. It puts the doctor in a terrible position.

          • Somewhereinthemiddle

            Again, I’m not talking about situations that are AMA. Examples that come to mind are women who have had a primary CS for breech, previa, and then go on to have pregnancies that do not include those complications. If a woman has adequate fluid levels, goes into labor within a reasonable amount of time around her due date, etc, etc, etc, it is unethical to deny her respectful access to VBAC. Some providers and facilities don’t allow vbac. Women who are forced to use those facilites or those providers are facing unnecessary obstacles to adequate care to accomodate care that falls within ACOG recommendations.

          • Somewhereinthemiddle

            *forced to use those facilities or those providers through geographical or insurance limitations are facing*

          • Somewhereinthemiddle

            And as far as I know, physicians aren’t obligated to take patients at all. Patients can be dropped from care for any number of reasons and it has happened to several friends of mine. One is a well educated professional with no interest in natural birth or any of that NCB jazz, would *never* consider a home birth, loves modern medicine, enjoyed her epidural, etc. She knew she wanted 4 children and had a CS with her first for breech. After reading the stats, etc, she was interested in vbac since she desired a larger family and she wanted to do it in the hospital. She went to the practice where she had her first for her prenatal appointment, asked the normal questions and then brought up VBAC. Two weeks later she got a letter in the mail she was being dropped by the practice without explanation, leaving her to assume that it was related to her questions about vbac. Those barriers to care aren’t terribly uncommon for someone interested in TOLAC.

          • fiftyfifty1

            Well, I guess this well educated professional friend of yours will just have to rely upon her many advantages and get herself to somewhere that offers VBACs. Her doctors were obligated to offer her safe care. And they did so. But she didn’t want what they had to offer, so she will have to look elsewhere. Yes, it would have been more convenient if VBAC had been offered in the town she lived in. But it wasn’t. If she wants a TOLAC she’s have to be inconvenienced I guess. Poor thing.

          • Somewhereinthemiddle

            I wasn’t asking for pity for the “poor thing”. Enough with the sarcasm, okay? We may not agree but I have refrained from dishing out the snark and I would appreciate the same. She did end up finding more than adequate care with an OB and went on to have three more children. My point was, that kind of thing happens and I think we need to honest about it.

            But for the sake of arguement, change the scenario to where she was on medicaid and was kicked out of the only practice in her town that accepted that insurance. Does that seem right or ethical? So a woman’s choices are to accept a cesarean, deceive her provider and show up in labor refusing a cs with a provider or facility who ins’t insured or allowed to accept vbacs, or seek care from a provider who is further away than is reasonable for a woman wanting a TOLAC.

          • fiftyfifty1

            “She did end up finding more than adequate care with an OB and went on to have three more children (via vbac incidentally)”

            So sounds like there was actually no problem. She had access to a provider who was able to offer what she wanted.

            Yet you relate her story as if there were some problem. And I’m assuming she told it to you as if there were some problem. And yes, turning a non-problem story into a problem narrative where women are supposedly dropped from practices without explanation due to even asking questions about VBAC is right out of the NCB playbook. And then trying to stretch this far-fetched story about a privileged women and extend it to Medicaid recipients and make it sound that poor women are being denied care and left with no place to turn for even mentioning VBAC, yes that is a ploy for pity.

          • Somewhereinthemiddle

            Not at all. It is *reality* not a ploy for pity. You’ve basically said, yes, women are denied reasonable care, they should shut up and deal with it. I don’t agree. It is not out of the NCB playbook as this lady had *zero* interest in NCB, she just didn’t want additional cesareans. But nice try deflecting from the real discussion.

            The reason from my relating this story is that she was surprised by being dropped from care that quickly and without explanation. I would think that *most* women would be surprised by that.

          • fiftyfifty1

            Once again, your friend was not denied reasonable care. The first doctor she consulted offered to deliver her baby by RCS and did not offer VBACs. Your friend accessed another doc who did offer VBAC. Pretending that anyone, much less Medicaid patients, were harmed in the process is laughable.

            ” It is not out of the NCB playbook as this lady had *zero* interest in NCB, she just didn’t want additional cesareans.”

            Ah, so your friend was accepting of the whole thing and understood the doctor’s reasons, and it was you who added the NCB spin.

          • Somewhereinthemiddle

            Please stop throwing “NCB” around. You disagree so you throw the ultimate insult at me? I’m not accepting that from you. This is about quality patient care. She asked about having a vbac at a hospital equipped with 24/7 OR access and that “allows” vbacs and she was dropped from care by her provider. Since nothing else was amiss, she assumed that that was the reason why and was surprised that that was all it took. We live in a major city so it was no big deal to find another provider but she didn’t want to switch providers. They didn’t refer her out, tell her that they weren’t comfortable with that choice. She was just dismissed from care and I would think that any reasonable person would be surprised by that and want an explanation. What is NCB about that?

          • fiftyfifty1

            You two live in a MAJOR CITY?!!! And she is whining about being told a certain doc didn’t offer VBAC because she “didn’t want to switch providers”! Sorry, but this level of ridiculous entitlement is absolutely nothing more than absorbed NCB rhetoric. Ridiculous.

          • Somewhereinthemiddle

            Again, wasn’t whining and I didn’t imply whining. She was confused why she was “fired” as a patient by a practice who was at a hospital that is equppied to handle vbac and they never told her why she was being released. It ended up being fine and I didn’t impy that anything wasn’t fine in her case but if she was turned down without explanation other women are almost certainly experiencing the same thing. I don’t know why you are bent on turning this into something that it is not.

            Here I thought we had turned a corner and started to understand one another, lol.

          • fiftyfifty1

            So she doesn’t even know why she was dismissed. Didn’t even follow up. But you (and she?) are sure it was because she merely asked some questions about VBAC. Please.

          • Somewhereinthemiddle

            She did follow up with the office manager and the physician and got no answers. I have stated several times that she was left to assume to assume that it was her questions about vbac since she wasn’t given a reason, not that it definitely was. I wasn’t there so there is no way to be certain obvious but she was a compliant patient. Why else would a compliant patient be dropped from a practice?

          • fiftyfifty1

            “Why else would a compliant patient be dropped from a practice? ”
            Doc seldom dismiss patients. They do it only when they have reason to believe that a patient could do somthing really crazy and dangerous. Asking questions like “Would I be a good candidate for VBAC because I want to have a large family?” and “If you can’t offer VBAC, do you have a recommendation of who it town does that is good?” would never get a person booted. Now something like arguing with an OB they they should or must offer it, or spewing the NCB VBAC talking points, or calling them unethical and asking questions like “What if I just refuse the CS when the time comes?” …something like that, yes, might be seen as a threat. Who wants to be stuck in the position of having a VBAC patient show up in labor in your lobby and refusing to leave when you don’t have the resources?

          • rh1985

            There are reasons why a doctor might not be comfortable with VBACs. If the hospital can handle them than ideally the doctor would refer to a doctor who will do them, but neither of us were there when the conversation happened. The doctor probably doesn’t do VBACs either because of financial/insurance reasons or because the risk is unacceptable to them personally (Perhaps due to having witnessed a very bad outcome before) and they don’t want have to live with it if something goes horribly wrong.

          • KarenJJ

            Are they good enough reasons for a doctor to “pick and choose” what care they provide to their patients? It’s one thing to exclude something because they can’t medically provide for it or because they believe that medically it is not a good option (and I guess VBAC is a grey area there because there might be many doctors that actually do believe that VBAC is not a good option). It does seem to be a bit of a cop out though if they are not wanting to pay the sort of insurances that their colleagues are paying so they can just take on the easier stuff. I guess if they’ve got a few strikes against them and are financially unable to get the insurance would be one thing.

          • Who?

            Maybe the doctors aren’t picking and choosing care offerings, but picking and choosing patients? How often do medical professionals comment on here about the time it takes to reassure/support the pregnant and worried well?

            If you already have a room full of patients waiting to see you, and someone you don’t know comes in with the same profile as the woman who drove you nuts six months ago, you might just let her go gently nice and early. Surely this would be really easy if there is someone with an emptier waiting room or more patience for that style of patient, or whatever, around the corner.

          • Daleth

            How is it a “cop out” to decide that you don’t want to pay for expensive insurance that only a handful of patients would need, i.e., insurance that you don’t get enough business to cover the cost of? To me that just sounds like a reasonable business decision, since the alternative is basically “OBs are unethical and unfair and mean if they won’t all voluntarily reduce their income by X thousand dollars a year just to personally serve the few women who actually want VBACs!”

            Why should *every* OB carry that insurance and take that financial hit, when they are in a major city and know that there are other OB’s in town who do provide VBACs?

          • KarenJJ

            For the same reason that I don’t just hand over all the difficult jobs that might get my hands dirty to my colleagues. If you’re employed to perform a role you need to take the good with the bad and offer services that befit your role and your profession. If your hospital can provide VBAC and you can obtain insurance, what right do we have to just take on the “easy” cases? If TOLAC is a reasonable medical choice and we value a women’s autonomy, then what right does a doctor have to deny that?

          • Daleth

            If your colleagues are willing, able and insured to do a given job, while you are less willing and don’t have insurance, and the work your colleagues do is sufficient to meet the demand for that job… why on earth would you feel you have an obligation to get insured and do that job too? Why do you feel obligated to reduce your income by $X thousand a year just so that one more person is available to do that job, even though the demand isn’t high and your colleagues are able to meet all of it?

            And even in areas where there aren’t colleagues able to meet the local demand, doctors do not have an obligation to be able to provide every possible procedure that falls under the umbrella of that doctor’s specialty. For example, some surgeons can provide robot-assisted surgery on XYZ body part while other surgeons in the same field only do traditional (non-robot assisted) surgery on that body part.

          • KarenJJ

            I guess as long as everyone’s happy and everyone’s aware that Dr xxx doesn’t do VBAC because they won’t purchase the insurance coverage necessary for it. I’d personally not have a lot of respect for a doctor or a colleague that does that. Why should other colleagues pick up your slack? They pay their insurance too. But maybe medicine doesn’t really work like that.

          • Daleth

            I don’t see them as picking up someone else’s slack. There simply aren’t enough women who want VBACs and are medically good candidates for it to justify every obstetrician in America paying tens of thousands of dollars a year for VBAC insurance coverage. Different doctors have different niches even when they are in the same practice area (obstetrics or whatever).

          • Amy Tuteur, MD

            There is no VBAC coverage to buy. The insurance company simply takes away your insurance if you attend VBACs.

          • Medwife

            Her provider dropped her without a word of explanation. She’d been with this practice through her last pregnancy and birth. It was cold. It’s not how my (physician owned) practice treats people, and it’s not how I’d want to be treated.

          • fiftyfifty1

            Do you really believe that? That she was dropped without a word of explanation? Just for inquiring about VBAC? It’s not how your physician-owned group treats people because it’s not how ANY group actually treats people. There is more to this story that is getting told.

          • Somewhereinthemiddle

            If there is more to the story, I am not aware.

          • KarenJJ

            If an obgyn works for a hospital that can provide VBAC for good candidates and a patient is a good candidate for VBAC, why would an obgyn not offer a VBAC as a choice to their patients? Is that actually a common thing?

          • fiftyfifty1

            Because that hospital, or that individual doc might not have VBAC insurance for whatever reason (e.g. it got pulled after a disaster case, that hospital or doc doesn’t do enough volume to make it work financially, hospital doesn’t have 24/7 in-house anesthesia, doc is part of a small practice so they can’t guarantee somebody can be in-house 24/7).

            VBAC advocates/NCB advocates will have you believe that docs and hospitals are all set up and ready to go and denying women out of spite or laziness or something, but that is not the case. There is always a reason, but the VBAC advocate won’t stick around to listen.

          • KarenJJ

            That makes sense. So it’s largely a resourcing issue with the hospital or the practise, or due to a doctor unable to get insurance cover due to a recent poor outcome. It’s not due to doctors just deciding they get enough business without offering VBAC and then being able to negotiate cheaper insurance because of it.

          • fiftyfifty1

            ” It’s not due to doctors just deciding they get enough business without offering VBAC and then being able to negotiate cheaper insurance because of it.”
            Rural hospitals (and even many urban and suburban hospitals) are in financial crisis. The bottom line can be the difference between staying open and closing. Why should hospitals or individual doctors put their practices in financial peril to provide a service that most women don’t actually need, but rather just prefer?

          • KarenJJ

            Very different system to here then. Regional hospitals are largely government owned and run so they don’t need to be financially viable as such.

          • Somewhereinthemiddle

            Which vbac advocate? Me? Or are you using that more generally? If you are referring to me, I’ve been hanging around here for a couple of years, so no, I’m not off to disppear.

            I don’t know anyone who thinks that doctors refuse vbac out of spite.

          • KarenJJ

            So perhaps it would have been better if they’d told her that they can not provide for a VBAC to her face?

            In some way I think I understand what you are saying, for a provider to not provide a full range of options that are available to them for their own personal/financial reasons makes you wonder what they are doing in that profession in the first place. I’ve recently been through a discussion about access to birth control pills via family doctors due to their own religious reasons (ie the doctors reasons, not the patients reasons) and whether the doctors religious reasons not to provide the pill should trump the patient’s access to the pill.

          • Somewhereinthemiddle

            Yes, that is an accurate summary of my opinion KarenJJ. And this extends more so to the facility and hospital as it does to the individual care provider. There are hopsital that are equipped to handle vbacs (ORs, anesthesia in house, etc) that have policies that prohibit them, I guess for insurance reasons? If you are in the business of caring for women and their unborn babies, ACOG says that if women are good candidates they should have access to vbac, and the resources are available, why make that option unavailable.

            I personally think it would have made more sense for them to state to her that they don’t attend vbacs and that she should seek care elsewhere if that was what she was seeking. I mean, if a care provider withholds care, despite the fact that in this case it wasn’t a hardship, it is more respectful to inform her of why the decision was made.

          • KarenJJ

            I wonder if the VBAC option is more complicated for hospitals in the US. Where I am the public and private hospitals that can provide medically for high risk births (and as I understand it, VBAC is considered a high risk birth) do offer it for patients that are considered to be good candidates. I don’t know of any obgyns that would refuse a VBAC to a good candidate just because they don’t want to ‘get their hands dirty’ as such or want to pay for cheaper insurance levels by fobbing off the harder stuff elsewhere. Definitely if they don’t deal with high risk obstetrics due to training/staffing/experience is one thing, but to just take on the ‘easy’ cases for personal and financial reasons doesn’t make much sense to me and I don’t know if that is particularly wide spread (or as widespread as women are led to believe).

          • Somewhereinthemiddle

            I wasn’t referring to my friend when I said “denied reasonable access to care”. More twisting of my words more unneccessary snark.

            We don’t agree, I’m good with that.

          • Montserrat Blanco

            To me it sounds more like a problem with USA health system than a problem with OBs.

            I live and practice in Spain. Our health system is public, funded with taxes and patients only have to pay a small fee for out of hospital medication.

            Here she might have got an OB or a midwife that did not provide VBAC (highly unlikely). In that case she could have asked to be transferred to another hospital/OB near her home at mo charge. It is highly unlikely because as far as I know all the hospitals that have obstetric care (95% of all health system) do have OB and anesthesia 24/7, so if she is a good candidate she would have got that straight away. She would have been attended by whoever was on call on the day of the birth, but that person would have access to all her medical records. In any case we do not force women to have a CS, so if she turns up at L&D in labor…

            If OBs in your system can choose patients then, that is the problem. In our system you can only get rid of a patient in some cases after they literally punch you in the face.

          • Somewhereinthemiddle

            It is a system problem and systems are comprised of individuals who can choose to opt out. The cards are most definitely stacked against OBs in many way, even the ones who *want* to provide vbac and can’t for a myriad of reasons.

            Another part of the issue that OB isn’t a money maker in many hospitals so taking increased risk in additon to the money issue influences policy. I don’t pretend to know all the ins and outs of why our system leads to women not having access to vbac but it does andI don’t think it is right.

          • An Actual Attorney

            Don’t forget how big the US is, compared to most of Europe. I lived in a rural area, and would have to take a day off work and drive 3 hours each direction for a basic pap or exam. Parts of the country didn’t have running water (not well water, I mean no running water). My peers just a few years older, remembered getting electricity.

          • Medwife

            .

          • Somewhereinthemiddle

            Yes, I know which AMA we are refering to here. 🙂

          • EmbraceYourInnerCrone

            Also even if the homebirth goes badly and the family rushes to the ER and the hospital does what they can to resolve the situation, the hospital may end up being sued and lose. Johns Hopkins and the lawsuit for 55 million for not doing a Csection quickly enough for a home birth gone wrong transfer… Why did the parents not sue the midwife? Why bother they don’t carry insurance.

          • Daleth

            Are you really saying that it is unfair/unethical that every medical option a patient could possibly want is not available in every small town in America?

          • fiftyfifty1

            To be clear, if a doc or hospital is not insured to do VBACs they can’t do them. It doesn’t matter how good of a candidate she is.

            I agree that wanting a large family is a good reason to try to VBAC if you are a good candidate. But this is where I think adult women (and their partners) need to step up to the plate with their choices. The options are not homebirth vs. drive hours while in active labor. What responsible adults do is find a way to spend the last couple of weeks in pregnancy living near a hospital that offers VBAC. It’s strange how VBAC advocacy groups always say that docs should set aside their reservations (and insurance limitations) and offer VBACs. Why don’t these same groups just put a little effort into finding host families for rural women wanting to VBAC?

          • Somewhereinthemiddle

            That isn’t a reasonable option for most families, especially when the pregnant mother is employed full-time or there are children in school.

            And just because they aren’t insured to cover VBACs doesn’t make denying access to adequate care acceptible, even though the situation deems it a reality.

          • fiftyfifty1

            “That isn’t a reasonable option for most families, especially when the pregnant mother is employed full-time or there are children in school.”

            Well, we all make choices I guess. It seems to me that if you come from a family that *actually* values large families, then your family will have to pull together and support the woman. Surely they will have to find a way. It’s no different than if one of their child had a health condition that required them to seek specialty care at a Children’s Hospital. They would make it work. Nobody would think to complain that these services weren’t available in the middle of nowhere. Nobody would pout and try to claim that they were being “forced” to just keep the child home to be treated by an unlicensed alternative healer.

            No, this is about the rhetoric of NCB that says that women “deserve” a VBAC whether it is available or not and that doctors are “denying” women their “right” to VBAC out of nothing more than stubbornness.

          • Somewhereinthemiddle

            Well call me crazy but yes, I *do* think women deserve access to quality care whether they are looking for a VBAC or an elective cesarean. It may not be a reality but I think women deserve better. It isn’t NCB rhetoric to want a VBAC (within reasonable limits), it is patient autonomy and preference. And it is supported by ACOG, so I feel pretty justified in presenting it as a reasonable option.

            And sure, families do make illness work but people lose jobs, families suffer financially, go into debt, etc. It doesn’t seem to be a fair tradeoff for financial solvency or an incision in your uterus that may make future pregnancies more dangerous.

          • fiftyfifty1

            You keep mentioning what “ACOG supports” but you never seem to mention what ACOG *requires* which is that the doctor, anesthesiologist, OR team and OR room be ready immediately for the crash CS that will happen in at least 1/200 TOLACs. Sure ACOG supports VBACs, but nowhere does it require doctors or hospitals to offer them. Why? Because they know it could bankrupt a doctor and then where would this leave the town’s women? Providing VBACs means a doctor can never leave town if s/he has a pregnant VBAC patient anywhere near term. Then when the woman goes into labor the doc has to cancel an entire day (2 days?) of clinic visits and procedures to be immediately available. And the doc will be paying his/her nurses overtime as well. And how will the anesthesiologist feel about this? There went his/her schedule too. And this doesn’t even take into account the increase in insurance premiums that an OB will have to pay for offering VBACs. That alone can put a rural OB out of business (if s/he could even find an insurer to cover at any price)!

            But no, it’s all about the woman and what will be “inconvenient” for her, and how it might be a financial burden to her to have to travel to get the type of birth she wants.

          • Somewhereinthemiddle

            http://www.acog.org/About-ACOG/News-Room/News-Releases/2010/Ob-Gyns-Issue-Less-Restrictive-VBAC-Guidelines

            “The risk of uterine rupture during a TOLAC is low—between 0.5% and 0.9%—but if it occurs, it is an emergency situation. A uterine rupture can cause serious injury to a mother and her baby. The College maintains that a TOLAC is most safely undertaken where staff can immediately provide an emergency cesarean, but recognizes that such resources may not be universally available.

            “Given the onerous medical liability climate for ob-gyns, interpretation of The College’s earlier guidelines led many hospitals to refuse allowing VBACs altogether,” said Dr. Waldman. “Our primary goal is to promote the safest environment for labor and delivery, not to restrict women’s access to VBAC.”

            Women and their physicians may still make a plan for a TOLAC in situations where there may not be “immediately available” staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk. “It is absolutely critical that a woman and her physician discuss VBAC early in the prenatal care period so that logistical plans can be made well in advance,” said Dr. Grobman. And those hospitals that lack “immediately available” staff should develop a clear process for gathering them quickly and all hospitals should have a plan in place for managing emergency uterine ruptures, however rarely they may occur, Dr. Grobman added.

            The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC. On the other hand, if, during prenatal care, a physician is uncomfortable with a patient’s desire to undergo VBAC, it is appropriate to refer her to another physician or center.”

          • fiftyfifty1

            “On the other hand, if, during prenatal care, a physician is uncomfortable with a patient’s desire to undergo VBAC, it is appropriate to refer her to another physician or center.”

            Are you asserting that this doesn’t happen, that docs are refusing to refer?

          • Somewhereinthemiddle

            Of course they transfer care, but the options are often limited or geographically further away that is reasonable safe.

          • fiftyfifty1

            And that is why it can be a bummer to live in a rural area. That’s why my friend who wanted a VBAC had to choose between 2 inconvenient options (living 2 hours away in the nearest city or driving the 2 hours at the very first hint of possible labor). Bummer for her! That’s why my friend’s father sold his cabin after his first heart attack. Bummer for him, but he wanted to be near the cath lab! That’s why my cousin has to drive 2 hours each way for her son’s damn orthodontist visits (the local dentist says he doesn’t do braces, the nerve!).

            You can’t always get what you want when you live in a rural area. Everybody but VBAC activists understand this.

          • fiftyfifty1

            “What if the only doctor a woman has reasonable access to denies her access to an elective cesarean?”

            Having the hometown doc “deny” you a CS happens all the time in rural areas. If you live in a rural area, your doc may be an FP who doesn’t do CS at all. Or your hospital might not have an active OR. That’s the downside of choosing to live in a rural area, no?

            “Or she has to drive 2 or more hours away to get to a provider (remember all those pesky prenatal visits) or a facilty that will provide one?”

            So a woman wanting an elective CS will just have to do those long car rides, or perhaps move temporarily into a bigger town, or be a reasonable person who partners well with her providers and maybe the city doc will agree that the hometown doc can do some or most of her prenatal visits.

            “We don’t offer this here, we’ll have to help you set this up at the next big referral center” is a phrase rural people hear all the time from maternity care, to pediatric specialty care, to oncology care, to cardiac care, to trauma care to psychiatric care. The only ones who hear this and feel they have been “denied” something that they were “entitled” to are VBAC advocates.

          • Somewhereinthemiddle

            The difference is VBAC doesn’t reqire ongoing treatment, just possibily additional support during labor.

          • fiftyfifty1

            Yes, many rural hospitals without ORs are making the decision not to offer OB at all. As part of my training I did a rotation at one that had to send women out by ambulance 30 minutes away if they needed CS. I routinely vacation in a town that is 2 hours from the nearest OR. High risk women are asked to live in the bigger town toward the ends of their pregnancies. It would absolutely bankrupt this already struggling hospital to devote all their resources to the individual women who might want to VBAC. Sorry ladies.

            “The difference is VBAC doesn’t reqire ongoing treatment, just possibily additional support during labor.”

            “Just possibly” additional support during labor?! LOL!

          • Somewhereinthemiddle

            Why is that funny? She may need additonal support (i.e. a surgical team, not a small or minor thing I understand), if she ruptures.

            Again, I realize that there is a discrepancy between how things have to happen because of insurance, rural resources, etc and the ideal. No one is “blaming” doctors. The situation is shitty no doubt. But I happen to think that women do deserve better care, especially the ones that have to be trucked 30 minutes away by ambulance for a CS. I am not unsympathetic to the plight of the medical community in regards to the balancing act. But it still sucks that women have sometimes dangerous decisions to make regarding care.

            You are hammering away at me like I’ve attacked hospitals and doctors. It’s a shitty situation all around that women (and physicians) have to make compromises in quality of care.

          • fiftyfifty1

            It’s funny because you are so obviously playing dumb. “May” need more support? Please, the whole labor is different! She needs to have the entire surgical team on a short leash the entire time, not just “if she ruptures”. She needs to be on 24/7 monitoring. The doc may have to cancel the whole day. S/he can’t be tied up in another surgery, so the hysterectomy etc that was planned will have to be canceled. Many rural OBs visit more than one town (I did my med school OB rotation with a rural OB, so I know). But if a VBAC is in labor, 30 minutes away by car is not good enough. So goodbye to the office schedule. And what about the anesthesiologist? They also may travel between 2 small hospitals doing anesthesia for tonsilectomies, appys, you name it. But now anesth has to cancel and stick close too. What if the woman continues to labor at night? Realistically everyone needs to be in hospital.

            Women who want a VBAC seldom have the behind-the-scenes knowledge of all the resources (time and $$) that go into dealing with a VBAC. They can’t understand why they can’t just get what they want, because it’s all about them and they are convinced that it’s all is going to end well anyway. For those who have been part of a rural hospital budget meeting, or who have frantically dealt with trying to airlift out a damaged baby, let’s say it looks real different.

          • Somewhereinthemiddle

            But how is that any different from any other obstetrical emergency? Prolapse, abruption, rupture of an unscarred uertus, hemorrhage, fetal distress, etc you know them better than I do. If those resources aren’t available for those emergencies, why be in the baby business at all? Why not just send everyone to the larger maternity centers?

          • fiftyfifty1

            We know that with VBAC, 1 out of 200 labors will end in a crash CS due to rupture, and if that CS doesn’t happen in minutes, the baby will be dead. This is a much higher risk than with a low-risk pregnancy. A TOLAC contains all those other risks you mentioned PLUS this 1/200 certainty on top of it. Small hospitals refuse to do VBACs for the same reason that they refuse to do other vaginal births with known added risk (twins, SGA fetus, malposition, placental abnormality, insulin dep diabetes). Nobody blames rural hospitals for referring out these other high-risk cases, but VBAC activists want to be treated different than other high-risk cases.

            As to whether rural hospitals should stop doing OB altogether, that’s a great question. The reality is that more and more of that are coming to that exact conclusion. The ones that stay open often do so only because of being the only “island” around at all. The town I vacation in is 30 minutes from the Canadian border and 2 hours from the nearest (small) city. If it did not offer any OB services, there would be some women 4 hours from any care.

          • Somewhereinthemiddle

            And yes, I can see your point about how inconvenient, expensive, and stressful that can be for the people supporting a mom having a TOLAC. My question is what counts as a rural hospital? The hospitals I am thinking about have emergency services, maternity services, etc but still don’t accept vbacs. I’m not taking about the tiny little hospitals that are little more than triage centers, I’m talking about hospitals that serve the surrounding 120 miles.

          • fiftyfifty1

            Here’s an idea. Have a sit down visit with somebody in the know from that hospital. Ask very sincerely why that hospital made the decision not to offer VBACs and then LISTEN. Don’t interrupt with 100 VBAC advocacy/NCB advocacy reasons you have heard of why all hospitals should and could offer them. Actually LISTEN.

          • Somewhereinthemiddle

            I personally would be happy to listen. I would also love to hear more about the insurance process about what leads hospitals and providers to not have insurance to cover those types of patients. I am asking this in earnest, not to be antagonistic, you know, listening. Do providers opt not to carry the insurance? If so, why? Is it massively more expensive? Does the volume of vbacs they see not justify the expense? Are they denied coverage from the insurance comapnies for reasons like not having access to an adequate NICU? I sincerely would love to know so I can understand what is leading to the problems women are facing in regards to access to vbac. I have many physicians (no OBs) in my family and have no interest in demonizing physicians.

          • fiftyfifty1

            So go ask. Stop getting your talking points from pro-NCB VBAC advocacy sites.

          • Somewhereinthemiddle

            By dismissing genuine concerns as “talking points”, you are proving the point about the reservation people have about the very real issues that obstetric community and mothers and babies are facing. But we can agree to disagree on that point.

          • fiftyfifty1

            Yes, we obviously disagree. I have no dog in this fight. I don’t provide OB services. But I know the NCB talking points regarding VBAC and they go something like this:
            -OBs deny VBACs for no reason at all (insert some dubious story of a friend being fired for even mentioning the word VBAC)
            -OBs must do it because they are greedy (you ask with wide eyes, “Could VBAC insurance really be more expensive?”)
            -OBs aren’t following Evidence Based Care (and then link to some ACOG statement that doesn’t even apply to a particular doc)
            -OBs don’t understand that there are RISKS to repeat CS (as if it isn’t OBs themselves that have to deal with accreta, scarring etc)
            -Rupture risk is low (as if 1 in 200 is low when it’s a total fatal emergency)

            You are one big list of talking points but you don’t see it because you regard yourself as educated on the matter.

          • Somewhereinthemiddle

            I’d be more than happy. Somehow I have my doubts about hospitals and physicians being oh so excited about transparency regarding their insurance set-up, their policies, and why they don’t provide certain types of care.

            You care to share how you practice in this regard and why?

          • fiftyfifty1

            I’m a family physician who doesn’t do OB, so have nothing personal to add. But I disagree with you regarding what physicians and hospitals will and will not share if they believe you are asking a sincere question vs. just setting them up to slam them with NCB talking points.

            I find it so odd how VBAC advocates (including yourself) link to long ACOG statements as if OBs weren’t already familiar with them. Do you really think OBs are ignorant about the pros and cons of VBAC? Do you think they don’t understand that accreta is a risk? THEY are the ones who have to deal with accreta when it happens just as THEY are the ones who have to deal with rupture. Find an OB and ask and LISTEN. And leave all your preconceived offensive doubts about how “transparent” (because that is just a dog whistle substitute word for “honest” and “ethical”) OBs are willing to be.

          • Somewhereinthemiddle

            I am here. I am listening. I am asking sincere questions. Not sure what else you expect me to do.

          • fiftyfifty1

            What I expect is for you to actually learn about the factors that go into offering VBACs before you make ignorant VBAC advocacy statements like “All hospitals that offer OB services should offer VBACs”.

            You admit that you know nothing about why some providers opt not to carry VBAC insurance (sounds like this is the first you’ve even been aware that such a thing exists!). You have no idea what it costs. You know nothing about L&D volumes or bottom line. You have no idea why an insurance company might deny an OB coverage or what facilities and policies they require to even offer it. You admit you have never talked to OB about these issues.

            Yet Somewhereinthemiddle thinks she knows best and that she is justified in proclaiming that All Hospitals That Do OB Should Offer VBACs. Such Dunning Kruger bullshit.

          • Somewhereinthemiddle

            Did you even read what I wrote? I directed my doubts about the transparency of insurance companies but I would assume that a good number of OBs wouldn’t be super comfortable talking about their insurance situation either. And they probably have good reason not to be because of exposing their weaknesses liability wise.

          • fiftyfifty1

            No actually you didn’t cast doubt on the transparency of insurance companies, you said you had doubts about the transparency of “hospitals and physicians”.

            “And they probably have good reason not to be because of exposing their weaknesses liability wise.”

            What are you talking about? How would explaining what procedures their insurance does or does not cover “expose their weakness”? There is no deeper hidden agenda or cover up here, I assure you, LOL. It’s simple economics and practicalities.

          • Samantha06

            “I personally would be happy to listen. I would also love to hear more about the insurance process about what leads hospitals and providers to not have insurance to cover those types of patients.”

            But you aren’t listening! Fiftyfifty1 has spelled it out pretty well for you. It’s about RISK. Insurance companies are only concerned with risk. The higher the risk the higher the cost. Most hospitals and physicians are not going to pay out huge insurance premiums just to have coverage for a high risk situation. Why would they consider placing themselves or their patients in that situation anyway? It’s about PATIENT SAFETY. It’s simply not safe to allow a woman to VBAC in a small, rural hospital that doesn’t have the capabilities to deal with it. You don’t seem to be getting it. You seem to be pretty brain-washed by NCB rhetoric.

          • Somewhereinthemiddle

            No, I want to understand why hospitals and physicians are refusing women a TOLAC which a *valid* thing to want to understand. And yes, I read her reply to someone else above that detailed more closely the insurance process. I am sure that a myriad of different insurance choices are made based on individual circumstances and I want to understand those.

            And again, you guys are breaking out the ultimate in insults. “NCB!” “Brainwashed!” Please, I’ve been coming around here for the last two years. If I were brainwashed by the bullshit I would have run for the hills a long time ago. Thinking that patients should have reasonable access to vbac and bodily autonomy isn’t brainwashed. Again, it is supported by ACOG. When in doubt, throw around the insults to shut down the conversation!

          • Guest

            Because the doçtors and/or hospital administration and/or insurance companies decided that the well known risks of a VBAC in their hospital setting made it less safe than a c/s.

          • Amy Tuteur, MD

            It’s not the fault of doctors. This is an old post, but it explains the issue:

            http://www.skepticalob.com/2009/08/doctors-used-to-encourage-vbac-what.html

          • Samantha06

            Hospitals and physicians don’t just refuse TOLAC across the board. Patients do have reasonable access to VBAC in both the US and Canada. I’m not sure why you think otherwise. Of course it’s supported by ACOG. That isn’t the issue here. It’s about risk.

            “The difference is VBAC doesn’t require ongoing treatment, just possibily additional support during labor.”

            That statement is completely erroneous. Have you discussed this with your care provider? No one is insulting you and yes, to those of us who work in the field, you do sound like you’ve fallen for the rhetoric.

          • Somewhereinthemiddle

            I don’t think that knowing several women who had to travel several hours in labor is “falling for the rhetoric”. But since that is strictly a matter of opinion, this is one of the points upon which we can agree to disagree.

          • Daleth

            Knowing women who “had to travel while in labor” (i.e., lived too far from a hospital that was equipped and able to offer VBAC, and chose not to move temporarily closer to the VBAC hospital near the end of their pregnancies) has nothing to do with rhetoric.

            But deciding that those women should not have had to travel at all–in other words, that VBAC should have been offered at the local hospital of their choice–is falling for the rhetoric.

            Particularly if you still believe, after everything that’s been discussed here, that the women you know were somehow wronged by the fact that the high-risk medical option of their choice was not available at every local hospital.

          • Somewhereinthemiddle

            And somehow you are coming to the conclusion that I said that vbac should be available at every local hospital. I never said that and don’t think that should be the case. That assertion has been extrapolated from what I actually said and continue to say which was women should have reasonable access to vbac at hospitals that are equipped to handle vbacs. According to women I have spoken with, that is not what is happening. In the fervor to disprove my assertion that denying reasonable care to women, many people have morphed what I have stated into something that suits their points.

            As far as I can tell I can neither prove that that is happening and you cannot disprove that is happening so it is a matter of opinion. At this point this conversation feels like I am having to clarify, reclairify, and clairify again the points I have made ad nauseaum.

          • Daleth

            Sure, women should have reasonable access to VBACs at hospitals that are equipped to handle VBACs. But you still haven’t pointed to any hospitals where that’s not the case. What does the fact that X number of your friends had to travel to get TOLAC/VBAC tell you about whether the hospitals close to them **were equipped** to handle VBACs? Absolutely nothing.

            Most likely, the reason they had to travel was either that their local hospital wasn’t equipped for VBAC, or their local hospital had policies on what level of VBAC risk it was willing to take (for instance, many hospitals that offer VBAC will not offer it to women who have had a c-section with a vertical incision, due to the much higher risk that vertical incisions will cause uterine rupture) and your friend insisted on a VBAC despite not meeting their policy’s medical parameters.

            And I don’t think anyone was twisting your words to serve their own rhetoric. If I and others here have said you think VBAC should be available in every local hospital in America, it’s because you repeatedly said it was somehow “unfair/unethical” that anyone ever had to drive 100 miles or 2 hours to access a VBAC.

          • Somewhereinthemiddle

            What I *have* heard of is women are having to literally and figuratively drive past hospitals that are closer to their homes, are equipped to handle vbacs, but do not “do” vbacs either because there isn’t a provider who is either able or willing to take them or because the facility doesn’t allow it. Instead, they have to drive an additional hour and a half to get to a different facility where they are “allowed” to vbac. Now, you are more than welcome to not believe those stories. *I* personally have never been in that situation and have excellent options available to me.

            As far as I can tell, no one is denying that providers and hospitals disallow vbacs and sometimes it is related to factors other than the availability of anesthesia. Which is my point and I extand to state that this sometimes puts undue stress on families and places mothers and babies in less safe situations. If there was an easy answer to how to balance safety risk, maternal preference, provider preference, insurance, liability, etc, we wouldn’t be having this conversation and the vbac question would be an easy one. As of right now, there doesn’t seem to be a consensus on how to balance all of those aspects. So here we are, at a stalemate.

          • Somewhereinthemiddle

            I also never stated that it was safe for women to vbac in a small rural hospital without access to anesthesia. But thanls again, to someone else putting words in my mouth.

          • rh1985

            Yep, on one of my IVF boards there is an expectant twin mom from Alaska, she was sent to the city at 31 weeks and will be there until delivery, local facilities can’t handle the potential complications.

          • KarenJJ

            Same thing happens where I live. The state is the geographic size of Western Europe and people living in remote areas often have to fly to the city for treatment (maternity or otherwise – we shared a room with a boy that had a broken leg that had been flown two hours via the flying doctors service to the Children’s hospital when my boy was in for surgery on his foot).

          • fiftyfifty1

            Yes, and notice how she accepts this like an adult, even though she could just as easily argue that if some hospitals offer it, hers should too. That most twin births end up just fine.That it is inconvenient for her to travel, blah blah blah.

          • Montserrat Blanco

            I think a good part of the issue is how the health and law system are set up in the USA.

            I live in Spain. Here if you want a VBAC you go to your OB (free) and talk about the options. If you are a good candidate you can have a trial of labor. All hospitals with maternity units have OBs and anesthesia 24/7. That is also free for the patient (paid by taxes). You will be attended by the OB on call/midwives on call. And that is it.

            If you are a bad candidate you will be offered another CS and explained why you are a bad candidate. If you turn up to L&D on labor and refuse a CS you will receive medical attention despite that. If in that case there is a bad outcome it is highly unlikely you will sue, given that you were advised agaisnt it and it would probably be difficult to find a lawyer. In any case if you sue you are unlikely to get any money, especially if you have signed that you did not want the CS, as is usually the case. Here payments are usually only awarded if there is damage done and you were not properly informed that could be an option or if there was a serious case of malpractice (like ignoring a bad trace of fetal monitoring).

          • Poogles

            “If we go with your line of thinking, insurance companies should (and maybe do?) have a say so in who gets to have an elective cesarean or not? And doctors? What if the only doctor a woman has reasonable access to denies her access to an elective cesarean? Or hospital policy denies elective cesareans? Or she has to drive 2 or more hours away to get to a provider (remember all those pesky prenatal visits) or a facilty that will provide one?”

            Well, health insurance companies definitely get to say whether or not a patient can have an “elective” (maternal request) CS (or, at least, whether they will cover it), but not sure about the medmal insurance. Doctors most definitely get to decide whether or not to provide MRCS and they cannot be forced to do so.

            I, personally, am hoping to have a MRCS when the time comes. I am aware that I probably face an uphill battle between finding an OB who is MRCS-friendly and trying to get insurance to cover it. I realize that this may mean I have to travel longer distances to find an OB/hospital that will work with me. I also realize this means I may be SOL and will have to face a TOL/vaginal delivery if I want to have a child without moving to a completely different region.

            While I would absolutely love if most OB’s reviewed risks of both modes of delivery (CS and vaginal) and then let women decide which route they want to take, I also do not see the current situation as “unreasonable.”

          • KarenJJ

            “While I would absolutely love if most OB’s reviewed risks of both modes of delivery (CS and vaginal) and then let women decide which route they want to take, I also do not see the current situation as “unreasonable.””

            Why isn’t it “unreasonable”? I should think that when there are options that are a good choice medically and ethically, then definitely discuss the risks and let women decide.

          • Poogles

            “Why isn’t it “unreasonable”? I should think that when there are options that are a good choice medically and ethically, then definitely discuss the risks and let women decide.”

            To be clear, I absolutely hate that health insurance companies can dictate care by refusing to cover safe, reasonable options (such as MRCS). I only feel that it isn’t unreasonable that not all doctors will agree to perform them – with the increasing pressure to reduce CS rates, the widespread belief that vaginal is almost always better, and the hassle of fighting with the health insurance companies, I can see why it isn’t becoming a more commonly offered choice as fast as I would like.

          • Somewhereinthemiddle

            I find that sort of situation to be unacceptable even if you don’t. Good luck with your search! I hope you are able to find a provider to give you what you want and that you don’t end up having to go hours away from home to get it.

            I personally feel like I’ve won the lottery because in my area and with my insurance, I have the ability to chose an elective CS at a great hospital or have an unmedicated vaginal water delivery also at a great hospital all within 45 minutes of my house. Those are choices that I’ve never taken for granted and I strongly feel that other women deserve the same options.

          • Poogles

            The city I live in has about 8 hospitals that offer L&D – so I really hope that I don’t have to look too far (I haven’t put any feelers out yet), and I am very aware of the advantages I have being near so many hospital providers (I love my city!). If I was not near to so many choices, I would expect my chances of getting an MRCS would be greatly reduced unless I relocated (temporarily or permanently).

            “I strongly feel that other women deserve the same options. ”

            Ideally, sure! Unfortunately, “ideally” doesn’t always work in reality, so with finite resources some things have to get left out (VBAC services & waterbirth options for all women, all over this massive country (US), for instance).

          • The Computer Ate My Nym

            Some hospitals aren’t insured to cover VBACs or don’t offer VBACs because they don’t have the facilities to make VBAC safe. A hospital that doesn’t, for example, have 24/7 anesthesia and OR access is not a safe place for a VBAC where there might be a uterine rupture at any time. You can’t wait to call in anesthesia while someone’s bleeding out from a uterine rupture and if the hospital isn’t ready to take the patient to the OR immediately they might as well be at home. The hospital is being honest in not making a promise they can’t fulfill.

          • Guest

            And just because they aren’t insured to cover VBACs doesn’t make denying access to adequate care acceptible, even though the situation deems it a reality.

          • fiftyfifty1

            “And just because they aren’t insured to cover VBACs doesn’t make denying access to adequate care acceptible, even though the situation deems it a reality.”

            Huh? what are you saying exactly?

          • Somewhereinthemiddle

            I’m saying that even though the reality is that insurance companies are dictating the care women receive, it is still a shitty state of affairs.

          • fiftyfifty1

            If something is safe, it is cheap to insure. It’s only when things end in expensive disasters that they become expensive to insure. Insurance companies have no ideology driving them. One or two babies damaged in VBAC ruptures could bankrupt an insurance company.

            A hospital deciding that VBAC insurance is way too expensive to consider is a “shitty state of affairs” only in the same way that driving through rural Kansas and not having immediate access to a tornado shelter is a “shitty state of affairs”. Is the highway department “shitty” for deciding to spend their money on routine road maintenance rather than on digging roadside tornado shelters? If you want immediate access to a tornado shelter, you better live in town, because building a tornado shelter is expensive.

            It ain’t nobody’s fault that 1/200 VBACs end with the shit hitting the fan, and frequently an (expensive) damaged baby in the process.

          • KarenJJ

            Well to be honest it’s either the insurance company or the government in the case of national health schemes. The health care we all receive is often limited in some way or other by resources, knowledge, access etc.

          • Daleth

            I’m sure cancer and organ transplant patients “want to see someone closer to home” too, but if the patients have chosen to live in an area where there are no organ transplant hospitals or world-class cancer treatment centers within 100 miles, then guess what? They have to travel to get treatment. And not because anyone “forced” them to live in a place with only basic medical care available; that was their choice.

            Or do you really think that every capability of modern medicine should be available in every town in America? Have you thought about how much that would cost, and how wasteful it would be–since there simply aren’t enough patients who need every possible procedure to justify making every possible procedure available everywhere?

          • The Bofa on the Sofa

            Or do you really think that every capability of modern medicine should be available in every town in America?

            We’ve actually seen that argument before – actually, the converse – that if they can’t offer it all, then they shouldn’t be available at all.

          • Somewhereinthemiddle

            I’m sure they would and I am sure that for some patients, geography does indeed play a role as a barrier to adequate care. Just because that is the reality of the situation doesn’t make right. I’m sure that someone’s grandmother on Medicaid who lives in rural nowhere’s ville is getting crappy care next to a monied retiree living in Boston, New York, and LA. It may be a cruel reality but I’m not good with saying it’s okay.

          • The Computer Ate My Nym

            Some transplant and specialty care centers offer help finding temporary housing or have housing available to patients and families of patients undergoing care at these centers. It seems like pregnancy, being an inherently time limited condition, would be ideal for this sort of thing: just move into the housing near the hospital at, say, 7-8 months, and you’re right there for the TOL in a safe setting. Of course, this implies being able to get off from work soon enough (there is no guaranteed maternity leave in the US, as far as I know), but there’s only so much the hospital can do.

          • Daleth

            There is no guaranteed paid maternity leave, but there is FMLA (Family and Medical Leave Act), which provides up to 12 weeks unpaid leave.

          • KarenJJ

            We have this where I live. http://www.wacountry.health.wa.gov.au/index.php?id=pats

            As I said, where I live the state is huge and services are concentrated in the city. Even in other larger remote places, eg Darwin, you have to travel for care. One of my friends had a detached retina and was despatched on a 3 hour commercial flight for eye surgery. It’s something people that live in remote places are very aware of.

          • Daleth

            If you’re not good with saying it’s okay that rural areas have fewer of civilization’s resources (world-class hospitals, great libraries, etc.) than cities and university towns do, what alternative do you propose? And how should it be paid for?

          • Ash

            Cool, let’s just shut down every hospital in the USA except for tertiary care centers.

            That’ll surely improve people’s health.

          • Somewhereinthemiddle

            Look, I realize that the reality that someone in a rural area is going to have less access to top of the line care. A person in a rural area is almost less likely to have the monetary means with which to travel to a major metropolitan area for treatment. By default, their care is going to be less top of the line and whatnot. But I will absolutely *not* accept that those people are less deserving of quality care than someone who has access to those resources. Call me an idealist but even it may be a reality that they won’t get the care, doesn’t mean that they deserve it. And I am not comfortable throwing my hands up and saying “Oh well, sucks for them!”.

          • KarenJJ

            I don’t think people are throwing their hands up. Doctors are looking at options to help bring better services to regional areas using technology and using specialists that travel to remote areas. It’s not perfect but I do think it has gotten better over the years.

          • Somewhereinthemiddle

            Also, I keep using the word fair and that isn’t what I mean. What I mean is ethical.

          • Daleth

            How is it unfair or unethical to say “we don’t do VBACs because we don’t have anesthesiologists on site 24/7”? Not every hospital has or is capable of having 24/7 anesthesiology services.

            But it would be completely unethical and against practice guidelines to attend a VBAC without an anesthesiologist on site, because if a uterine rupture occurs you need an immediate crash c-section… and thus you need someone qualified to anesthesize the woman.

          • Somewhereinthemiddle

            Not having adequate anesthesia *is* a valid reason for not attending VBACs. But here are hospitals and providers who do have resources who do not accept vbac patients.

          • Daleth

            Name one. And by “one” I mean “a hospital,” since there is no such thing as a doctor who has an OR and 24/7 anesthesiology staff, so I’m not sure what you mean by “providers who do have [the] resources” to provide VBACs.

          • Somewhereinthemiddle

            There in lies the rub. The lists compiled are done so by organizations that illicit eye rolls around here so I won’t bother. The ones that come to mind from specific instances that I am personally privy to were in Florida, New Jersey, and one other midwestern state that I don’t recall. Anecdata and all that…

          • KarenJJ

            Actually I think that’s a shame if the evidence exists that we can’t see it ourselves. I actually agree that if it a woman is a good candidate and ACOG guidelines state that TOLAC is suitable under certain conditions and the hospital meets those conditions and can get insurance to cover it, then why would they not offer it? Why would the hospital not require its employees to cover a full spectrum of services? I don’t know that it’s all that widespread – I certainly have only heard of issues for women that are much higher risk with a TOLAC than those that are typically good candidates OR if they are in a regional area where the hospitals don’t take on high risk obstetrics. But I’m not in the US so I don’t know.

          • Somewhereinthemiddle

            Me too. I would really like to have a breakdown of the numbers of women this affects and get a better idea of what types of improvements, if any, would be realistically feasible.

          • Daleth

            People may roll their eyes at certain organizations in general, but that doesn’t mean they roll their eyes at properly sourced data provided by those organizations. So have at it.

          • Somewhereinthemiddle

            ICAN used to keep database of hospitals that had either bans or de facto bans, meaning even though it may be permitted at the facility, there were no providers willing to attend. ICAN isn’t exactly a fantastic source to begin with, so need to point that out. It’s not active any more as far as I can tell and this list made from their list is the only thing I could locate in the 10 minutes I had to dedicate to looking. Yep, I know this isn’t a rock solid source of information, but it’s the only thing close that appears to be available. If anyone has a more reliable source that they know of off the top of their head, I’d be interested in seeing it.

            http://www.babygaga.com/t-695103/vbacs-and-hospital-policies-by-state.html

          • Daleth

            That’s only half of the equation (“hospitals that had bans or de facto
            bans”). Where is the other half?

            What you said is that “there are hospitals… who do have resources who do not accept VBAC patients.” So where is the evidence that
            the hospitals on that ICAN list **had the resources** (24/7 anesthesiologists etc.) to offer VBACs?

          • Somewhereinthemiddle

            That part is anecdotal and has come from women that I have come into contact with. Again, I recognize that I’m not making a rock solid case. But if women are searching and driving two or more hours to a provider, I believe that there is something to the stories. If that isn’t good enough for some cause for concern for you, that’s okay.

            I don’t personally have the time to go through the list and do my own personal verification of the list or the stories women are sharing. But if there was a way to reliably verify and collect data, it would be great.

          • Daleth

            I completely agree with you that it’s true that some women in the US have to travel two or more hours to get to a hospital where they can attempt a VBAC.

            But why do you believe, despite an apparently total lack of any evidence, that local hospitals that COULD offer VBAC (i.e., have 24/7 anesthesiologists, 24/7 OR staff, etc., as required by ACOG) nevertheless ban VBACs?

            And why do you (if I’m not mistaken) still believe, despite the obvious resources/logistics/reality issues that have been mentioned here ad infinitum, that every podunk hospital in America ought to be offering VBACs?

          • Somewhereinthemiddle

            I *never* stated that every podunk hospital in the US should allow vbacs. Why do you guys keep stating that I said that? I even said in one of my first posts that it shouldn’t extend to hospitals that don’t have access to anesthesia if you care to go back and read.

            I’ve said that I don’t have any solid evidence. I believe the anecdotes of women who are saying they are running into this obstacle. If you don’t believe them, that’s your perogative. Again, at this point it is an opinion and what you choose to believe since neither one of us have any solid evidence.

          • Daleth

            I believe their anecdotes too. I believe that they weren’t able to get a TOLAC/VBAC attempt at the hospital of their choice. Absolutely, that does happen.

            However, generally it happens either because the hospital she likes isn’t equipped to provide VBACs (i.e. doesn’t meet ACOG guidelines on staffing, etc.), or because she herself does not meet that hospital’s parameters for a TOLAC (i.e., she has a medical history or condition that risks her out of trying for a VBAC).

            I’m just not clear on why you have decided that the reason your friends had to drive an hour or two to get a VBAC was some nefarious deficiency in American healthcare or some “unfair/unethical” decision on the part of local doctors. You’re free to believe that, despite apparently having no evidence for it… and you’re also free to believe in Sasquatch.

          • Somewhereinthemiddle

            I personally think it is unethical for a provider or hospital to not look at vbac patients on a case by case basis and decide who is a good candidate and who is not, yes. Instead, *some* have decided to ban them altogether for x,y,z reasons that have been discussed in other parts of the thread. It is a difference of opinion if your thoughts differ on the topic. My opinion on the topic isn’t “sasquatch”, it based of what I believe to be legitimate sources of information.

          • Amy Tuteur, MD

            What makes you think that doctors and hospitals are the decision makers on these issues? They’re not. What do you propose to do to change the minds of the actual decision makers, insurance companies?

          • The Bofa on the Sofa

            What do you propose to do to change the minds of the actual decision makers, insurance companies?

            Stop letting people sue for bad outcomes?

          • Somewhereinthemiddle

            How do the insurance companies arrive at their decisions about which providers are permitted to accept vbacs and which are not? Again, sincere question not snark. And honestly, I don’t know the answer to change the minds of the insurance companies. ACOG has statements that have expressed (limited) support of vbac. The NIH study appears to show that it is a reasonable choice for some women. What do you think would convince them?

            As a small aside, I was present for a conversation with an OB who purposefully does not allow vbacs at his practice at all because he believes that cesareans are a superior choice for almost all women. This was before I was even considering having children and he was my bosses OB and we were doing some business with them. *That* was an interesting conversation, lol!

          • Daleth

            Hospitals ban VBACs either because they are not equipped/staffed to perform VBACs to the ACOG standard, or because the cost of insurance for VBACs is so high that the cost/benefit analysis comes out against it.

            I mean, if a hospital is looking at a $500,000/year bill for insurance and the local demographics suggest they’re only going to get maybe 50 VBAC patients a year, the math does not work. They have to take that $500k from somewhere. Where, in your opinion, should they take it from? Emergency services? Cardiology?

            And what makes you think that hospitals that are equipped and insured for VBACs do NOT look at patients on a case by case basis?

            It’s so puzzling to me where you got all these strong opinions that XYZ is true (e.g., that hospitals don’t look at patients on a case by case basis). It’s not like you’ve mentioned even anecdotal evidence that XYZ is true. You seem to just be making up “facts” and then forming opinions about them.

          • Somewhereinthemiddle

            Listen, we can agree to disagree. As fun as this conversation/ debate has been, I’ve neglected some things I need to be focusing on and need to get back to it. I have no new information to provide and it does’t seem that you do either. I’m good with just saying we don’t agree rather than continuing to hammer on at the same points. I’m okay with you not seeing things from my perspective and you seem to be good not seeing things from mine. No big deal.

            In any case, I’ll be lingering around reading Dr Amy’s blog and continuing to learn from the information shared.

          • Somewhereinthemiddle

            *it would be great and either show that women are indeed having issues accessing care or that I and they are full of shit.*

          • Daleth

            If by “having issues accessing care” you mean “some women have to drive 2+ hours to get a VBAC because not all hospitals offer them,” everyone here is in complete agreement with you that that is the case.

            Where you and I are in disagreement is in our conclusions about that fact. You seem to have concluded that every woman in America ought to be able to have a TOLAC/VBAC attempt at the local hospital of her choice.

            I disagree, not because I have anything against VBACs but because high-resource procedures are typically not available at small local hospitals, and cannot be available there because there is not infinite money in the world. The local hospital you can’t get VBACs at is the same place where you also can’t get a heart/lung transplant, bariatric surgery, treatment for rare cancers, or for that matter even IVF.

          • Somewhereinthemiddle

            Oy. Y’all keep telling me that I said *every* hospital should have access to care but I think you guys are reading each others posts and just assuming that somewhere along the line I said that because someone said that I did. I didn’t actually say that.

          • Daleth

            You said, quote, “it *is* unfair/ unethical that some hospitals and providers disallow VBACs out of hand.” How are we to interpret that, if not as meaning that you think all hospitals should allow VBACs?

          • Somewhereinthemiddle

            And you are ignoring how many of the other times that I stated hospitals that have anesthesia and can adequate support a vbac? How many time do I need to state that without being completely redundant. Come on now.

          • Amy Tuteur, MD

            You are pounding on doctors and hospitals when they are not at fault. What is your solution to the problem of malpractice insurance companies refusing to cover VBACs? I haven’t seen you offer any solutions.

          • Somewhereinthemiddle

            As a patient who has zero influence or direct dealing with insurance companies, I don’t really think I am the most qualified to assess and implement insurance negotiations on the behalf of physicians and hospitals. I may be wrong but it doesn’t appear on the surface that most physicians, ACOG, or hospitals are fighting insurance companies to fight vbacs. Am I wrong? Again, sincere question. Almost *all* of what goes on between insurance companies and hospitals, practices, and physicians is not exactly public knowledge and there doesn’t appear to be much transparency. Not sure why that is. You appear to be blaming me “the general patient population” for not understanding a process that appears to be purposefully kept away from public knowledge either by the providers, practices, and hospitals oor by the insurance companies. I would imagine that that is probably more so the insurance companies since the are SO well known for being completely transparent and clear about policies. (That was snark by the way, directed at insurance companies). From the outside, unless stated otherwise, providers, practices, and hospitals appear to be complicit. If that is not the case, please clarify how that is not the case.

            Again, I don’t know how to fix the issues. It doesn’t seem that *anyone* knows how. As someone inside the medical field, I would be open to hearing your opinions on what needs to happen and maybe as a patient I would be able to understand where I might be able to assist in the process.

          • Amy Tuteur, MD

            You’ve spent two days blaming doctors for robbing women of VBACs when it has been out of their hands for years. If you are truly committed to making VBACs more available for women, it would help to stop mischaracterizing what is going on.

            Whether or not you presonally have direct influence on malpractice insurers doesn’t prevent you from offering a solution to the problem of malpractice insurers refusing to cover procedures because THEY deem them to be too risky, regardless of what the doctor, hospital and patient think.

          • Somewhereinthemiddle

            I would love to see a breakdown of the reasons why physicians choose not to attend vbacs. I think I saw the results of a poll somewhere, maybe the NIH study? Where physicians were able to list why they don’t attend vbacs. I’ll look for it in a bit.

          • Amy Tuteur, MD

            They don’t attend VBACs because ACOG has set guidelines for hospitals and many hospitals can’t meet those guidelines. In addition, even when the hospital can meet the guidelines, some malpractice insurers have forbidden doctors to attend VBAC by threatening to void their coverage. Since obstetricians must have coverage while they work and for 21 years after retirement, they can’t do VBACs if losing coverage is a possibility.

          • Somewhereinthemiddle

            Well that is shitty and unfair and leaves both the provider and the patient in a terrible position. In any case, for some reason I though there were actual numbers but this what the NIH consensus says about why physicians don’t attend vbacs. Obviously it is hardly comprehensive but it’s what I could find with the window of time on my hands.

            “Concerns over liability risk have a major impact on the willingness of physicians and health care institutions to offer trial of labor. These concerns derive from the perception that catastrophic events associated with trial of labor could lead to compensable claims with large verdicts or settlements for fetal/maternal injury—regardless of the adequacy of informed consent. Clearly, these medical malpractice issues affect practice patterns among health care providers and they played a role in the genesis of the College’s 1999 “immediately available” guideline.

            Members of the American College of Obstetricians and Gynecologists confirm that concern over liability is a main reason they stopped offering trial of labor. A 2009 College survey revealed that 30 percent of obstetricians stopped offering trial of labor or performing VBACs because of the risk or fear of professional liability claims or litigation. This is further compounded by 29 percent acknowledging having increased their number of cesarean deliveries and 8 percent having stopped practicing obstetrics altogether. In a recent study of College Fellows, risk of liability was among the primary reasons cited for performing a cesarean delivery.

            In addition, studies have attempted to model the impact of tort reform on primary and repeat cesarean delivery rates and have shown that modest improvements in the medical-legal climate may result in increases in VBAC and reductions in cesarean deliveries. These analyses suggest that both caps on noneconomic damages and reductions in physician malpractice premiums would result in fewer cesarean deliveries.”

          • Somewhereinthemiddle

            Also, can you see how frustrating is can be for patients who do not understand how physicians, practices, and hospitals who have their hands tied? Do you expect the general population base to be able to recognize, process, and navigate the insurance process that hospitals dedicate entire teams to negotiate? All they know is that they have to drive by a reasonable hospital that they would like to utilize for safety reasons and can’t.

          • Amy Tuteur, MD

            As a matter of fact, in this setting, I do, since doctors have been describing the situation for years, only to be ignored by VBAC activists who prefer to pretend that the problem is doctors and the solution is HBACs.

          • Mac Sherbert

            The ICAN list is really not accurate. They have the hosptial I had my kids at listed as DeFacto. My OB was perfectly fine with a VBAC and practically encouraged it. Dr. told me she was very comfortable doing VBACs at that Hospital. I also know women who had VBACs at the hospital. …Or maybe they are just looking for hospital that will let anyone VBAC no matter what.

          • Somewhereinthemiddle

            The argument can be made that if anesthesia is not available to all laboring patients, not just vbac, that hospitals are irresponsible for having maternity services since any one can have a serious obstetrical emergency at any time. If a hospital has a laboring patient with an abruption, prolapse, or a hemorrhage and no/ limited access to anesthesia, what do they do? This is a sincere question. How likely are they to be able to save the baby or mother?

          • Daleth

            Just because an argument can be made doesn’t mean the argument is valid or makes sense. People have argued at length and passionately about how many angels can dance on the head of a pin, and NAMBLA argues that people should be able to have anal sex with little kids. Those arguments “can be made.” So what?

            So let’s look at “the argument… that if [24/7 on-site] anesthesia is not available to all laboring patients, not just vbac, hospitals are irresponsible for having maternity services since anyone can have a serious obstetrical emergency…”

            There are two gigantic problems with that argument.

            The first is an “apples to oranges” problem: VBAC has a 1/200 risk of needing an immediate crash c-section. No other obstetrical emergency has anywhere near that high a risk, AND the vast majority of obstetrical emergencies that require c-section do not require that it be performed in 5-10 minutes or less after the emergency becomes apparent. In other words, lacking the resources for VBAC does not mean you lack the resources to deal with most other obstetrical emergencies.

            The second is a reality problem. In reality, the only alternatives to some hospitals offering maternity services but not VBAC are either (a) hospitals that can’t offer VBAC stop offering maternity services, which means huge numbers of women have NO access to maternity services within less than 2+ hours’ drive from their home; or (b) every hospital that offers maternity services also offers VBAC, which would require hundreds of millions of dollars for the necessary equipment and personnel… in other words, everyone’s health care costs would go up and massive amounts of money would be wasted because most of the time, those resources–the 24/7 anesthesiologists, etc.–would sit idle and unneeded.

            Forgive me, but I really feel like you don’t WANT to understand this–you just want to continue feeling like the pregnant women of America are being treated unethically, so you won’t hear any of the reasons that the situation is how it is.

          • Somewhereinthemiddle

            If that’s what you think of my opinion, I’m good with that. The dead horse has officially been beaten. We can agree to disagree.

          • KarenJJ

            “And it *is* unfair/ unethical that some hospitals and providers disallow VBACs out of hand.”

            I think the problem is that we don’t have a lot of evidence that this is all that widespread amongst hospitals and practitioners that can deal with high risk obstetrics.

          • Somewhereinthemiddle

            I’m also no claiming to know anything about specific case by case scenarios and you seem to be suggesting that I am. Again, do not put words into my mouth. And that is exactly what I am suggesting that things like TOLAC should be considered on a case by case basis and I don’t see at all where you got that I was suggesting otherwise.

          • KarenJJ

            I don’t think that’s what she’s saying, because a TOLAC is a reasonable option for many women. TOLAC is not outside the standard of practice for an obgyn.

            Where do you draw the line at calling yourself a professional if you are unwilling to commit to the full spectrum of services of your profession? It was like the argument I had recently about whether a doctor’s right to object to giving a woman the pill based on the doctor’s religious convictions trumps the right for the woman to access a legal and medically indicated contraception?

            For doctors and regional hospitals, obviously the lack of resources make VBAC unavailable, but are there restrictions in more reasonable locations that are purely for doctor convenience? I don’t know, I’m not in the US.

          • Daleth

            “Forced”? That word is so inapplicable here. Unless you’re one of those eternal victims who believes exclusively in an external locus of control.

          • Somewhereinthemiddle

            Maybe forced isn’t the best word choice. Have barriers to care that make attempting an HBAC appear to be an attractive and feasible option compared to the alternatives.

          • Daleth

            Those barriers exist for two reasons:
            (1) reality – it is not possible to offer every single option available in modern medicine in every single hospital in America. The resources aren’t there, and that’s largely because the demand isn’t there. Just as there aren’t organ transplant hospitals in every small town because there aren’t enough transplant patients to use them (i.e. to pay for/financially support them), there aren’t VBAC hospitals in every small town for the same reason.

            Let me break that down for you: a hospital would need at least 3 anesthesiologists, plus the necessary nurses/residents/assistants, to provide 24/7 anesthesiology, as required to provide VBACs. On average, anesthesiologists earn $300k/year. Does every hospital in America have a spare $900k/year? No. Does every hospital have enough local women wanting VBACs, and willing to pay the $3000 or so that obstetric anesthesia costs, to add up to $900k/year? No.

            And,

            (2) medical indications – not everyone who wants a VBAC is a good candidate for a VBAC. If you ask around and multiple doctors refuse to assist at your VBAC, only a fool with a persecution complex would conclude that HBAC is the best choice. Reasonable people would think, “Hmm, if multiple doctors have said I am too high-risk for a TOLAC/VBAC, maybe I am too high-risk for a TOLAC/VBAC.”

          • EmbraceYourInnerCrone

            What about the Italian visitor who suffered a panic attack while visiting the U K specifically Essex. The local medical authority committed her for several weeks and performed a c section. They sent her home without her daughter. And adopted out the baby “in case the mother replased”. That doesn’t sound like bodily autonomy to me. As for VBAC there are no other procedures that I know of that a medical facility can be forced to allow if you are a bad candidate (Lasix to correct vision or cardiac bypass if you are a better candidate for angioplasty ) so why should hospitals be forced to do the sometimes much more risky VBAC if they know from your medical history it’s going to likely end very badly?

          • Mattie

            Yeh I agree that poor woman who had the forced section is terrible, and IMO she was assaulted, however the doctors didn’t do it without her consent, they did it with a court order, and had nothing to do with the adoption of the baby. That was a failing of the courts not of the hospital. The difference with the other procedures is that birth is inevitable. people don’t just stay pregnant forever if you don’t let them give birth the way they want. By turning away women and refusing them choice you are either forcing them to have unsafe births at home, or performing procedures on them without consent (not consent if it’s coerced, which it is if they have no choice). So that IMO is clinical negligence.

          • Amazed

            Refusing them reasonable choice. No one is obliged to drag their ass to the women’s preferable birthplace just so they can assist the women. Patients go to the doctors providing a special kind of clinical skills, not the other way round.

            You don’t go into my house and demand that I make you tea in my coffee machine. However, you are not obliged to drink coffee. You can just go to the woman next door and ask to use her machine which does make tea.

          • Mattie

            I guess this speaks to a cultural difference, maybe because of the way healthcare in the UK is funded? But yeh in the UK, doctors and midwives have a duty of care and have to provide care to all women including supporting decisions they do not agree with or that are risky, literally they cannot refuse to care for a pregnant or labouring woman. So that means if a woman refuses to attend hospital then someone has to attend her at home, if she’s had 3 previous sections and wants a VBAC then she has to be supported, if she insists on a breech vaginal birth then they have to facilitate it. No doubt there are lots of cases where they don’t provide the information in the hope that women will choose the option preferred by doctors (that is ethically questionable IMO but that’s an informed consent issue) but if the woman insists on a course of action she has to be cared for, or it’s negligence.

          • Mattie

            Also, it would be difficult to research but interesting to see how many HBACs involve women forced to birth at home due to choices not being respected/not able to birth in hospital, if that number is in any way significant then it would be better for VBACs to be offered by hospitals so that women have a better chance of making it through healthy with a healthy baby.

          • Amazed

            No, not cultural differences. Just my own mindset. And besides, here we have one of the, let’s say it gently, not too great healthcare systems, so many others would be a good difference. I do understand that legally, it might be just as you say. However, I don’t find it to be the right thing to do ethically . And I cannot help but see it as a dangerous hazard on the women. After all, they are the ones who have to live with the result of their birth in much greater extent than everyone involved in their care, so I just don’t understand risking your child’s life for the sake of having your choice respected and then howl, “If they had only catered to my dangerous choice, I wouldn’t have been forced to make this other, even more dangerous choice. It’s their fault that my baby is dead/my baby is not healthy/I am not healthy! Poor little me had no choice but do it!”

            Mind you, I am not saying that I want anyone have the right to do this choice that I cannot fathom removed. I absolutely think thaty a women who insists on HVBA4B her breech triplets has the right to do so – but no doctor or hospital should be obliged to cater to her wish to risk 4 lives in the process if they feel it’s unsafe just because Her Highness will do it at home otherwise.

            Reading your post makes me feel that you advocate for patients being ebabled to coerce physicians into supporting unsafe choices. If we’re into it, why not demand that patients have the right to force their doctors to treat their cancer with homeopathy? To change compresses on a broken foot that is given no rest because patient believes that body knows how to heal itself? And call those treatment? Or are you advocating only for pregnant women being able to go into any hospital of their choice and dictate the care they want? Like, “I feel that a c-section is not a good choice. Let’s get an induction instead. No, no, I’d like to have a forceps used.”

            I’m more than a bit troubled that you seem to think women waving their own unborn baby and her very own health as a weapon for blackmail is fine. That’s without taking into account that not very many women will be forced into a c-section despite their will, so their decision to pop the kid out at home has more to do with them making a point (without actually believing that someone might die because hey, it’s 21 century. Who dies in childbirth? Not in the first world, not healthy, low-risk women and babies like them.)

          • Mattie

            I mean, I do have a different view of homebirth than many on this site (although that may be down to my own experience in the world of midwifery training). I can see why you might view it as coercion of HCPs, but it’s more that they are required to provide care, which a patient is entitled to refuse, but they cannot refuse to give it. Perhaps it is because most women do not have a named doctor that can say “I don’t do VBACs” and can really just walk in to any NHS hospital in the UK in labour and they have to be cared for, and in the sense that they can refuse or insist on any procedure or process they do sort of get to dictate the care. I just don’t see how you can avoid that without refusing to provide care to a labouring woman. With regard to other situations, I don’t know how it works. I do know that there are for example certain things doctors cannot provide (NHS doesn’t fund them, they are not trained to do them etc..) and there have been patients who have gone elsewhere for their desired treatment (well known cases of children with cancer being taken to the US against medical advice to be treated at the Burzinski Clinic for example). But in most cases patients do have choice in their care, in most fields.

          • Amazed

            But you said it yourself: they can really just walk in to any NHS hospital in labour and refuse a c-section. I really don’t know of a single hospital in the entire wide world that would force a woman to have an unwanted c-section. And I wouldn’t have it any other way. So why, then, are some women determined on popping the kid out at home and insist that they were forced to do it because their choice wasn’t respected? I feel that the disrespect they mean is that their choices aren’t ment with a bent knee, great adoration, and affirmations that there’s not a wee problem with them and the women are the Birth Goddesses of Womanhood because they are going to give birth their way, no matter what.

            I am always amazed that sometimes, laws and regulations, and clinical experience care more about mothers’ and babies’ health than mothers themselves who insist on their choice to the possible detriment of both.

          • Ash

            rare, but it’s happened

            http://www.nytimes.com/2014/05/17/nyregion/mother-accuses-doctors-of-forcing-a-c-section-and-files-suit.html

            I’m 99% sure that the mother will win the lawsuit, as she should.

          • Amazed

            Right. I meant it like systematic politics on the part of the healthcare system. Dr Amy has written about this case. Of course she should win.

            I feel great sympathy for her for having a procedure done against her will. I feel no sympathy for her begging for another hour or two hours to keep endangering her baby after it became clear that it wasn’t working, just like it hadn’t the first two times – surprise, surprise. But she should win. That was her body. End of story.

          • Daleth

            In that New York case, she was at a VBAC-friendly hospital and her VBAC was apparently going so badly that the HOSPITAL’S LAWYER told the doctor to go ahead and do a c-section. For a hospital’s lawyer to do that–to basically say, “Go ahead and do a CS even though it’s going to get us sued”–the alternative must have been horrifying.

            In other words the hospital lawyer must have been convinced that the hospital’s only options were (a) do a CS, come out with a healthy mom and baby, and get sued because she didn’t consent; or (b) continue with the VBAC, end up with a dead or brain-injured baby and possibly a dead or at least hysterectomied mom, and get sued.

            Obviously hospitals would rather not get sued at all, but I think anyone with a conscience, or for that matter a bank account, would rather be sued for assault (unconsented CS) than sued for the death or permanent brain injury of a baby. If the medical situation was so bad that those appeared to be your only options, which one would you choose?

          • Ash

            I would not do the c-section. Adult, competent patients have the right to refuse care.

          • Sarah

            In a UK context, a woman can’t be prevented from attempting VBAC in a hospital if she wants, but she doesn’t have to be allowed her choice of hospital facility. So a woman can rock up for her VBA5C or whatever, and she’s got to be allowed entry (unless they’re full in which case she’s sent elsewhere) but she doesn’t have to be given care in the MLU. The hospital are within their rights to offer her CLU or nothing. For better or for worse, this is unacceptable to some women.

            I have read, on parenting forums, about women who wanted to give birth in the MLU and were too high risk attempting homebirth instead. I have also read about women who, in this situation, ‘threatened’ homebirth and were eventually allowed to plan MLU births. I don’t know how common this is though. But I don’t mind admitting that I’d much rather such women were in an MLU attached to a hospital, where at least help is at hand if the shit (or meconium) hits the fan rather than at home.

          • Amazed

            I don’t think someone would be against it. But I don’t mind admitting that I am totally fine with them being left to homebirth as well if the hospital so choose. Everyone’s choice is being respected!

            There will always be extremists. That isn’t a reason to turn catering to all their whims into a practice that counters all principles of sound practice. While I’d like to see such women and their children make it, I think that they put even some terrorists to shame. Terrorists, as a rule, won’t sacrifice their children’s lives. Just other people’s. Of course, I’m talking about women who realize that is what they’re doing. I believe many of them don’t.

          • Cobalt

            Who is responsible for if they don’t make it through with a healthy baby? If a woman insists on a VBAC, and the doctor disagrees and says it’s too dangerous, does she still get to use on behalf of her injured baby? The courts have said yes. The doctor gets punished for providing care during the VBAC.

          • SF Mom & Psychologist

            Mattie, I have a problem with your repeated use of the word “forced.” Imagine saying that I was “forced” to eat at home because I didn’t like what was being served at the restaurant.

            Nobody is “forcing” these women to birth at home. (Well, perhaps the women are “forcing” themselves.) They are choosing to birth at home because they don’t like the hospital options available. Many other women in the same position might be unhappy with the hospital option but still CHOOSE it. If they were being literally locked out of the hospital, that might be a bit closer to “forcing” them to birth at home. In the end, they are choosing home birth.

          • Mattie

            That’s fair, forced isn’t the right word. I think it’s hard for me to understand how doctors could be ok with having policies that mean women cannot make acceptable (in many other healthcare systems that rely on evidence to make decisions) choices.

            Obviously there’s no guarantee of VBAC being successful, but many are especially after 1 section. Also risks of homebirth with unlicensed HCP are undeniably huge, but without the option of TOL or VBAC in a hospital women who want a VBAC due to weighing the risks of complications vs the benefits of successful vaginal birth, recovery time, cost etc… don’t actually have an option of a VBAC other than at home. I will say that I am coming from a totally different healthcare system, where the insurance and hospital policies are also different, so that is probably colouring my view of this hugely.

            Of course both risks and benefits are hypothetical, but that’s what goes in to a decision making process for a lot of women, actually having the option to have a TOL in a hospital would be the best option for most women when judging the risks of VBAC, but if they believe (for whatever reason) that the benefits of a vaginal birth for them outweigh the risks of VBAC at home they would make that choice over a repeat c-section.

          • AllieFoyle

            And yet I’ve heard of many women in the UK being denied epidurals, being turned away from labor wards that are overly full, not being able to choose a c-section, even a repeat, being forced to have instrumental deliveries they didn’t want, often after begging for a section.

            To an outsider, it appears that the idea of a duty to care and facilitate women’s choices is applied preferentially to things that are in keeping with a preference for the midwife’s ideal of natural, unmedicated childbirth.

          • Mattie

            Yes, you’re right. I have heard of it too. Although those are all somewhat different issues so I’d need to look at them individually, the only one which is..not acceptable, but makes the most sense is when units have to close because they are full, that is to do with staffing as well as facilities. It is unusual and also not wanted by staff when the unit closes especially if it is a high-risk unit or regional centre, but there are minimum safe staffing levels that must be adhered to, and also a limit on number of beds available, if those are met the unit has to close for patient safety and women must be diverted to other units. This also happens when NICU is full, which ends up with labouring women who have babies that will need NICU having to be transferred (sometimes by air) to the nearest same-level NICU with a space. Funding increases would remedy this, but they’re not there yet.

            Epidural denial is totally unacceptable (you can have an epidural as soon as someone is available to do it, is understandable if also questionable with appropriate staffing levels). The new NMC Code of practice actually has a section that should limit this practice, but it does rely heavily on those who fail being reported to the Trust or to the NMC.

            The refusal of c-section (be it maternal choice elective, elective repeat, or maternal choice during labour) is totally unacceptable, it should be up to the mother and her choice should be supported and the staff should accommodate it where possible. That I will not argue with, and guidelines should be updated to reflect this because there really is no excuse.

          • momofone

            “Patients go to the doctors providing a special kind of clinical skills, not the other way round.”

            Exactly. I live in a rural area. When I needed surgery last year, I chose to go to a larger area about 100 miles from home, though I could have had surgery at the small local hospital where I live. Because I wanted access to the resources available at the larger hospital, I went there. How is it reasonable to expect that a hospital/provider can provide a service or resource I want just because I want it?

          • Sarah

            The Italian woman’s case was an unusual and extremely specific set of circumstances. She was found not to have capacity. Extrapolating from the treatment of an individual deemed unable to consent isn’t going to give you an accurate picture of the system as a whole. Women who have capacity and who want to VBAC against medical advice can and do in the NHS. Also, there was a great deal more to the family law proceedings than you mention here. I don’t think you’ve read the judgment. There are a lot of things wrong with both UK pregnancy/childbirth systems and the family courts, but this case doesn’t illustrate either.

          • Dr Kitty

            It wasn’t “a panic attack”. It was, as I understand it, a relapse of mania in BPAD, with lack of insight and psychotic features.

            The lady was, at the time, sectioned under the mental heath act, meaning that she was a risk to herself or others, and seriously incapacitated by mental illness.

            The Trust applied for a court order for a CS, on the advice of a consultant obstetrician and psychiatrist that it was in her best interest. THE SOLICITOR ACTING ON BEHALF OF THE PATIENT DID NOT OPPOSE THE COURT ORDERED CAESAREAN, AGREEING IT WAS IN HER BEST INTEREST.

            You can read the judgement and some of the judge’s views in the case here:

            http://www.localgovernmentlawyer.co.uk/index.php?option=com_content&view=article&id=16493%3Acourt-of-protection-publishes-judgment-authorising-caesarean-section&catid=52&Itemid=20

            It wasn’t assault, I’m afraid, it was legally carried out on clear medical evidence of the best interest of the patient (not of her baby, of the patient) based on the likelihood of UR in someone with two previous CS. Because of her illness, she would not have been able to co-operate with appropriate intrapartum monitoring and assessment, and other options that were less invasive had been considered and rejected.

            She did not have capacity to consent to surgery, or to refuse consent to the surgery, and thus the court made a decision on her behalf based on her best interest.

            If one does not have capacity, one cannot make decisions. That is the line where autonomy stops.

            It’s why dementia patients without advanced directives are treated in their best interests, children are treated in their est interests, unconscious people are treated in their best interests, and yes, some very mentally ill people can be treated in their best interests, even if it overrides their expressed wishes at the time.

            Were social services heavy handed in removing the child and placing her for adoption- yes. But the CS was a separate matter and not, as far as I can see, either medically or legally suspect.

            Is autonomy important- yes.
            Is autonomy dependent on capacity- yes.

          • attitude devant

            Thank you for that information.

          • Medwife

            Yes, that really improved my understanding of the situation. It seemed so totally un-UK of them, more like something that would happen in Indiana.

          • Sony2282

            What about my friend in another socialist medicine country who had a primary c-section after 36 hours of labor and 3 hours of pushing. She then had to beg, plead and cry in order to get the repeat c-section she wanted for her second! They even made her meet with a psychologist before they would agree to it and didn’t agree with it until she was 36 weeks. She was left stressing and worried until the very end. Doesn’t sound like respecting her decisions and autonomy. They wanted to force her into a VBAC!

          • Sarah

            Well this is the thing. Assuming you have capacity and nobody holds you down while they operate, you can’t be forced into a section. But you can be forced into a vaginal birth. So it’s a lot easier to exercise your right to autonomy if what you want is a vaginal birth. Because it doesn’t involve anyone else actually doing anything.

          • Inmara

            Sounds similar to my country (Latvia) where in order to reduce medically indicated C-sections and therefore costs for government (indicated C-sections are subsidized, elective are for a fee and insurance rarely covers it) breech alone is not an indication for C-section and also indication from another doctor (like neurologist) can be met with resistance from hospital staff. Elective C-sections are available, of course, but they cost so much that some women can’t afford them without going into serious debt. Also, Ministry of Health embraces this old WHO recommendation of magic 15% of C-sections (actual number is around 23 %) and tries everything to bring the number down.

      • Medwife

        I agree with you on VBAC bans, but that woman was not forced into a home birth. She chose it. She could have gone into the hospital and refused the section. Stories that hit the media aside, the vast majority will have their TOLAC, albeit in possibly a hostile atmosphere. Either way, had her priority been a living baby, she would have gone to the hospital.

        The lack of judgment there was staggering. She called every provider anywhere near her, every facility, and they ALL said it was an unacceptable risk. She gets guiltily referred to a “traditional” (read: unlicensed) midwife who travels around doing dangerous shit no one else will risk their license for, and this superduperqualified lady thinks it’s a great idea. She will be happy to do it (for a tiny fee). Sold!

        • Mattie

          Well actually I wouldn’t want to go to a hospital where I didn’t feel my choices were respected and that I may be taken advantage of. Also, this unacceptable risk led to the vaginal birth of a healthy baby. That same birth could have happened in hospital, and if complications occurred then hospital would have been the safest place…she wanted to be in hospital, they basically said ‘if you don’t do what we want we won’t support you’ that is wrong. If hospitals want to work on decreasing the numbers of home births, and births by unlicensed midwives then they need to work with the women, and support them and their choices, because at least that way they keep their trust and can monitor them. For example, why are women having normal births in hospitals still not allowed to eat, despite no recent evidence supporting that…it just seems so weirdly old fashioned while trying to be high-tech.

          • fiftyfifty1

            “Well actually I wouldn’t want to go to a hospital where I didn’t feel my choices were respected ”

            So, basically you want the docs and nurses to fake respect for your dangerous choices so that you can feel comfortable?

          • Mattie

            I would want to be respected as an autonomous individual who has the right to make decisions about her own body…yes. I would not want to feel that I was likely to encounter mocking, humiliation or coercive tactics by hospital staff as I don’t feel that is acceptable care. I would want to be informed of the options and risks, as well as the rationale behind suggested clinical decisions and then I would want them to accept my decision and continue to care for me in an impartial way even if my decision is not what you would do…or what you think is right.

          • toni

            hm, i’m not sure how you could effectively communicate to someone that what they are doing is very risky (keeping the patient informed) without some hint of judgment. doctors aren’t robots, they care about their patients and want you to make good choices. If you’re smiling the whole time you explain to someone that a VBAC is not a safe option for them they might not take your warning seriously.. and then they can claim they were not fully aware of the dangers

          • momofone

            But accepting your right to make a decision about your treatment and being obligated to oversee said treatment (and bear the attendant responsibilities) are two different things.

          • Mattie

            I just don’t understand how if things are documented (e.g. discussed with patient risks of VBAC with her history, advised a repeat c-section. Patient declined and requested TOL/VBAC, plan in place for TOL. Patient will be induced or expectant management to take place after 40 wks, c-section to be performed if patient fails to progress in labour or complications arise) and the patient accepts the plan there is any liability for the HCP. Assuming patients are allowed to consent to or refuse treatment and there’s no malpractice there would be any legal case possible. Women have the right to make choices but they also have to be aware of the potential consequences of their choices, and have to deal with them.

          • The Bofa on the Sofa

            I just don’t understand how if things are documented (e.g. discussed
            with patient risks of VBAC with her history, advised a repeat c-section.
            Patient declined and requested TOL/VBAC, plan in place for TOL. Patient
            will be induced or expectant management to take place after 40 wks,
            c-section to be performed if patient fails to progress in labour or
            complications arise) and the patient accepts the plan there is any
            liability for the HCP.

            Because the HCP is the professional and therefore has the best understanding of the issues involved. And it’s fair – there is absolutely no way that you can expect a patient to understand the real concept of risk involved, they don’t have the expertise.

            It is this way, and it HAS to be this way, to protect the patients from unscrupulous providers. Note that we already see it with midwives, who will tell the patient there are risks but downplay them. If it wasn’t this way, providers would just have you sign a pile of paperwork saying you acknowledge the risks regardless of whether you really do.

            This is to protect patients.

          • Mattie

            But it doesn’t ‘have’ to be this way, in fact is it not this way in many places and people seem to be just fine, and also HCPs aren’t constantly terrified of being sued because someone might regret their decision after something bad happens.

            Yes you can have bad doctors or midwives not telling people the truth, but in that case it’s malpractice and that is a different issue. Should something go to court it’s going to be pretty obvious if it was an issue of a badly trained HCP lying to the patient/lying in court about their actions or a case of a woman refusing care or procedures at the time and now having to deal with the consequences.

            There seems to be an odd culture in the US of treating everyone like children incapable of making decisions and dealing with the results. If you decline a c-section and your baby dies, it’s terribly sad, but that was a risk of declining a c-section, you can’t turn around and sue your doctor because your baby died, it was the result of your choice. You can’t allow informed consent if you say this is what I recommend, these are the risks of not doing that, but I’ll only continue caring for you if you do what I recommend anyway. You can only recommend certain things, and hope the person agrees with the recommendation, you can’t just refuse to treat people that make bad choices in case they sue you.

            Even in the UK if someone is insistent on a course of action that is incredibly risky they go through more than one HCP who all explain the risks, these conversations are documented as is the labour/birth etc… but the women have that choice, and do have to live with the results of their choices, good or bad. This is designed to ensure that they are given the correct information and the aim is to get them to choose a safer course of action (hospital birth centre instead of home, early induction with aim of vaginal birth instead of VBAC whenever woman labours naturally etc…). But at the end of it all, the woman still has final say, and the HCPs are covered because they did everything right with regard to informed consent, they wouldn’t just ‘wash their hands’ of a patient.

          • The Bofa on the Sofa

            Yes you can have bad doctors or midwives not telling people the truth,
            but in that case it’s malpractice and that is a different issue.

            It’s not about lying, it’s about attitude. A doctor can give the facts, “There is a 1/200 chance of rupture” but can follow up with, “But don’t worry, I’ve never seen it be a problem”

            None of it is a lie, and the patient signs off. So there is a problem, and the patient says, “I didn’t really understand the magnitude of the risk!” “So what, you signed the paper.”

            You think lay people really understand risk? What’s riskier, drunk driving or childbirth? How about the following:

            A mother is about due, and goes to a party with her husband, and he has enough drinks to make him legally drunk. She goes into labor, and so they are going to rush off to the hospital. He drives.

            What is more likely? That they die in a car wreck? Or that she dies in labor?

            In fact, it’s not all that close. You think most people would get the answer right?

          • Mattie

            No, but then you also teach doctors and midwives how to discuss consent, as well as providing literature on various options that gives the facts to reduce the effect of a person saying things a certain way. You would also discuss the effects of the complication, so there is a 1/200 chance of (complication), that means that in the population of x people y people will have (complication), this risk increases with ‘risk factors’ by x%. If (complication) happens this is the procedure, if that doesn’t work we would do this. Given your history and presence of risk factors I would suggest that the safest option for you is (option). I do accept that I don’t understand how it works with doctors’ insurance (here or in the US, I am neither a doctor nor a lawyer) but from the outside it does seem an unusually litigious system, where fear of litigation actually potentially stops women giving true informed consent. If you want to give birth in hospital, but do not want to schedule a repeat section, you do not have that option. You either consent, then refuse when in labour, or risk being ‘fired’ by your OB.

            But again, if doctor’s cannot perform VBACs or any other procedure because their insurer won’t allow it, they’re just as stuck as the patients =/

          • The Bofa on the Sofa

            No, but then you also teach doctors and midwives how to discuss consent,

            So now you are going to require them to discuss it in an appropriate way?

            Again, you can’t get around the issue of rhetoric being used to influence decisions. And don’t think this is a US issue – UK midwives are currently misleading patients about risks, and it is costing lives. You don’t see that with doctors in the US. You DO see it with midwives in the US, because they aren’t subject to things like malpractice suits, and they don’t bother with any sort of informed consent.

            Insurance works pretty easy. Insurance companies figure out how likely it is that the people they insure will have damage suits against them and how much it will cost. Then they distribute those costs among all the people they insure in the form of premiums. However, in determining that risk, they take into account things like their practices. Doctors that do VBACS are more likely to have suits against them, and so they have to pay those costs of premiums. Doctors that do VBACS without proper precautions are even more likely to lose damage suits, and, in those cases, the risk of large payout is so high that insurance companies won’t even insure it. So doctors have to fulfill the requirements of the insurance companies or they are not insured against a bad outcome.

            Insurance does allow for a more litigious system, but that is a GOOD thing. People NEED recourse against those who do things improperly. Otherwise, you get crap like US lay midwives, who run around killing babies due to incompetence with absolutely no recourse for the parents, because they don’t have any money. Since they are all individual freelancers, they don’t lose anything.

            The civil court system is extremely important. It protects citizens. Remember, if doctors don’t do thing out of fear of being sued, it is because others have been sued and LOST for doing that in the past. And they aren’t getting sued for good outcomes, it means that bad outcomes have occurred. If premiums are high, it shows that the risk of a bad outcome/cost of the bad outcome is high. The insurance company isn’t ideological, it’s about money.

          • Mattie

            I mean of course I would require that it be discussed in an appropriate way, the same way it’s required here. If people don’t do it, then they become liable for malpractice claims. Also when I said I didn’t get how insurance in the US vs UK works, I meant in the sense that there aren’t things doctors can refuse to do in the UK, like if a woman wants a TOL even against medical advice, she’ll get it, because they can’t refuse to care for her. Whereas in the US they can and do refuse to perform things like VBAC, and Doctor Amy mentioned that in some instances it is the doctors’ insurers that won’t allow them to perform VBAC, so that is obviously different to the UK, all NHS clinical staff have malpractice insurance…so just wondering how that works. Unless it’s just a case of ‘well you were given the risks and decided to do this anyway, you aren’t entitled to anything’ or a large amount of out of court settlements. I really don’t know, but if anyone does I am genuinely interested cause there seems to be a huge disparity.

            Civil courts are definitely very important, I would never want to remove that system, it just seems like a totally different culture in the US with the amount of things that people sue for, but that could just be because I hear all the overblown press and never get the full facts because I don’t live there/understand. Do you personally feel that some lawsuits are ‘in hindsight I wish I hadn’t made that decision, it’s your fault for letting me make it’ or is it that most doctors don’t let it get to the point of a bad decision? What if, for example, a woman went in to hospital but refused a c-section and the baby died? Would she have a case for litigation? (I hope this doesn’t seem sarcastic, just trying to make sense of the variations of procedure).

          • The Bofa on the Sofa

            I mean of course I would require that it be discussed in an appropriate way,

            But that is what the current system does! By putting the responsibility on the HCP, they have a responsibility to clearly describe the risks.

            This is exactly what the lawsuits are about. People who have bad outcomes who claim that they didn’t fully understand the risks.

            Meanwhile, midwives, who aren’t subject to such recourse, run around telling their patients bullshit about how these are the risks, but oh don’t worry about them because they aren’t big.

            Real HCPs take risks seriously and inform patients and practice taking that into account. Pseudo-hacks don’t. And the reason this is is because of the civil court system.

          • Mattie

            Yeh of course, I don’t think uninsured providers do anyone any good…well themselves, because they don’t have any consequences for their actions. But like that still doesn’t explain how the UK system allows patients to essentially refuse care, or choose risky options, and doctors and midwives still provide care, either our standards for consent being gained or refused are less or there’s less incidence of litigation in general. I really don’t know , but clearly the NHS medical malpractice insurance allows it.

          • The Bofa on the Sofa

            But like that still doesn’t explain how the UK system allows patients to essentially refuse care, or choose risky options, and doctors and midwives still provide care,

            But UK midwives are NOT providing great care! Did you read the recent report? It’s a culture of denying risks, and it is costing lives.

            And what do the parents have as a recourse? They get an inquiry done, with no consequences to the midwives involved.

            Jeebus, UK midwives are the poster children for why there needs to be liability, because they have failed so badly at conveying the actual risks to their patients.

          • Mattie

            The recent report of one hospital where huge failings occurred. That is not what happens in the rest of the country, with the rest of the thousands if midwives employed in the NHS, and it is not what is taught in midwifery training programs or what is assessed during those programs. You can’t extrapolate one incident involving a handful of midwives, to the rest of England or the UK. The failings at that hospital included many other professionals, not just midwives.

            That is not at all what happens, parents have the option of suing the hospital the same way that they would if it was any other issue of medical malpractice. Also the midwife will likely be investigated by the NMC and if they find failings in care, or malpractice they have sanctions they place on midwives up to and including striking off the register.

            My question, which you still haven’t acknowledged, is that given the fact that malpractice insurance in the NHS covers all NHS clinical staff, why is it that risky procedures are ‘allowed’ by the insurers, even if it’s the patient insisting against medical advice. Whereas in the US the insurance companies do not. Is it that our view of what constitutes malpractice is different, or that fewer people sue so it’s cheaper? That is what I don’t understand.

          • The Bofa on the Sofa

            The recent report of one hospital where huge failings occurred. That is not what happens in the rest of the country,

            You really think this was isolated to that one hospital? Come on, it’s the whole attitude of the RCM!!!!!!! See the other post – the position of the major midwife organization in the UK is that they are the “Guardians of Normal Birth.” This is EXACTLY what the report was criticizing! And you seriously claim it was an isolated incident?

            Not at all.

            And you keep asking how they can allow risky procedures, you are missing the answer: they do it because they accept bad outcomes. If what happened to James Whitcombe had happened in a hospital in the US, there would be massive lawsuits, and lots of people would pay. In the UK, there is a inquest and a report that gets ignored. That’s why there is a difference in insurance restrictions.

          • Mattie

            Yes it is the very definition of an isolated incident, in that it is one hospital. Whenever a baby or woman dies in labour, or postpartum, or any serious injury occurs there is a hospital enquiry and if any failings or malpractice on the part of the staff it is then passed on to the relevant governing bodies. Why do you keep bringing up the RCM? They are a campaign organisation, that not all midwives are members of. it’s like saying that a trade union for any profession has more control over that profession than its governing body.

            Additionally, the idea of being a guardian of normal birth is not a support of unmedicated vaginal birth, it’s a support for midwives working in their scope of practice…and that they are trained to do that. Doctors do not need to do what midwives are trained and qualified to do, they need to do the things midwives are not qualified to do. The problem at Morecambe was that midwives did not work within their scope of practice, and did not refer when they should have. Which was a failing of that hospital, that unit, and the management who did not organise appropriate investigations or report staff who were breaking the regulations.

          • Amy Tuteur, MD

            Mattie, you are just making up your claims. The author of the report said specifically that this was NOT just one hospital.

          • Mattie

            I’d be interested to know what section of the report stated that these events were not simply present in the Morecambe Bay NHS Trust. Because while the report gives suggestion on the wider response from agencies such as the GMC and NMC I cannot find where it specifically says that the problems in Morecambe are also happening everywhere else.

          • Poogles

            “why is it that risky procedures are ‘allowed’ by the insurers, even if it’s the patient insisting against medical advice. Whereas in the US the insurance companies do not. Is it that our view of what constitutes malpractice is different, or that fewer people sue so it’s cheaper?”

            I haven’t seen anyone else directly address this yet, so I’ll take a shot.

            I think there are 2 major contributors to this – the US seems to be generally more litigious (cutural differences, I think) and when it comes to medicine (and especially childbirth), there is the added pressure for the family/patient to find a way to pay for medical bills and possibly life-long care. With no universal health insurance, a birth injury in the US will absolutely bankrupt a family if they can’t find some way to offset the costs.

            So, in the US, the medmal insurance companies have to take into consideration that childbirth-related lawsuits are not only inevitable but that they involve HUGE payouts – so they try to have their insured avoid as much risk as possible, even if it means a woman can’t give birth exactly the way she desires.

            Here are a few SOB posts that look at various ways this plays out in the US:

            “Nearly 77% of obstetrician/gynecologists have been sued at least once in their career and almost half have been sued three or more times.”
            http://www.skepticalob.com/2010/03/why-is-cesarean-rate-sky-high.html

            ” If enough women claim that they cannot possibly understand the risks of VBAC and enough lawyers encourage lawsuits based on that theory, obstetricians and hospitals have no choice but to respond to their demands.”
            http://www.skepticalob.com/2009/08/doctors-used-to-encourage-vbac-what.html

            “But it did not matter to this jury that the scientific evidence does not support prophylactic C-section for macrosomia. It did not matter that, due to limitations in existing ultrasound technology, it was literally impossible for doctors to establish a fetal weight any closer than 2 pounds in either direction. All that mattered was what was clear in hindsight: a C-section would have prevented the tragedy that befell this specific child.”
            http://www.skepticalob.com/2011/11/jury-awards-144-million-for-failure-to.html

            “It will cost an incredible amount of money to care for Enzo and Muhlhan herself is judgment proof, since she apparently carried no insurance. Hmmm, who else was involved in the case that has lots of money? Ahh, yes, the hospital; Johns Hopkins hospital carries lots of insurance. Let’s sue them. Who’s actually responsible for Enzo’s brain injury? Who cares?”
            http://www.skepticalob.com/2012/06/homebirth-ends-with-brain-damage.html

          • Mattie

            Thank you! Reading your post it seems to obvious, like of course people are going to need to pay for medical expenses resulting from birth injury, as there’s no other way to fund them. It’s so obvious but like not having to think about paying for healthcare on a regular basis means I just forget that it’s a thing. I need to work on that, because I want to move to the US and it’s gonna be a hell of a culture shock just in that respect.

          • Cobalt

            That unacceptable risk, translated into another circumstance:

            Every day, about 200 kids ride the bus to my kid’s elementary school. If riding the school bus had the same risk level as uterine rupture at VBAC, then EVERY DAY one of those kids would need an emergency surgery performed within minutes of problem onset in order to prevent them and their mother dying of blood loss and asphyxiation. And that’s assuming the risk of rupture is on the low end.

            If there are any factors present which necessitated the prior cesarean, or if the mother has had multiple cesareans, or if any other risk factors are present, the risk of rupture is higher.

          • fiftyfifty1

            “For example, why are women having normal births in hospitals still not allowed to eat, despite no recent evidence supporting that.”

            There is no reason a woman who has had a normal birth shouldn’t have been allowed to eat, in retrospect. But none of us knows ahead of time if we will indeed have this normal birth. What if all is going well, and then the cord prolapses and it’s a crash general anesthesia CS? Do you really want a full stomach for that? Have you ever treated a case of aspiration-triggered ARDS? I have, and if you ever had you would have a very different perspective on the matter.

            Natural childbirth activists use this “they won’t let you eat” whining to try to paint hospitals as barbaric and uncaring. They never mention that almost no woman in active labor actually wants to eat. They never mention the high percentage of vomiting. They never mention that your body doesn’t need to eat in labor. It’s just an NCB talking point.

          • Mattie

            Well, it varies by woman, some do want to eat (small amounts, not meals) or drink and we would give ranitidine preoperatively in emergency sections to prevent acid aspiration, actually keeping energy levels up is helpful during labour and that’s best done with allowing women to eat and drink if they want to.

          • toni

            I was given jello cubes, chicken stock and ice lollies to suck. I’d brought my own sweets (werther’s originals) to keep my energy up but I guess they had already thought about that for me. I could be wrong but I doubt there is an absolute ban on eating anything in many maternity wards these days

          • fiftyfifty1

            Yes, the policy at every hospital I’ve worked in was “clears once in active labor”.

          • Amy M

            Yeah, I was allowed water and juice. I might have convinced them to give me OJ at one point, I can’t remember. I don’t remember if I felt hungry, but I do remember I was pretty thirsty.

          • rh1985

            Is that the nasty purple stuff?

          • Mattie

            possibly, I actually never saw it administered. Its brand name is Zantac

          • Medwife

            I just want to add that policies like eating/drinking in labor are WINDOW DRESSING. It doesn’t really matter. I wish more women could be bothered to see past window dressing to the life or death issues. It’s not worth staying away from the facilities with life saving capability.

          • theadequatemother

            so there was just a big review of complications of obstetrical anesthesia…http://www.ncbi.nlm.nih.gov/pubmed/24845921

            data from 250 000 anesthetics, including 5000 GAs for emergency CS and from 30 institutions…there was not a single case of aspiration. Now, some of those are going to have labouring women on clear fluids or NPO still and some are going to be more liberal. But not a single case of aspiration. That’s very interesting to me.

            Another thing that is interesting to me is that if you go and look at the original paper by Mendelson (aspiration pneumonitis was called medelson syndrome for many years) and this paper was published in 1946, the only people who got sick or died were those that aspirated large chunks…one was steak I believe. All pregnant women are treated by us as if they are at risk of full stomach, whether or not their stomach is “full” or they are fasted. So clearly one of two things is true: either the risk is overblown or we are very good at mitigating that risk. Or both.

          • fiftyfifty1

            So since it doesn’t matter, I suppose you’ve stopped asking when the last time you ate was? As I’ve mentioned here before, I had a planned CS, but ended up going into labor before my scheduled date. I must have been asked 8 different times when I ate last and how much it was, including by the anesthesiologist.

          • Kq

            My mother almost died from aspiration when I was born (77). She’d eaten a big steak dinner because they told her there was no way she’d go into labor that night. But she did, and needed a cs.

          • Medwife

            Women eat in labor where I work. Aspiration pneumonitis is actually more likely to occur either in an empty stomach (vomiting and aspirating bile) or with large chunky food (steak etc).

          • moto_librarian

            Congratulations!

          • Medwife

            🙂

          • Aliciaspinnet

            I remember a former consultant of mine telling me that refusal of consent had to be treated in the exact same way as giving consent – in that it’s absolutely the right of a patient to refuse a procedure but it is the doctors duty to make sure the patient is fully informed of the risks of not having that procedure. You keep talking about “support” but if it was the medical opinion of an obstetrician that a vaginal birth posed unacceptable risks then it is their duty to tell their patient that – and it’s their duty to make that very clear. I’m sure that telling their patient “This is dangerous, this poses a high risk of death and disability for both you and your child, this is a very bad idea” is not going to be seen as supportive, but it is the right thing to do. Saying “I don’t recommend this but I will support whatever you decide” gives a bad choice a certain legitimacy.

          • Mattie

            when I say support I don’t mean that the riskiest option should be legitimised but rather that after the individual has been given the options with all the risks and potential outcomes, if they decide on the riskiest option for whatever reason (like choosing homebirth because for example they have a fear of hospitals) then you should still care for that patient to the best of your ability, and not badger them in to changing their mind…be supportive after the decision is made, not during the process. Consent or refusal of consent should definitely be entirely informed, and I would never argue against that. Although also things like further reading or consultation should be offered if appropriate (talking like place of birth discussion, or prenatal testing options where there is time to make decisions rather than decisions in labour which don’t have the time for that much further discussion).

          • Amy Tuteur, MD

            The right to make a choice should be respected. That’s different from claiming that all choices are worthy of respect.

            Moreover, physicians also have a right to make certain choices. That must be respected, too.

            In addition, patients need to understand that doctors are legally constrained by their insurers. If a doctor’s malpractice insurer says she can’t attend VBACs, then she can’t attend VBACs. It makes no difference whether the doctor and/or the patient thinks VBAC is a safe option. The insurance company gets to make the decision.

            It’s one thing if you acknowledge the magnitude of the increased risk and declare that the risk is acceptable to you. It is another thing entirely when you refuse to believe that there is increased risk because you choose to believe the nonsense fabricated by many VBAC activists.

            Informed consent involves being informed, and informed is determined by impartial analysis of the evidence not by whether or not the patient thinks she is knowledgeable.

          • Somewhereinthemiddle

            This is a sincere question. What if a physician’s or hospital’s insurance doesn’t allow them to attend VBACs and a patient comes in and requests a TOLAC, refusing a repeat CS. Of course assuming that everything is fine and good with mother and baby and a CS isn’t indicated. What is the physician obligated to do? Care for them, respecting their wishes? Transfer their care to another physician? Can they legally abandon the care of that patient? Or legal do they have a right to demand the patient undergo a CS? (I assume the last one isn’t really an option)

          • Medwife

            This recently occurred where I work. The hospital has a VBAC ban and the physician’s insurance didn’t cover it. I don’t know what kind of consent form was worked out but it was and the birth was attended by the physician. The patient was an ideal VBAC candidate.

            VBAC as a “procedure” isn’t much like any other procedure because it’s the natural consequence of pregnancy. If you sit on your hands, it’s still going to happen. You can’t kick someone out who’s in active labor. After all counseling is said and done, you can a)monitor as the patient will allow and catch the baby or b)start calling the lawyers for a court order, and b) is a big, big deal.

          • The Computer Ate My Nym

            I’m not an OB, but I’d be inclined to say start any management that needs to be started immediately and as soon as the patient is medically stable to be left for a few minutes go call risk management. Document everything in detail. Consider transfer to another facility if it’s safe and appropriate (i.e. stable early labor and the woman who is in labor requests it knowing the risks.)

          • Somewhereinthemiddle

            See, I think it is nuts to put a laboring vbac patient into an ambulance and truck her to another hospital an hour or more away.

          • The Computer Ate My Nym

            I see your point. I’d only consider it if she’s in prodromal phase, understands the risks, and agrees that she is willing to take the risk rather than have a c-section. Though in the same circumstances, maybe the best bet would be to call in anesthesia and open an OR so as to be ready for emergencies. If you have the kind of time needed to call an ambulance you probably have the time to call anesthesia and the OR techs.

          • Mattie

            That’s interesting, I don’t actually know how insurance for doctors works within the NHS, because doctors are covered even if patients make risky decisions and the outcomes are bad. I think as long as they follow correct protocol and document recommended procedures and refusal to consent. I do think duty of care overrides individual doctor preference here.

            Yeh I definitely agree that you need to be fully aware of the real risks, as showed by science not biased propaganda, but for example the woman in the documentary knew the risks which is why she wanted TOL in a hospital and really wasn’t happy having her baby at home. Then it all went fine and she was like ‘I’ll totally have my next with a midwife, midwives are great’ which is just frustrating because it wasn’t the midwife that made it go fine, it was just luck.

          • Melly

            I had two hospital births. I was encouraged to eat dinner both times. I was never denied food. And I know many other moms who ate freely during labour.

          • Mattie

            That’s good 🙂 I’m glad it’s changing, I guess I used a bad example. I did think there was an increase in the amount of women having IV fluids during labour even if they don’t have an epidural/synto up, but again that may vary depending on the hospital etc…

          • fiftyfifty1

            What’s with the focus on having an IV during L&D? You say it like it’s a bad thing.

          • Mattie

            Because why would you want an unnecessary, uncomfortable (painful) procedure that means you have a needle stuck in your hand and have to worry about tubing when you move around. That would be a bad thing IMO

          • Amy Tuteur, MD

            An IV, by your own admission, is merely uncomfortable, yet you are okay with an official policy that encourages women to endure the excruciating pain of labor and birth? Do you see the massive hypocrisy of that position?

          • Mattie

            No, I’m fine with women choosing an epidural, or having an IV in place for synto, just not as standard when there is no reason to do it. Put the IV in if you need to give IV fluids, or medication but not until then,

          • fiftyfifty1

            Exhibit A everyone:

            Mattie, the Guardian of Normal Birth!

            She has decided that what your REALLY want and need is an IV-free birth. She’s sure the discomfort of an IV is too much for you. She’s sure you won’t be wanting an epidural (who wants to be that sort of loser?) She’s sure you won’t mind the team frantically searching for a vein in the event of a PPH or other emergency. She’s sure you’ll be comforted by her reassurance that such emergencies are actually “rare”. She considers eating and drinking during labor to be a victory against The Man, and she’s sure you share that same viewpoint, even if you happen to be nauseated and barfing. And to top it off, she can help you be less uptight about your birth, and maybe with her “help” you won’t even ASK for any of those nasty interventions she’s sure you don’t really want (and if you do, she’ll kindly pretend not to hear it and won’t hold it against you, but instead say “I knew you could do it” when it’s all over)

          • Mattie

            Yep you got me, congrats. I am a mean midwife who doesn’t want to give women pain relief. I like how me saying that it doesn’t make sense to give IVs as standard equals me wanting women writhing in agony and bleeding to death. What purpose does inserting IV fluids serve in a woman labouring fine, with no complications who doesn’t want an epidural? Other than limit her movement and require a fluid balance chart that then effects her ability to eat or drink should she want to.

          • fiftyfifty1

            Come now, have you never heard of a hep-lock?

            And requires a fluid balance chart!? Oh noes! More work for our poor midwife! She hates those pesky things. And then if a mother would want to eat or drink on top of that, imagine the math involved. It would be too complicated so we will just say she can’t now. Missy, if you want to eat or drink you do as I say and refuse an IV!

          • Mattie

            I hadn’t, although have now. I don’t know if they’re used over here as standard, it could be a cost issue as often is with the NHS. Also, one of the reasons it is difficult when women have IVs (I don’t mean difficult as in inconvenient, or annoying) is that they require one-to-one midwifery support constantly once an IV goes in, now that is fine, and in reality all women in labour should have one-to-one support constantly anyway, but the reality is that maternity units are incredibly understaffed and it isn’t possible. Having one midwife with one patient means the other midwives have to absorb the other patients she can’t care for. It wouldn’t be possible to have all women on an IV at the same time, because there aren’t enough staff.

            That is not right, it’s totally unacceptable, and it means decisions are made based on more factors than just one individual situation. However that could explain why IVs aren’t standard in delivery suite’s over here, and it may also explain why hep-locks are not used (that is a guess, I don’t actually know, but I will see if I can find out).

            Also we wouldn’t tell people that they can’t eat or drink with an IV in, or encourage them to refuse one if they want to eat/drink. it is just down to having to have one-to-one care for every woman with an IV in/fluid balance chart going, which is why they may not be standard.

          • toni

            that sounds so OTT to me… constant one to one midwife support because you have a cannula in? Even if you’re not hooked up to anything? it’s just a tube in your wrist :/ And why would you need constant baby sitting even if you were receiving fluids? That’s the excuse they come up with for denying epidurals isnt it? That a patient can’t be left alone once they receive one and there aren’t enough midwives for that.

            i delivered at a US hospital, i had a heplock/cannula but was never attached to an IV bag. They used it to give me some stadol and pitocin at the end for the placenta. it’s piece of fricking plastic, they can’t be that expensive and they could save your life

          • Mattie

            well they wouldn’t have a cannula in and not be hooked up to anything, as I said we don’t use hep-locks (don’t know why, cost was a guess, because that’s the reason for most things on the NHS). If there’s an epidural in, or synto then you have to be doing BP really frequently, so even if you weren’t in the room all the time, the amount of in and out would make it nonsensical, you couldn’t be caring for another women in the between times. I think that’s why the rules are there, although again I might be wrong. You’d never deny an epidural because of it, the woman can choose to have one (within the hospital guidelines which midwives do not create, they just work within them) and then the rest of the midwives care for the one or two other women the one-to-one midwife had.

          • moto_librarian

            Let me tell you why hep-locks are standard at most hospitals: I had a “textbook” unmedicated labor and delivery with my first child. I arrived at the hospital dilated to 9 cm., and was ready to push fairly soon after. I did not get a hep lock since I had progressed so quickly. When I began hemorrhaging due to a cervical laceration, I would have given my right arm for I.V. access. I had to endure the manual examination of my uterus and manual removal of clots with no pain medication. They also had to give me an injection of pitocin (rather than running it through an I.V.) and I got cytotec rectally. They were finally able to run a line before they wheeled me to the OR for surgical repair of my cervix, and I still remember the bliss of the fentanyl. I was fortunate that they didn’t encounter issues with getting the I.V. in – I have small veins, and am a “hard stick” even in the best of times. I was also lucky that I didn’t need blood immediately.

            I have pretty much zero patience for the whole “I.V.s and heplocks are uncomfortable/impair movement” argument.

          • fiftyfifty1

            Sounds like the motivation to “encourage” women not to have pain relief in the UK is due to ideology in some places and peer pressure at others (i.e. if your patient takes an IV or epidural that means more work for the rest of us, so don’t do it).

          • AllieFoyle

            Yes, exactly. While individual midwives may want to respect women’s choices, the system is set up so that there is a huge incentive to have patients not get epidurals because of staffing and workflow issues. It’s very troubling. If a unit can only handle, say, three patients with epidurals at any one time, what happens to women number 4, 5, 6… who also want them? Obviously they won’t get them, or they’ll be put off and told that they don’t need one or it’s too early or late or some rubbish. It’s fundamentally unethical. These are decisions that are not being made in the interest of the patient; proper patient care is subordinated by the interests of people who’ve decided to allocate resources to the goal they believe is most important: promoting the type of birth that they prefer.

          • The Bofa on the Sofa

            And this is why it is so disturbing that midwives are complicit in this.

            For example, if the hospital came out and said, “We try to restrict the number of epidurals because we can’t afford to staff the unit enough to have more epidurals” how would the public respond? I think there would be outrage!

            So instead, they try to convince women that epidurals are bad and unnecessary, so to convince them that the lack of access is a feature.

            Same problem, same root cause, but just a complete difference of how it’s presented.

          • toni

            how do you administer the pethidine? you seem like a decent person and you’re getting a lot of flack and i think some of it is unfair.. i don’t like to pile on but this makes no sense to me. a heplock/cannula just on its own requires one needle, a tiny piece of tubing and some masking tape. it could save your life, how could cost be the issue? it’s such basic care, like having enough gauze or iodine. how much does a TENS machine cost or a birthing pool? both pretty useless extravagances that aren’t as useful as a simple heplock but those are the things that midwives have pushed to make available to labouring women..

          • Mattie

            Thank you 🙂 I’m just someone who was involved in midwifery and saw a huge amount of midwives doing their very best in situations that are far from ideal. You are right, it does seem ludicrous that they spend money on birth pools or tens machines but our high risk unit had one birth pool (inflatable) and people brought their own tens machines. Usually people hire them from shops. But yeh, you would think that ensuring iv access in an emergency is pretty vital. I think my initial reaction is like why would you intervene unless something was wrong but I’m glad I said it cause now I understand.

          • Dr Kitty

            Of course you have cannulas that aren’t hooked up to anything!
            Mattie, I have patients who are AT HOME with cannulas, that aren’t hooked up to anything except the IV antibiotics the district nurse gives them two or three times a day. The cannulas last 72 hrs, no problem, with just a flush of saline two or three times a day. People in A&E usually get a cannula stuck in and routine bloods by the triage nurse and that line usually never gets connected to anything either.

            Cost is not a factor, it’s either a clinical decision based on misunderstanding of risk or someone’s idea of a patient friendly policy.

            A hep lock is just a name for when you attach a luer connector tube to the end of a venflon and fill it with hepasal. Totally exists in the NHS.

          • Mattie

            Thank you, yeh I am totally putting my hands up and saying I was totally wrong, and I am glad. Now to extend the IV access to birth centres and other ‘low risk’ birth places, because it’s an important safety precaution.

          • Medwife

            That’s so odd. I don’t get it. If someone has a saline lock you have to do extra charting?

            Although, tbh in the US the RNs have to chart ins and outs on every laboring patient, just like any other hospital unit.

          • Mattie

            Well like I said, I don’t think we use them, in theory no just a saline lock wouldn’t need constant monitoring, but epidurals and synto drips do.

          • Medwife

            Absence of IV access would make me very twitchy.

          • CrownedMedwife

            Wish I could upvote, but I’ll leave you with a ME TOO, instead. IV access is non-negotiable. I’m astounded to learn it’s not a standard in UK.

          • fiftyfifty1

            And this is exactly what Dr. Tuteur is talking about. Dressing up what is best for midwives and calling it best for women.

            WHY it is best for midwives is immaterial. Whether it is due to staffing shortages, or pay, or turf, or professional prestige or ideology. The fact is, what is motivating you to promote going IV-free is the fact that it is inconvenient for you. But no, you say the real reason is that it is “too uncomfortable” for the woman.

            I think you have a good heart and actually want what is best for patients. When a good person runs up against cognitive dissonance like this, there are 2 choices. You can cling harder to the idea that what you promote is all for the benefit of women (whether they realize it or not!) or you can reexamine your assumptions from the lens of really putting the patient first and see where that takes you.

          • Mattie

            I’ll try and answer both comments at the same time. Also thanks for actually being patient with me and not just writing me off as a nut 🙂

            So fiftyfifty yes you’re right that issues with staffing definitely is not a reason for cutting corners or limiting choice to women. But unfortunately there’s no way to create more money to fund more midwives. So what can they do. Mer I feel for you, and also it’s made me think because I am also a very difficult stick most of the time, and naturally slim with skinny veins. So yeh thinking about it I would rather have the iv or a lock done initially even if I hate needles because trying to get one in if I was bleeding would be really difficult. Ideally maternity care in the UK would be a lot better, and I think in a safe and effective system there is a place for well qualified midwives but with strict guidelines and a clear scope of practice.

          • fiftyfifty1

            “So what can they do.”
            In my opinion, the place to start is to be honest about the underlying pressures and motivations. Instead of saying that IVs are bad, or too uncomfortable, or too unnatural, you can say “We don’t have enough $ or staffing right now to offer them to everybody”. Then the real problem is clear, and you can clearheadedly look for solutions. Maybe it’s getting heplocks, maybe it’s pushing for more funding, maybe it’s having a local paper do a story. Maybe it’s nothing more than being aware there is a problem, and keeping your eyes out for a solution in the future. I don’t know, but I know the solution isn’t to trick ourselves into believing it’s ideal just because it’s what’s easiest for our own interests now.

          • Mattie

            That all sounds really good. More funding would definitely be awesome but may take a while. You’re right that the answer may be to actually request heplocks as standard because they can be done by midwives and do provide an added level of safety at a really reasonable price. Also while also being available in birth centres and at home births (they’re problematic I know but they are currently available and I can’t see that changing much at the moment) to maybe help a bit.

          • Mer

            I’m not sure why having an IV would necessitate one on one care, various patients get IV’s all the time and don’t require a single nurse to care for only them. I know that in my hospital once a laboring patient gets an epidural they move to one on one care because of the extra management that epidurals require.

            I just realized something, if one on one care isn’t possible, perhaps thats the reason women are being so heavily encouraged towards natural childbirth in the UK? Because the resources for an epidural aren’t available?

          • The Computer Ate My Nym

            What purpose does inserting IV fluids serve in a woman labouring fine, with no complications who doesn’t want an epidural?

            See today’s post for a dramatic answer to that question: Hemorrhage can be unexpected, sudden, and rapidly fatal. You don’t want to be messing around trying to get an IV in a badly dehydrated woman who is bleeding to death. You want to be hanging fluids through the existing IV and running to the blood bank for the blood you typed and crossed earlier using the sample obtained when you put the IV in. Similarly with an amniotic fluid embolus: there isn’t time to waste starting an IV. Put in a hep lock and forget it until and unless you need it.

            Charting fluid balance is the provider’s responsibility and shouldn’t interfere with the patient’s eating. She just needs to tell you what she’s eating so you can add it to the balance.

          • Mattie

            Yeh that’s true, I do know that with women with previous history of PPH an IV is inserted on arrival and blood is typed for cross, I think the reason it isn’t done as standard is due to lack of staffing (my comment to fiftyfifty1) and although that is totally unacceptable…it’s reality for a lot of hospitals. The government has promised funds for more midwifery jobs and training places, which would improve staffing levels and care nationally, but it hasn’t materialised yet. The staffing issue, as well as funding for maternity care (including OBs, facilities, more units to serve more people) is actually one of the better things the RCM has campaigned for, although not quite as vocally as their campaign for normal birth unfortunately.

          • The Computer Ate My Nym

            You don’t have enough personnel to put IVs in everyone? That is terrifying.

          • Dr Kitty

            Mattie, I’m appalled.

            Where I worked it was the SHO’s job to stick a green venflon in every single woman as she arrived on labour ward, and to use that opportunity to take blood for and FBP and crossmatch. This was an NHS hospital, and universal IV access and admission bloods are still the policy.

            10mls of normal saline as a flush every 12 hrs work perfectly to keep the line patent, you don’t have to connect a bag of fluids or start a fluid balance chart unless you need to.

            It takes 5minutes to stick in a line, and midwives who do the training for IV access and phlebotomy get extra pay, so by the end of the four months I worked in that hospital at least half of the midwives were doing their own lines and bloods and I didn’t get bleeped, because they had all decided to go on the course..

            You don’t need extra staffing. You just need people willing to spend 5 minutes that they could have spent doing something else sticking a venflon in instead. Given that the midwives are extolling constant one to one support during labour, you think that they’d find the time!

            Pregnant women who aren’t unwell are the easiest people to get lines into. Pregnant women who are bleeding are some of the hardest.
            Midwives are doing their own bloods at antenatal clinics already, it isn’t as if they are being asked to take on specialist skills.

            Hell, midwives get a full two days of learning to do blood draws and start IVs, with a set number of supervised procedures, most Drs of my vintage had a see one, do one training experience!

          • Mattie

            That’s interesting and thanks for sharing your experience. I’m not sure if things have changed or if I am just shockingly wrong. I hope it’s the latter because it definitely seems like a really good idea now I’ve thought about it more and had the reasoning explained. Also if it is policy on high risk units and not on all units then it should be extended

          • KarenJJ

            I had a heplock inserted because I was chronically anaemic and in the event of a haemorrhage I’d be in need of fluids/transfusion sooner than others. I didn’t want one but when my obgyn explained that to me (and especially now that I’ve heard of ‘collapsed veins’) I was fine with it. It wasn’t that big a deal.

          • Mattie

            Yeh that makes sense, and also there were risk factors present. I think had you given birth in the UK (you didn’t say if you did, but mentioned having an OB which would suggest US) you would also have been given an IV during labour, as a precaution. It’s just not done as standard over here and not sure if we use hep-locks, but I may be wrong on that.

          • KarenJJ

            This was in Australia.

          • Ainsley Nicholson

            I’ve had a heplock for two of my births – in the USA, in a hospital. I didn’t want to have an IV unless it was necessary, but I also didn’t want to risk having them not be able to find my veins in an emergency situation, so a hep-lock was a good middle ground. Both times all I had to do was ask, and they were happy to set up the hep-lock. For the second of the two births, the placement was a little odd and uncomfortable, so I requested it that it be removed and reinserted, and again my request was accomodated with no objections.

          • Mattie

            That sounds great, and shows that they’re respecting your choice while also keeping things safe and keeping you alive, which nobody should (could if they have any heart at all) object to.

          • MaineJen

            You know it is more difficult to get an IV into someone who is already dehydrated, don’t you?

          • Mattie

            Yeh, I do. After reading responses to this it’s totally clear to me that saline locks/cannulas are the way to go, even in ‘low risk’ birth places. Although IV fluids might not be necessary if the woman is drinking normally, is not showing signs of dehydration etc.. and obviously if IV access is available fluids are easy to set up if the woman does become dehydrated.

          • Mishimoo

            Have you ever had an I.V?

            Yes, they pinch a little. The larger cannulas can be really annoying. They do get in the way a bit, but to me, IV fluids are one of the most amazing inventions, ever. Even when I have not noticeably been dehydrated and have had an IV for safety reasons, it took me from feeling vaguely crappy to feeling a whole lot better.

            (Also, it’s better to get the line in BEFORE dehydration, as dehydration makes it harder to find decent veins and can decrease the placement options)

          • Mattie

            Sorry that might have not been v clear, so I’ve not ever needed IV fluids (had medication via IV but not the same thing haha) but what I mean is that yeh after reading about stuff on here it seems like getting a heplock or cannula in on admission, even not connected to fluids, would be awesome because if then fluids, pitocin (synto), ABX, PPH management meds are needed then you already have that access. I don’t think women who are ‘well’ need fluids necessarily, they can drink and stay hydrated that way, but if they need them or want them then they can be set up easily and with little disturbance to the patient if the IV access is there already.

          • Mishimoo

            Yeah, they are a really useful tool and I adore them despite the discomfort because it makes me feel safer. I just wanted to point out that even well-seeming women can need them, because fluid intake is something that wasn’t on my mind when I was in labour and I always look/act fine.

            Plus, things can very quickly turn into an emergency even with the most low-risk people. So yeah, a cannula is a great thing to have in, but being sure that it hasn’t suddenly clotted off is even better, hence my personal preference for IV fluids (even if it’s low flow). You can still move around with them – I went to the toilet, showered, bounced on the gym ball – and they’re not as big a deal as some people like to make out.

          • Cobalt

            Location matters for clotting. I prefer elbow because it’s out of my way, nurses always want to stick the back of my hand because then I can’t “pinch” the catheter and clog it up. A nice nurse will compromise with anywhere on the lower forearm.

          • Mishimoo

            I’m ‘lucky’ in that regard – the only decent vein I have is the cephalic/antecubital in my left forearm. Everything else is too close to the surface (according to the various nurses/doctors I’ve seen over the years), and the right side is one of the first things to hide if I’m anything less than perfectly hydrated. So it’s in a comfortable spot for me as I’m right-handed, and a useful spot for the nurses.

          • Mattie

            Yeh, that’s very true, I think if you like them then awesome, and if you need them then you need them (we were always encouraging women to drink and had jugs of ice water in every room that were refilled whenever they were empty) we would also check how often they would pee, and checked their urine during labour to try and keep on top of dehydration, it can be tricky especially when maternity units can get so warm, but I think if care is individualised and women have options and their choices are respected while maintaining safe care then you are doing your best as a care provider.

          • Roadstergal

            Oh god yes, there is something about that cool, calming rush of saline that is just so… nice.

          • Cobalt

            I don’t like IVs, even saline, because (aside from my general dislike of needles) they “taste” funny. Like I can taste the medication in my mouth even though it’s going into my arm. IV hydration tastes like licking a cold fork. It’s just…weird.

            Doesn’t stop me from getting them when I need them, but it’s definitely an undesired side effect.

          • Mishimoo

            I’ve honestly lost count of how many I’ve had, but yes. They take you from feeling awful to feeling human again and it is so soothing that I often fall asleep. The only bad experience I’ve had was my dear husband having 2 bags of very cold saline and needing to be warmed up again because his temperature dropped. The doctor was distinctly unimpressed and the nurse hopefully learnt to keep a better eye on things.

          • Daleth

            You don’t know if an IV is necessary or not until after birth–sometimes a while after, as in my case, when internal bleeding sent me into hypovolemic shock about two hours after my babies were born. Thank god I already had a heplock (IV port) in my hand; that’s what enabled the team of doctors and nurses who burst into my recovery room to save my life.

          • My experience has been that when a woman reaches 7cm dilatation, she often wants to turn on her left side, and vomits. Indeed, we even call the phenomenon the “7 cm sign”, it’s so common.

            Just think how pleasant it is for a laboring woman if her stomach was full…

            There’s another reason why, in the past, a woman in labor was denied food: if a crash C/S had to be done, and there was no time to do an epidural, the possibility of complications resulting from aspirated stomach contents, always a risk with general anesthesia, were increased.

            I haven’t got anything against a light diet, even though intestinal activity shuts down in labor but it’s worth thinking about why eating might not be such a good idea.

      • Deborah

        In Australia where I live and practice midwifery (hospital) there are two large tertiary hospitals that facilitate trial of labor after more than one c/s. They are equipped with high level nurseries and adult high dependency units. All other metropolitan hospitals facilitate trial of labor after one c/s. Country hospitals do not facilitate them at all. The very real risk of death or injury to mother and baby from a ruptured uterus is the reason for this. (1:200 after one c/s – higher after more than one)
        To facilitate a choice for women and their babies that may possibly result in death for either would be unethical, unprofessional and immoral. To use the term “forcing them to choose” is similar to saying because I won’t allow my child to inject amphetamines in my home I am “forcing him” onto the street.
        Very often, in my experience, the “informed decisions” that you speak of are not informed at all. They are presented in such a way by people who want you to believe their philosophy and buy their ideology and services, as outlined in the above quote “we value the acceptance of death as the possible outcome of birth”. Everything else they say is irrelevant in the face of that statement. It says it all. Even if you and your baby die we are committed to this agenda and we won’t change our practice, improve our standards or be held accountable in any way.

  • Bombshellrisa

    OT: CPMs have fragile egos. Why else would they need to invent a title for ones who are retiring? http://narm.org/news/new-retired-cpm-status/

    • Box of Salt

      Sounds to me like it’s just a way for NARM to collect an extra $65 from them (with the justification that they won’t delete your records from their files).

      • Bombshellrisa

        It just seems so strange! If you earn an MD or JD or PhD, you will always be a doctor, retired or not. Supposedly you “earn” your CPM through a course of study and training, why the designation of “retired”? It’s funny that they mock Dr Amy’s credibility as a retired doctor but are willing to consider a “CPM-retired” as credible and worth listening to.

  • Driving

    I loved my scheduled c-section. Vaginal birth was fine, too, but c-sec was much easier to recover from and did not damage my bladder.

  • KBCme

    I’m so glad I found this site, but really wish I had found it before my first was born. I ended up with a csection after being induced at 41 wks. The ‘woo’ voices kept telling me I’d ‘given in’, that really it was done due to convenience of doc (it was Friday night, after all). Or you know, it could have been his 30+ years of experience as an OB and seeing that after 12 hours of labor I hadn’t progressed, baby was high that even if I labored another 12 hours I still wasn’t likely to have a vaginal birth. How dare I trust him! I briefly had considered a birthing center but I could never figure out the math. If I hemorraged (a small, but real risk), even with the birth center a block away from the hospital, I didn’t see how I could get there in less than 15 minutes. By then, I’d have bled out. Thanks for helping get the word out Dr. Amy!

    • SporkParade

      Those woo voices are obnoxiously persistent. Welcome to the best comments section on the internet!

    • Bombshellrisa

      Hello and welcome!
      There is something about getting care from an OB 30+ years into their career that gives you confidence. Good for you for “giving in” so you could be a mother to your child.

    • Montserrat Blanco

      Welcome!

      You valued your baby life and wellbeing higher than your own… You made the right choice and I am sure you are a great mom. I hope you recovered well from your C-section.

  • Bombshellrisa

    OT: Just had to share this: a mother is selling her birth kit because she no longer is going to birth with a CPM. Instead of just scrolling through, a much of women (including the mod of the page, who is a CPM herself) ask “why aren’t you birthing with this midwife anymore?”. I posted a couple screen shots.

    • Bombshellrisa

      Here is the screen shot

      • Bombshellrisa

        Notice the comment “I hope whatever birth experience you choose that you and your baby are happy”. Because it’s all about the experience, never the outcome.

        • Bombshellrisa

          The contents of the birth kit

          • rh1985

            *gasp* not a HAT!

          • Bombshellrisa

            Oh! Maybe that is why she isn’t going to birth with that midwife!

          • Susan

            I have been pondering something re the no hat thing. So the last thing I saw the rational for no hat is skin to skin without a hat is good enough and the mom gets some hormonal change from smelling baby head. Also the baby friendlys don’t want you to wash the baby’s hands as smell of their unwashed hands helps with breastfeeding. Assuming they really believe this crap, what about waterbirth? Isn’t baby going to come out without the essential birth goo?

          • yentavegan

            stop trying to apply any logic to what the woo-crowd does. Believe me I tried for years to justify their narishkiet.

          • Roadstergal

            Yeah, but there’s poop in the water, so blahdy blah microbiome.

          • Therese

            Size 4 diapers?? Must be planning on a very big baby!

          • wookie130

            Ha! My 2 year-old (who is 26 lbs) and my 7 month old (who is 20 lbs) wear size 4’s!

          • Somewhereinthemiddle

            I would think those are going to be used as post birth pads for mom. 🙂 Or to put ice in for cold packs for the perineum.

          • Dr Kitty

            WHY?
            You can buy perfectly adequate maternity pads, and some crushed ice in a ziplock bag, one of those re-usable gel icepacks or putting a few sanitary towels in the fridge would work just as well and be less bulky.

          • Somewhereinthemiddle

            I don’t know because I’ve not ever tried it. I like the cold packs that you smoosh up and they get cold. But several women I know swear by cutting into a diaper and putting ice in there. Seems unnecessarily messy to me but whatever blows your skirt up! Or, you know, cools your perineum. 😉

          • Inmara

            I have heard that diapers are more comfortable for postpartum bleeding too – no need to worry about leaks. I have fairly heavy periods and even biggest pads doesn’t prevent leaking sometimes, so I can see a point in using diapers after delivery.

          • Somewhereinthemiddle

            Yeah, I have a friend (looking into a hysterectomy) who uses diapers because her period is so heavy.

          • Dr Kitty

            But the point is that post partum you shouldn’t be losing so much blood that maternity pads aren’t enough to do the job.
            If you’re changing a pad more often than every two hours you need assessed.

            I’m afraid I gave major side-eye to the perineal cold pack/ pad on Amazon that cited the “convenient” fact that it could absorb up to 450g of fluid.

            That isn’t convenient, that is a good way to prevent a PPH being discovered.

          • fiftyfifty1

            Well Dr. Kitty, that’s why it only absorbs 450g of fluid, see? Because a PPH by definition is 500 g. So just put on that handy dandy pad, and if it overflows, why then even a CPM can tell it’s a PPH without having to measure or do math.

          • ForeverMe

            Fifty, I think you’re spot on. Or even… it’s only 450, let’s use one more pad……. and some cinnamon breath …… and a placenta smoothie….. and tell ourselves *very sternly* to stop bleeding……. and take these Chinese herbs…..and….and….. before we go to the hospital.

          • Mad Hatter

            My nurse gave me frozen newborn size diapers as ice packs in the hospital. I guess they would get them wet and freeze them. I LOVED it! More comfortable than ice cubes and not really bigger than a overnight pad. I even used a few after I came home since I had 2nd degree tearing.

          • jenny

            At the hospital I had my kids at, they would put crushed ice in a diaper and use that as an ice pack. then a regular maternity pad. there may have been some kind of baggie too? All I remember is it was great because as the ice melted the diaper would absorb it, and so it was cold without being wet. Super comfy. I’m a believer.

          • Dr Kitty

            Uh…
            That kit makes no sense. The quantities in particular.

            Go to your local dollar store equivalent.
            Get a roll of garbage bags, a pack of drinking straws, a pack of nappies, a pack of super sanitary towels, a sports drink bottle with a squirty top, some blue nitrile kitchen gloves, a tape measure, a baby hat and some puppy training pads (instead of chux).

            Then all you are missing is the cord clamps, a pack of gauze and dressing tray, a tube of KY, a bulb syringe and a “memorable birth certificate”, most of which you’ll get at your local pharmacy, or online.

            Want to bet the midwife adds a substantial mark up and splits packs to save cost further?

            I bet you’d end up with more for less if you sourced it yourself.

          • LovleAnjel

            The hospital gave me all of that, and more, and it was “free” (covered by insurance).

          • The Bofa on the Sofa

            The hospital gave you a “memorable birth certificate”?

            I have to admit, I don’t even know what the hell that is.

          • KarenJJ

            Probably what parent’s who give birth to blobs in hospital and then ship them off to baby warehouses need so that they can actually remember that they have a baby…

          • D/

            It’s a decorative keepsake certificate with fill in the blanks for personalized information, physician signatures, footprints, etc. As a nursery nurse I always hated being asked to fill them out for folks since it required me to admit my handwriting is mostly atrocious. I did like having somewhere to do footprints that allowed a redo option though instead of putting accidental six toed impressions straight into people’s baby books 😉

          • EmbraceYourInnerCrone

            AT least where my daughter was born in California, the hospital gave us a “keepsake” birth certificate with her foot prints and the date and time she was born, its not an official document. to get the official government certificate of birth we went to the bureau of vital statistics office and filled out a request and the registrar gave us 2 “official” copies. Ones with the raised seal stamp amd registrars signature and the names and info of the parents.

          • Joy

            A BABY CAP?!? What type of CPM hats?

        • Allie P

          I would not like to have a birth experience. If i could skip it, that would be fine. I just want the baby.

          • Bombshellrisa

            I would also like to skip the birth experience. The ideal way to get a baby would be to wake up and not be pregnant anymore and find the cleaned, fed baby teleported from my womb to their crib.

          • Sarah

            I did enjoy all the medicinal heroin I got during mine, though. It would have cost quite a bit on the streets.

      • Cartman36

        If I paid $65 plus shipping and got this I probably would start to question Nancy’s motives and competence as well. I don’t see anything I couldn’t get at Walgreen’s.

  • WordSpinner

    You know, I sympathize with the idea that we sometimes take heroic measures that reduce quality of life without enough extension to justify the added suffering, and that death is always eventually inevitable and sometimes the best choice is to accept it and make it as free of suffering as possible.

    Your average C-section, however, is about as far away from that as possible for a medical intervention. C-sections save lives with a minimum of mostly short-term morbidity–the baby has 7 or 8 decades of possible healthy life, and the mother has about 5. That is not an intervention to shun.

  • rh1985

    I am from Connecticut. This state has many hospitals that offer VBACs and have 24/7 anesthesia available, and it’s a small state, no matter where you are you can get anywhere else in the state in less than 2 hours. If she couldn’t find a hospital to attempt a VBAC at, it was because she was a very bad candidate, not because there were VBAC bans.

    • Elizabeth A

      I don’t necessarily think you’re right there.

      CT is a wealthy, densely populated state. It has a wealth of resources that not all states have. A mother in Kentucky or Wyoming is going to have a totally different set of barriers to care than anyone in Connecticut.

      You saying you could find a VBAC where you live, so if she was a good candidate she shouldn’t have had trouble where she lives is like me saying that everyone should be able to get all their care at teaching hospitals of Harvard, because I can barely parallel park without hitting one.

      • toni

        the woman who lost her baby to the VBA2C was from Connecticut

      • rh1985

        The woman who lost her baby was from Connecticut and used midwives from New Haven. She could have gone to Yale which allows VBACs if she were a decent candidate. She either wanted a HB at any cost or just was a terrible candidate for a VBAC.

      • Pktaxwench

        A mother in Wyoming will be told to try to VBAC because there are no surgical staff within an hours drive of the shithole I lived in. It happened to me. And because the one helicopter of the hospital was out on a call, I couldn’t be air lifted to civilization for a repeat C. There home births on the prairie just make sense, because medical care is nonexistent. I held on through willpower until they could get a surgeon in.

        • Cobalt

          I used to live in rural nowheresville and our local hospital had a 50% cesarean rate. The one OB in town had a very low threshold for calling for a planned cesarean, because an emergency section wasn’t always immediately available.That hospital didn’t do VBACs, and most women elected a RCS instead of driving to the closest hospital that did, especially in winter. There was also a fairly high induction rate.

          Low risk women, who were very unlikely to need a cesarean, were seen by the GP in most cases. The cesarean rate for his patients was about 8%.

  • CanDoc

    I am nauseous. Pretty sure most the moms in their care don’t realize this is the modus operandi, and wouldn’t want their care if they did know.
    “We value the acceptance of death as a possible outcome of birth. We value our focus as supporting life rather than avoiding death… We place the emphasis of our care on supporting life… and not pathology, diagnosis, treatment of problems, and heroic solutions in an attempt to preserve life…”

  • Trixie

    This is truly chilling and very sad. I’m weary of all these HBAC deaths. It’s so preventable.

  • Daleth

    On the Cesarean by Choice network we’ve been talking about picking a day to be International Cesarean Awareness Day, and trying to decide which day it should be. So far my favorite of all the ideas shared is making it June 7, Virginia Apgar’s birthday.

    My twins had Apgar scores of 9 and 10 after their cesarean birth. SO HAPPY I chose a c-section.

    • Amy Tuteur, MD

      How about calling it Cesarean Appreciation Day?

      • demodocus’ spouse

        CAD?

      • toni

        yeah awareness days are usually for something bad aren’t they? I like the Virginia Apgar idea.

      • Cartman36

        Or, thanks Mom for valuing my life over your experience day?

        • Montserrat Blanco

          Do not forget your brain function…

      • Allie P

        I appreciate my mother’s cesarean. I haven’t had one (yet) but I’m sure if I did I’d appreciate it, too, for what ever reason it ends up occurring.

  • deafgimp

    I’m struggling to find the posts that explain the studies that have been done which show that homebirth is dangerous. Is there one link where all these posts can be found? I’m currently arguing with someone about homebirth and need to support my statements.

    • Jocelyn

      http://goo.gl/FXmP4p – Study from 2014 that found a death rate 4 times higher at home birth
      http://goo.gl/Xguiqi – Meta-analysis from 2013 that found a death rate 3 times higher at home birth
      http://goo.gl/Vm1NWC – Statistics from 2008 that found a death rate 3.5 times higher at home birth
      http://goo.gl/DE3OV5 – Statistics from 2012 that found a death rate 8 times higher at home birth
      http://goo.gl/T1hvSk – Study released last year that found a death rate 5.5 times higher at home birth (for low-risk pregnancies; for breech babies the death rate was 28 times higher)
      http://goo.gl/1Cfmi6 – Study that found that home birth babies suffer 18 times as many brain injuries
      http://goo.gl/3HQ0j9 – Study that found that 3 times as many babies born at home have seizures
      http://goo.gl/4IcUsC – Study that found 10 times as many babies born at home have a five minute Apgar score of 0

      • deafgimp

        I love you. Thank you.

    • Daleth

      I think the single most kick-ass study is the one out of Cornell that found a death rate 4.25 times higher in midwife-attended low-risk home births vs. midwife-attended low-risk hospital births. (Bear in mind that hospital midwives are real midwives, not CPMs or lay midwives.) It’s kick ass because:

      – It can’t be accused of being too small or selectively looking at certain births, because it looked at EVERY SINGLE low-risk birth (as defined in the study*) in the entire USA from 2007-09, over 10 million births.

      – It can’t be accused of being irrelevant to present-day births in the US because it was in the US and was recent.

      – It separated out planned home births from unplanned ones quite effectively–perhaps not perfectly, but very effectively. Here’s how: it separately analyzed midwife-attended home births (almost all of which are planned) from home births that were attended by non-midwives or were unattended (almost all of which are unplanned). Unsurprisingly, the death rate for non-midwife attended low-risk HB’s was 18.2/10,000, almost 50% higher than for midwife-attended ones.

      – If anything, it makes home birth look safer (and hospital birth with OB’s more dangerous) than it really is. Here’s how: any home birth that went wrong and ended in a hospital transfer before the baby was born was counted as a hospital birth. Every catastrophic home birth that ended with a dead baby born at the hospital was counted as a death in hospital birth.

      Link to the study: http://www.ajog.org/article/S0002-9378%2813%2901155-1/fulltext
      Link to Dr. Amy’s article on the study: http://www.skepticalob.com/2014/02/new-cornell-study-shows-homebirth-has-4x-higher-death-rate-than-comparable-risk-hospital-birth.html

      * The study defined low risk in terms of the baby, looking at every birth of a full term (37 or more weeks), singleton, vertex (head down) baby weighing at least 2500g (5.51lbs). It did not, however, control for high-risk mothers, i.e., preeclampsia, GD etc., because the data didn’t allow them to identify which moms were high risk, and that is no doubt why the neonatal death rate for OB-attended hospital births was slightly higher than the death rate for hospital midwives–5.4/10,000, vs. 3.2/10,000–because hospital midwives are required to risk out high-risk moms and send them to OB’s for delivery. However, the death rate for OB-attended births (which included virtually all high-risk moms) was still 2.44 times lower than the death rate for home birth midwives (which may have included some high-risk moms but was primarily low risk ones).

    • staceyjw

      Tell them to find ONE that shows HB safe in the USA. Cannot be done. Even the one they claim shows HB safety, doesn’t, and the rest are not in the USA so not relevant (besides, those show HB is still unsafe).

    • Amazed

      Tell them to have a look at the studies Australians took into consideration when they arrived at the conclusion that homebirth was not recommended.

      http://www.ranzcog.edu.au/documents/doc_view/2051-home-births-c-obs-2.html

  • staceyjw

    We have the tools. We have the knowledge. There is NO NEED for these deaths. They are 100% due to ideology.

    This is because even *with* poorly trained providers at home, just following simple, proven, risk out criteria, would be enough to cut out quite a few of these deaths. Simply keeping VBACs, and other high-risk from the start moms, from HB, would be a huge improvement!

    That so many other deaths would be easily prevented with the most basic off prenatal care, makes these deaths even more tragic than they already are. It is inexcusable.

    And those “MWs” that are *openly* ok with “letting go” are only that way because they are sociopaths. This level of callousness is not an attitude that normal people have, even if they are at peace with death. Its totally inappropriate to work with anyone in such dangerous, sensitive, situations, if you have these beliefs.

    They are the opposite of “with women”, they are exactly what they rail against. (Projection much?)

    • Ash

      Minnesota Birth Center is a freestanding, non hospital affiliated birth center staffed by CNMs that has robust risk out policies.

      In particular, baby must be head down, singleton. No TOLACs. Clients who don’t want glucose tolerance test, ultrasounds, and Rhogam if Rh- are not accepted.

      http://theminnesotabirthcenter.com/frequently-asked-questions/

      If HB MWs followed these guidelines, it would be a whole lot safer.

      • Cobalt

        “midwives are ideal providers to care for women with normal pregnancy and births”

        They’ve got that in the right order. You don’t get a “normal pregnancy and birth” because you have a midwife. You get a midwife if you’re having a normal (read straightforward, low risk, uncomplicated) pregnancy and birth. Assuming you want a midwife, midwife care should be an option, not a rule.

      • AA

        Edit–women who have had a previous history of 3 C-sections or more are excluded.

  • JJ

    “… We value the art of letting go and acknowledge death and loss as possible outcomes of pregnancy and birth.”

    Just what I want to hear from someone who is supposed to help keep me and my baby alive! GAG!

  • attitude devant

    Goddammit these NCB idiots make me so mad!

  • Minnie

    The stigmatizing over C-sections which leads women to need “heal” from one is sad. I admit, I really didn’t want to get one (mainly since I have never been in surgery and was afraid of going through any surgery, plus, unfounded or not, I was afraid of what a cut there would do to my core strength), but I ended up with a big baby and a cervix that wouldn’t open, so I had one. It wasn’t a traumatizing process that I needed healing from and talking to women in my area (some who were more NCB-inclined) were like “can you imagine before the surgery what would have happened to you?” and we pretty much agreed that one or both of us would have been dead.

    A more all-around alternative medicine type was like “Eventually you would have opened up and the natural process would have started like it has through time.” It just amazed me since she is a very intelligent woman and really aware of history. Also, a shortish woman with some Pacific Island heritage wouldn’t necessarily end up with a very tall Englishman and access to dairy she can’t normally process along with very a nutrient-rich diet, meanwhile creating a nutrient-suck of a baby. I was only 4 days late and my son was 9 lbs, 13 oz. 3 months later I have a 17 lb baby who is 27 inches long. Modern times, modern technology. It’s life-saving!

    On a different note, I see so many articles about needing to “heal” from a C-section by attempting a vaginal birth which made me wonder about what would happen if I have a second child. I’d rather stick with the pain I know and not risk anything happening to my uterus which was stretched incredibly during my last pregnancy. Do you have to attempt VBAC or can you make the request to just go straight to a C-Section? Honestly, I’d prefer the latter. My healing after my C-section was continuing with my workout process I did right up until I gave birth as soon as I could. For me it was about healing my body, rebuilding my core strength, not needing to heal from some broken ideal that vaginal birth is an exalted way.

    I’m still on a tangent, but when I first heard I was going to need a C-section I started crying and my OB was shocked since I was so calm and was like “this does NOT make you less of a woman” to which I was stunned and had to explain that I was more overwhelmed than anything. At that point you could have told me the baby is half out and you don’t feel any pain and I would have cried as I was exhausted the last week of my pregnancy. It struck me as sad that he’d have to explain that to his patients due to this ideal that is sold.

    • FEDUP MD

      You absolutely do not have to VBAC if you do not want to. At the beginning of my second pregnancy they asked what I wanted to do, I told them repeat csection, then when the OR schedule opened up a month before I turned 39 weeks we picked a date. Easy as anything.

      • FormerPhysicist

        Well, I came closer than I wanted to an unwanted and unplanned VBAC. But my OB was fantastic and came into the hospital super quick at 4 am to do the c/s when I went into labor from pre-E.

      • wookie130

        I certainly didn’t want to VBAC, and my doctor actually thought it would be just fine to try, for some reason. Good thing it didn’t appeal to me, and I opted for the repeat c-section, as my uterus was “paper thin”, and close to rupturing during the delivery of my second child. It’s discouraging when I see members of the medical community steeped in the woo. Ugh.

      • Dr Kitty

        I’m going to have the mandatory NHS 34w appointment to discuss delivery options and what the plan will be if I go into labour spontaneously.

        I’ve already been very clear that I don’t want a TOLAC or VBAC, and that this will not change.

        My OB has written “NOT FOR VBAC” on my notes in big letters and has said that he envisages the 34 week appointment being a short chat in which we choose a date for the CS.

        My husband knows that in the event I do go into labour, his only job is to say “she wants an epidural and a CSection” as loudly and as often as necessary until it happens!

        • Who?

          How’s the nausea?

          • Dr Kitty

            Much better, thanks!
            Feeling some kicks, actually enjoying eating…it’s all much rosier over at Casa de Kitty!

    • MichelleJo

      I have a friend who had three children by c-section, after being induced at 41 weeks and not remotely effaced or dilated 12 hours later. She was OK with it. But it stood her in good stead with her fourth pregnancy, which was a surprise triplet one! She carried them to 37 weeks and was up and about throughout. She had a planned c-section, and never really worried about going into labor too early for them to live or be healthy.

    • Roadstergal

      “needing to “heal” from a C-section by attempting a vaginal birth”

      I’d think keeping the incision clean, then progressing to PT when appropriate would do a lot more…!

    • Michele

      You can go straight to a C-section. That’s what I did with #2. If anyone (medical personnel anyway) gives you pushback I found the phrase “I am not comfortable with the additional risk to the baby with a VBAC attempt” gave me a lot of information. If they don’t quit trying to persuade you to “try” after that statement then they are too woo-infested for me.

  • Kazia

    I have premptively decided to get an epidural when I have kids. I don’t want to chance having an emergency c section under general anesthesia. It took 3 different anti emitics and 9 hours in the ER to get my nausea and vomiting under control and I do not want to spend the first days of my baby’s life trying not to vomit when I move.

    Also, I don’t like pain.

    • Cobalt

      That’s a very rational and reasonable way of looking at it. Make sure you tell your OB early on so you can get good advice on timing options, too soon and too late can both impact effectiveness.

      • Kazia

        I’ll try and remember! Kids are a pretty long way off for me still.

  • Are you nuts

    Truly heartbreaking.

  • yentavegan

    I am weeping for this mother. She will probably live a life of cognitive dissonance. Some point in the future after she has spent years denying the brain washing and violence that was done to her, her desperation will come to a head and she will suffer the consequences anew. She was lied to and encouraged to construct a fairy tale existence surrounding body and birth, Clap as hard as you might works only for tinkerbell. Real women rely on science.

    • Busbus

      Yes, it is incredibly sad. My heart breaks for her, too.

  • The Computer Ate My Nym

    Why would anyone who has had an emergency c-section twice think that being some place where they couldn’t get a third emergency c-section if something went wrong AGAIN was a good place to labor? Despite what it sounds like, I really don’t mean this to say “that woman was so dumb” but rather “What makes a person who is probably otherwise pretty rational and able to make decisions that have kept her alive for at least 20 or so years suddenly decide that this crazily dangerous thing is a good idea?” Because if we can’t identify that root cause, this will just keep happening.

    • MegaMechaMeg

      I think it is just magical thinking. We all do it in one way or another. Each time I buy a new shampoo I think that will be the one that fixes my thin frizzy hair despite all evidence to the contrary, and each time I come home and my hair is still thin and still frizzy and I get to laugh at myself for thinking that a different type of soap is going to fix it. With something like birth it seems like it would be easy to forget and second guess the decisions that were made, particularly if you have people telling you that if you just think hard enough in the right way it will work out.

      • Karen in SC

        And there is an entire chorus of “magical thinkers” to cheer you on

    • Melissa

      The book The Unpersuadables goes into how our current understanding of brain science can help explain how people can believe things that don’t have support in reality.

      Much of it is based on the fact that our brains are lazy and take a lot of shortcuts in understanding why things happen. These shortcuts are based on our sort of world view. If we didn’t have these shortcuts it might be impossible to function (imagine every time something happened that you didn’t expect, like someone cutting you off in traffic, you had to try and figure out why) but the shortcuts can lead us to dismiss things that conflict with them.

      Someone who believes “my body can do anything if I try hard enough” may have been very successful in much of their life with that worldview. But when presented with something where it failed (the ability to give birth vaginally) she was faced with either throwing out her entire world view and creating a new one or deciding that her view was right but something else prevented her from being able to succeed. (I’m simplifying it by a factor of about 1 million but the book does a great job of getting into the specific reasons why people can act seemingly irrational in these ways).

    • Elaine

      They think that the needs for the first two C-sections were caused by iatrogenic mismanagement of their labor, and that if they can just avoid “interventions” then labor will go swimmingly. Granted, I do not know these people personally, but I know the type, and we read about them all the time here.

      Are some doctors more pitocin-happy or csection-happy than others? Maybe… but in a lot of cases, interventions are done because there is a problem, not the other way around. An easy intervention-free birth was intervention free because it was easy, not easy because it was intervention free.

      • Sarah

        And even if both sections were 100% iatrogenic, that doesn’t mean VBAC after 2 EMCS stops being risky. A scar on your uterus is a scar on your uterus.

  • namaste863

    The whole purpose of pregnancy and birth is to get the kid. Whether they’re born vaginally, c-sectioned, adopted, or dropped on the front doorstep by the fucking Stork is beside the point. Why bother to do any of it at all, otherwise?

    • MegaMechaMeg

      I think it is kind of like wedding planning where you start out wanting something sweet and simple where you make your vows surrounded by the people that you love most and you somehow find yourself a year later caring about having matching champagne glasses to toast with and are freaking out because your veil lace doesn’t match your dress. You start off wanting a baby, but once the pregnancy is established and you start over thinking everything it snowballs to the point where the decision to get an epidural is now the biggest most important thing that has ever been decided and you are a monster if you try to clamp the cord.

      • SF Mom & Psychologist

        I see your point, but nobody dies or suffers serious injury if your lace veil doesn’t match your dress, or you used the wrong champagne flutes.

        • FrequentFlyer

          I thought some of those crazy women on Bridezillas might have hurt or killed someone if they hadn’t been on camera. Maybe if Born in the Wild or whatever it’s called fails, it can be replaced by Momzillas.

      • Who?

        I really hate it when the veil doesn’t match the dress (how can that happen in the 21st century) but it generally doesn’t have long term ramifications, particularly if you take it off for the photos.

        • Melissa

          I think what happens is that during pregnancy EVERY decision becomes the most important decision ever. Going to have a tuna fish salad for lunch? Do you want to poison your baby? Or, not having any fish at all Don’t you know that you need Omega-3 to build brain matter!

          9 months of every decision being treated as equally essential and I think that your brain is no longer able to really tell the difference between important and not. We need to be better at telling pregnant women not to sweat the small stuff like having a coffee in the afternoon.

          • Aliciaspinnet

            If I ever write a book about pregnancy, I would probably call it “Pregnant? Calm the f*** down”. With content like “You took a sip of alcohol. It almost certainly won’t have caused any harm. Just don’t overdo it. Now calm the f*** down”
            Although it’s funny to see how women won’t take the slightest risk with pregnancy but when it comes to home birth they will. I wonder if it’s partly a control thing – if I give birth in a hospital then the doctor is in control. If I give birth at home then I’m in control. If Im in control then nothing bad can happen because I can control it. It’s a bit like being afraid of flying but not of driving, even though statistically you’re probably safer on a plane.

          • Roadstergal

            I love the idea, especially if either Samuel L Jackson or Jonathan Banks agrees to do the audiobook.

            Or maybe Judi Dench.

          • Aliciaspinnet

            I’m thinking Morgan Freeman. I think we have a million dollar idea here.

          • KeeperOfTheBooks

            I’d totally buy it, especially if I can get an autographed copy. 😀
            I once informed a particularly sanctimonious nuisance that by my count, I was to avoid while pregnant all vegetables and fruits (eek! contamination from pesticides/runoff/various bacteria!), all dairy (eek! hormones! Lactose Is Bad!), all grains (GRAINS ARE TEH EVIL), and most meats most of the time (some organic chicken might be okay, but anything else would be too fatty). Ergo, the clear solution was to sit in the lotus position in a room padded with all-organic bamboo and eat/drink nothing but thrice-distilled spring water and the occasional boiled-for-three-hours (gotta kill any chance of bacteria!) organic chicken breast for the next nine months.
            For some reason, my OB didn’t think this would be healthy. Shows what he knows, right?! I knew I should have gone with a midwife! /sarcasm

        • MegaMechaMeg

          People really suck at scaling risk, and thanks to medical interventions most people have little firsthand experience with a pregnancy that went south. How many people are afraid of airplanes but have no problem driving a car?

          • Roadstergal

            “People really suck at scaling risk”

            This. I’m sure most of the HBAC-supportive women out there would have a shitfit at the implication that they might drive drunk, or drive their child around unbuckled, when those two actions are statistically less risky.

    • fiftyfifty1

      “The whole purpose of pregnancy and birth is to get the kid.”
      pshaw! I look at it as a rite of passage where I get to experience the liminal space.

  • Tsu Dho Nimh

    ” The ultimate result was a healthy baby boy born via cesarean and my broken heart and body.”

    A healthy baby boy is cause for a broken heart … this woman is not normal.

    • Amy M

      Lately, when I read the term “broken body” in reference to childbirth by Csection, I think : a broken body is one that has fallen 10 stories and hit the pavement. A body that has been carefully incised and sewn back together is hardly broken, especially since all the organ systems are still functioning as they were before the operation.

      • Inmara

        Let me guess, degree 3 or 4 tear from completely natural birth is much better definition of “broken body” than C-section incision. Then again, according to NCBers, having tears would mean that woman “didn’t trust birth” so it’s her fault, right?

        • attitude devant

          Heh. Just did a MRCS on someone who had to undergo a rectal sphincter repair after her first was born….

          • Empliau

            I am wincing in more than one direction at the thought of what she suffered, and simultaneously glad that there are people like you who can: a.) repair such injuries and b.) prevent them. Thanks (to all in ob-gyn) for what you do!

        • Amy M

          But even 3rd/4th degree tears can be repaired by a good surgeon, and usually are right after the birth. Unless we’re talking a homebirth where the woman was just supposed to sit in bed with her legs together for a few days, and then wonders why she always pees her pants.

      • Busbus

        I think it’s just incredibly misogynist to refer to any woman’s body that didn’t “perform” as expected as “broken.” This term makes me gag.

        • Sarah

          Well, it’s not for me to argue with anyone’s assessment of their own body after their section. But I certainly don’t feel like mine is broken.

      • Aliciaspinnet

        There are in so many women around the world who suffer terribly with obstetric fistulas which could have been prevented with an appropriate c section. I bet nearly all of them would have taken the option of having a “broken body” from a caesarean rather than being left with permanent continence issues.

    • Dr Kitty

      I don’t know how to put this.

      People think that they can do anything if only they try hard enough and want it enough. They’re young, they’re fit, they’re smart, they’re healthy- there is no reason why they can’t have anything they want!

      They have no reason to believe differently, because their privilege and wealth have protected them throughout their lives and these views have been unchallenged by any real life experience.

      Then, having planned and worked towards a goal, and being unable to achieve that goal, they see it, not as a goal that was simply unobtainable, or unrealistic, or unimportant, it becomes a BADGE OF PERSONAL FAILURE. It is an affront to their worldview. It challenges their core identity as a good person who deserves to be rewarded by the universe.

      Failure being something that they are not equipped to cope with well, not having experienced it much.

      So it becomes about proving that they aren’t broken, that the world still works they way they thought it did, that if they just try hard enough and want it enough they can have everything they want…

      …and the rest of us, who never had that worldview to begin with, shake our heads and fail to understand why they would risk the big picture (a baby) for something so unimportant (vaginal birth).

      Of course, I am neither a philosopher, nor a psychologist.

      • demodocus’ spouse

        My philosopher husband and psychologist mother in law don’t really understand this view either. (We have weird conversations)

        • Amazed

          As evidenced by the fact that your blind husband doesn’t value the art of letting go and does everything he can to keep the baby here on earth when he’s the one taking care of him. Such an artless soul you’ve married. Must be the philosophy thing. Not too many philosophers are artists at soul. One muse a person, I guess!

      • theadequatemother

        I think you put that pretty well. I was about to type something similar. I think it is also difficult to accept the fact that your health is not complete. That your body will not function perfectly until the day you drop magically dead from a lightning strike. That it will “fail” that you will need medical help and that medical help will be inconvenient, uncomfortable and potentially embarrassing. For a lot of young (or not so young) healthy women, pregnancy and childbirth is just their first taste of that and it’s hard to accept the fallibility of your own body…esp if you are, as you say, privileged and take it’s “health” very seriously and spend a lot of your disposable income on organic food and yoga classes (or pure barre I suppose now) etc. etc.

        Its protective to think that the CS was a “mistake” on the part of the OB. You didn’t really need it! You were bullied! Etc etc. And we exist in a protective bubble where nothing bad is supposed to happen to us or our children and the cognitive dissonance of it is such that if you go online and say “I would have died without the hospital and the OB” or “my baby would have died without the cs” the impetus to not believe that, and instead assume you are being “uneducated” and “dramatic/ histrionic” is so overwhelming that even if you had an emergency GA CS for cord prolapse you’d get several peeps on babycenter telling you that is was an unnecessarian and some CPM somewhere could have guided the baby out beside the cord or it was caused by diet or breathing hospital air or some such bull shi-t.

      • FrequentFlyer

        I think you’re on to something though. Any naive expectations I ever had for smooth sailing through life had pretty much been knocked out of me before I had children. Maybe if they hadn’t I would have reacted differently to my csections, or at least to the first one. That pregnancy had been going along very well until we were almost at the end. When there were problems and a csection was presented as the best option, I very calmly and without hesitation dropped Plan A in favor of Plan B. I like to think I would have behaved sensibly even if I hadn’t had any difficult experinces before, but who knows? Maybe I would be one of those women still pouting almost 13 years later because things didn’t go the “right” way. *Shudders*

        • Busbus

          I also agree with Dr. Kitty. When I started to question my previous beliefs after my second homebirth (where, luckily, everyone was healthy), one of the big shifts in my mind involved slowly realizing for the first time that bad things could happen to me, too. That I was not magically safe from heartbreak. That there was no difference between me and the parents who suffered a homebirth loss, except that I had been lucky and they hadn’t. It felt a bit like growing up.

      • KarenJJ

        I think this explains a lot too. If I remember correctly, someone recently pointed out that there seem to be a lot of people posting here that have disabilities and/or chronic illness that have already had to come to terms with the fact that their bodies aren’t 100% perfection and working as well as others. For me, the c-section came after a long line of issues I’d had.

        • Dr Kitty

          I think that might have been me who posted that too. 🙂

          It is something I have noticed.

          • KarenJJ

            I thought it might have been as well.

      • Francesca Violi

        I think you may be right, yet it seems to me really disturbing in a person in her situation. I mean, ok she had a first CS and she felt “broken” but then wasn’t the very existence of her healthy child, and of the next two, and the perspective of a fourth child to love, enough to “heal” her sense of failure? And also: as a doula , and with her history, she must know very well that something bad might happen (despite what they say to other people, they know this), so it’s not a case of a mother who had been misinformed. In order to heal herself, she consciously put her baby to such a risk, just thinking that everything would just end up well? I am an optimistic person myself but I really cant’ get around this fatalistic attitude in matters of life and death for your children… Perhaps because when I became a mother I developed a very
        strong sense that life is fragile and could turn on a dime…

  • Tsu Dho Nimh

    “We place the emphasis of our care on supporting life (preventive
    measures, good nutrition, emotional health, etc.) and not pathology,
    diagnosis, treatment of problems, and heroic solutions in an attempt to
    preserve life at any cost of quality
    .”

    So they think a baby born via C-section is “low quality”? That it should have not had its life preserved? That problems should not be treated? That problems should not be looked for in order to minimize or prevent damage?

    • Cobalt

      There certainly seems to be no perceived difference between a baby that has profound health problems that may be incompatible with life, regardless of delivery method, and a baby that’s totally fine after coming through the emergency exit.

      Supporting the use of cesareans IS supporting life.

    • FrequentFlyer

      Of course that’s what they think. I agree more and more with the idea that these people are, at their core, euginisists. Women and/or babies who aren’t able to survive birth without help should just die rather than contaminate the gene pool of higher quality humans and use up their resources.

  • The Computer Ate My Nym

    Nope, nope, nopity nope. I’ll accept that death is inevitable. I’ll even accept that there may be babies and mothers that we just can’t save. But I’m not going to pretend that I love it or find beauty in it. Certainly not when it’s healthy women and healthy babies dying.

  • Ash

    I wonder how the two MWs who attended the woman with a history of 2 c-sections feel about TOLAC now? Will they change their policy so they don’t take clients with a history of uterine incision? I have doubts.

    • Amazed

      Ah Ash! Don’t make me laugh under such a sad post. They won’t do any such thing and you know it. I’ll be amazed if they end up paying a single dollar in fine.

      BTW, when I first came here, I signed Amazed because I was stunned by the attitude of Janet Fraser and her fellow callous homebirthers. Now, I’ll be amazed if diehard homebirthers and midwives change their mind and practice even a little just because a tragedy occured. How expectations change…

    • manabanana

      How will these two midwives respond? How will MANA respond? How will NACPM respond?

      This is a class of midwives with no standards. They will continue to promote this kind of foolishness.

      Maybe a few individuals who get to experience a uterine rupture at home will be spooked and stop doing it. But for the most part, I think midwives will continue to offer VBAC and VBAmC, and they will offer it proudly- until they acquire some critical and reasoned thinking. But dwelling in reality is not midwives’ forte either.

  • Amazed

    Maria Zain Number Two but this time, it’s the child who is dead.

    I suppose that makes me a horrible person but I cannot see her as your average-taken-too-high-risk mom. She was bloody dangerous, she actively endangered other babies and finally killed her own.

    Disgusting.

  • Kq

    “The ultimate result was a healthy baby boy born via cesarean and my broken heart and body.”

    THIS SHIT MAKES ME SEE RED. Thanks for totally minimizing and STIGMATIZING csection births. You know, it is entirely possible to be happy with your section? try rejoicing in that healthy son? but noooooo it doesn’t count and you HAVE to be brokenhearted and blah blah blah.

    I’m so done with this.

    • Bugsy

      It’s all about the mom. Nothing else.

    • namaste863

      I agree. Based on her language, all she cared about was her “Natural” delivery. The baby himself was treated like a peach pit passing through her system. I’m actually amazed that a C-Section is thought of as the Worst Thing That Has Ever Happened to Anyone, Ever, and when the baby dies, it’s shrugged off as “Shit happens.” I’m pretty sure that for most rational people, it would be exactly the opposite. Babies deserve better than that.

      • attitude devant

        ^ ^ ^ THAT ^ ^ ^
        “…amazed that a C-Section is thought of as as the Worst Thing….and when the baby dies it’s shrugged off….

        THAT.

    • staceyjw

      The feelings of brokenness are totally induced too! If she hadn’t heard the NCB crap, I do not think she would feel that way. Being faulty and broken are the exact words of NCB purity. I wonder how common these feelings would be outside of places exposed too the Western brand of NCB?

      And what entitlement! She was able to GET A CS and save her baby! JFC. How many worldwide would dream of this outcome?

    • wookie130

      I am completely with you, really. It makes me HOSTILE. I just want to fishslap them all, and tell them to quit whining, and be grateful for their health, and for their babies.

  • The Bofa on the Sofa

    I think the part that gets me is that “acceptance of death” is something they “value.”

    Actually, it’s not that it “gets me” it’s that I don’t get it.

  • PrimaryCareDoc

    Why such relentless negativity, Dr. Amy? Why can’t you just move forward in a positive fashion and not look back at this stuff?
    (that was sarcasm, in the form of @WeMidwives)

    • MegaMechaMeg

      the baby could have died anywhere and at least they had the empowering birth that they wanted, right?
      #SARCASM

  • Amy

    I’ve read about and even experienced a lot of shocking behavior from people committed to the ideals of “natural family living” at the expense of the “living” part, but this may be one of the most appalling accounts I’ve ever read.

    HOW do so many otherwise intelligent people set aside common sense when it comes to their and their babies lives? How could ANYONE want to hire a health care provider who was so cavalier about patient death?

  • LovleAnjel

    “We place the emphasis of our care on supporting life (preventive measures, good nutrition, emotional health, etc.) and not pathology, diagnosis, treatment of problems, and heroic solutions in an attempt to preserve life at any cost of quality.”

    “…at any cost of quality.”

    I.e. “we prefer babies to be dead rather than injured.”

    Says a lot, huh?

    • Amy Tuteur, MD

      Alternatively, “any any cost of a quality birth experience.”

    • The Bofa on the Sofa

      “…at any cost of quality.”

      Actually, my question is more of, who’s quality of life are they worried about?

      Because look, supporting “good nutrition” and “emotional health” is talking about caring about the mother.

      This is exactly as Dr Amy notes, it’s about preserving the birth experience. THAT is the quality they are not willing to give up.

    • The Computer Ate My Nym

      If they place an emphasis on preventive measures, why don’t they go GTT? Or dip urine for protein? Or check BPs? Or do amniocentesis and ultrasounds? Vitamin K, hepatitis B immunization at birth, eye ointment, heartbeat monitoring…the list goes on and on. All preventive or early diagnostic tests that are shunned by the NCB movement. Heck, hats: there to prevent the newborn from getting cold.

      • Squillo

        Because what they’re trying to prevent is c-sections, inductions, or anything else BAD (read: they can’t do).

    • Bombshellrisa

      A review for a local CPM practice on Yelp mentions this “Another issue that made me extremely uncomfortable was this practice really relies a lot on you for the information. They never weigh you — they rely on you to provide that information. They have you pee in the bathroom and check your own urine with a strip; they don’t check it at all (my prior midwife always checked urine for protein and infections every single month herself). They don’t even measure your uterus regularly which I found really bizarre. The attitude in my opinion is a little too relaxed, which can lead to problems. Case in point, I developed a UTI in the first trimester and complained a few times to a couple of different midwives the first few months about symptoms, and they were brushed off. Not until 3 months later at the ER did the infection get diagnosed. All the pain and frankly expense of the ER visit could have been avoided with a simple urine test. Symptoms were brushed off again later when I complained of contractions; I was told to just take magnesium but I insisted on an u/s because I just didn’t feel “right.” Good thing — they found I was carrying very high amounts of amniotic fluid and they were in fact causing contractions. I was only in the 2nd trimester, so this was obviously a concern. But I am still fuming that I had to hound them for 3 days for the u/s referral. I shouldn’t have had to. Other issues came up like an ear infection that I was treated with natural garlic drops that smelled horrific for 3 weeks. I got so frustrated with the infection getting much worse that I saw an ENT who took care of the problem literally in 1 visit with pregnancy-safe drops. I just feel in general the midwives can get in over their head if you do have complications, but they have a chip on their shoulder about referring you out of their practice to take care of the issue. So you as the patient are left to suffer unnecessarily.”
      The reviewer ended up transferring to an OB practice and delivering at a hospital.

  • Abby Hummel

    If only that initial c-section was the most “heartbreaking” thing Cherise Sant had experienced during her births… How is a c-section heartbreaking? Wouldn’t needing one and not getting it, you know, like tons of women around the world, be the real heartbreaker?

    • Amy M

      I wonder how she feels about them now?

      • The Bofa on the Sofa

        I’m sure she has already let it go, because she values accepting death.

        But seriously, don’t underestimate the level of defiance that will come up.

        • Amy M

          True. How often have we heard: “It would have happened in the hospital too! His death was unpreventable! A csection could not have saved him!”

      • Cobalt

        It’s a cold thought, but it ran through my mind. Now she knows.

      • Cartman36

        I think her denial runs deep enough that she probably will say it was inevitable and would have happened in a hospital too.

        • Amy M

          Yep, I think you are right. It was just the first thought in my head, after I read what Abby wrote.

          • Cartman36

            Hopefully this tragedy will steer at least one person considering home birth to a hospital.

          • Amy M

            I think it could—here on this forum, there are women who used to home birth, but either from a near miss or an actual tragedy (their own or someone else’s), they change their minds. The really out-there hardcore people won’t change, but luckily most people aren’t that un-reachable.

          • Cartman36

            I am sure Dr. Amy’s “the doubtful fathers guide to homebirth” has saved lives as well. Now we just need the doubtful father’s guide to refusing vaccines. 🙂

          • The Bofa on the Sofa

            Considering that Sant is high-priestess in the religion that is NCB, I highly doubt that this event will make her change her mind. Yes, hopefully there will be those who read her story and will realize that was a really bad idea, but I don’t expect her to change at all. She’s in too deep.

          • nomofear

            I started on a preexisting, nonsensical distaste for hospitals, plus the fact that my mom delivered us without drugs (in hospitals, but without pain meds – like Dr Amy, actually). Then, I watched the business of being born, and then read it, and that cemented my woo. Plus, our insurance covered two freestanding birth centers, so I ran with it. Five years later, and in a second pregnancy – in a different state, and under a plan that wouldn’t cover freestanding birth centers, even if they existed here – oh, and a husband that would not have supported a repeat of the first experience – I was still sold on the woo, even after a pretty awful experience that first time. I do hold that I was less concerned with my experience delivering, as I was sold on the idea that all these hospital “interventions” hurt babies. Foolish, but I believed I was choosing the safer thing for her. She was fine, which I understand to be extremely fortunate, especially after it took me three hours to push her out because – surprise – it hurt so badly that I went into an illogical fugue state where I actively ignored contractions because I’d changed my mind and didn’t want to do this any more. At least in a hospital, they would have done something to snap me out of that, like threatening dreaded vacuums or something!

            Thank heavens I found this site and snapped out of that woo mentality. What? Epidurals don’t drug the baby? Episiotomies aren’t the root of all evil? Pain relief can make for a faster, safer, smoother delivery? Mind. Blown. Being awoken to science and reason on this allowed me to let go of some other things, too, like only buying organic foods. I have scientist friends who say it really doesn’t matter, but I listened to woo instead of them, until very recently. Gotta say, my crunchy family is going to be shocked when they see me loving this upcoming hospital experience, supplementing with formula from the get-go, and suddenly feeding my family NORMAL food.

            So, yes, people can change, but it’s hard to say what exactly is the best route to convince them. Had someone sent me this site, I can’t say that it would have helped. I found it when I was reading something on Ina may Gaskin, and someone linked to here in the comments. I also found that the couple of crunchy southern women that I sent links to all said basically that Dr Amy’s tone was ‘mean.’ I loved it, but I think if I have any friends who start talking about homebirth/NCB, I’ll start them with doula Dani’s The Business of Being Misled. Then ease them over here after sweet, nice doula Dani has put a chink in the armor.

        • The Bofa on the Sofa

          Of course, that is almost certainly not true.

          Remember, this was 41 1/2 weeks. If she had been induced at 41 weeks, that baby would still be alive. Maybe it would have turned into a c-section, but the baby would have lived.

          And if she had been induced at 40 weeks, she would have had a better chance of the baby being born alive without a c-section.

          Nothing good happens after 40 weeks.

          • Hannah

            Exactly. The fact is obfuscated consistently by NCB tropes and even in public health systems (Australia, Canada, UK) where a woman cannot demand an induction before 40+10.

          • The Bofa on the Sofa

            I’d suggest that VBACS should never be allowed to get to 41 weeks, and preferably sooner.

          • theadequatemother

            You can schedule an induction prior to 40+10 in Canada…its just the induction list is prioritized and social inductions are at the bottom so if things are busy you will be bumped by postdate inductions, GD and PIH inductions etc. My OB put me on the induction list at 40 weeks and was willing to do so anytime after 39. social inductions are certainly covered by provincial health insurance. All you need is a sympathetic care provider.

          • Bugsy

            Hmmm, does GD often lead to inductions up here? Taking notes…my GD son came 8 days early, and I’d prefer not to go past 40 weeks if I can help it. I’m not a particularly happy pregnant woman!

          • PrimaryCareDoc

            And of course then she’d be mourning her unnecessarian.

          • Mel

            Better to mourn an ‘unnecessarian’ than a child.

            That’s the irony for me. The loads of grief professed by the “scarred” women who had CS feels pathological to me.
            Shit, half of them are more vocal about how horrible the outcome of a healthy bouncing baby was than my students were when a well-loved senior drowned in a swimming accident just before graduation.

          • Since she had 2 previous C/Ss, I doubt she would have been induced fore the third baby. More likely, scheduled for a repeat elective aC/S and not allowed to go past the 40th week–very possibly scheduled for the op slightly before term. Considering that she had had both a very large baby and a borderline IUGR, she should have been having NSTs and ultrasounds in her 9th month in thi pregnancy.

      • Somewhereinthemiddle

        I would guess it would be something along the lines of “If I hadn’t had those two c-sections, I wouldn’t have ruptured.” Which is most likely true since an unscarred uterus is much less likely to rupture. But, knowing that a VBA2C is more likely to rupture than an unscarred uterus or after only “one” CS, it is wise to do a TOLAC in the hospital where they can save you and your baby if your previous incision opens.

  • fiftyfifty1

    Accepting death?
    Focusing on supporting life rather than avoiding death?
    Deemphasizing diagnosis and treatment of problems?
    Rejecting heroic attempts to preserve life?

    Sounds like a lovely philosophy…for a HOSPICE!
    Really?! You want to sign your perfectly healthy baby up for HOSPICE before even being born?

  • jhr

    HOMEBIRTHs with CPMs represent “the perfect storm” (i.e., convergence of otherwise unrelated phenomena) of historical reenactment, X-treme sport, narcissism, magical thinking. With the life of a precious baby in the balance…

  • moto_librarian

    “… We value the art of letting go and acknowledge death and loss as possible outcomes of pregnancy and birth.”

    “We value the acceptance of death as a possible outcome of birth. We value our focus as supporting life rather than avoiding death…”

    These “professional” statements need to be shared far and wide. Anyone who is considering a home birth needs to read them, because this is the closest that you are going to get to informed consent from home birth midwives. Know that these women value physiologic birth over your health and that of your unborn child. Know that they will never acknowledge that their hubris and lack of education and clinical experience are responsible for preventable deaths. Know that the vast majority of them will show no remorse for their role in these tragedies, but will instead blame you for “not trusting birth” or “not researching your midwife’s credentials.” Know that they will do damned near anything to avoid transferring you to the hospital, that they routinely downplay high-risk situations, and fail to adhere to their scope of practice. Know that when they cost you your life or that of your child that their colleagues will do nothing to adequately punish their “sister” midwife. Know that you will have no legal or financial recourse.

    If you know all of this, what mother would choose to have a home birth?

    • Amy M

      They might also blame you for not listening when they said they valued acceptance of death as a possible outcome, and if you can’t just let it be in the past you clearly are not practiced at the art of letting go.

      If you don’t want to accept death as a possible outcome of your pregnancy, you’d best see a (heartless) doctor and give birth in the (soulless) hospital, where they (artlessly) try to avoid death, you unenlightened modern sheeple.

      Homebirth: where only the most cold and calculating can withstand the spiritual intensity and achieve birth goddess nirvana.

    • Anonymous

      On a side note…one thing that really stuck with me when we were looking for an OB with our first was that our OB had dealt with some of the CPMs in the area, mostly in a negative way, and she told us how she dealt with patients going to a midwife instead of an OB:

      “Just ask them if they’ve ever declared bankruptcy.”

      Apparently almost all of the CPMs around here have at some point to avoid some sort of liability.

    • Who?

      Yes those couple of quotes should be front and centre on any and all material they distribute.

  • Bugsy

    So sad to hear of the needless death of beautiful babies.

    The pro-natural birth manta is so prevalent that I can barely stomach going to my birth club on Baby Center. It seems like there are so few pro-OB posts there. Practically every mom instead touts how wonderfully empathetic and kind midwives are, how they’ll let you have the birth _you_ want (and how OBs are much less concerned with how the mom feels emotionally).

    It makes me cringe. L&D isn’t about having the birth of _my_ dreams…it’s about having a healthy child. End of story.

    What the heck is wrong with modern society that our outcome is not having a healthy child, but instead having a birth experience that matches mommy’s expectations? Are we just that complacent in assuming that there will never be any complications in modern L&D?

    (Shakes my head and sighs…)

    • Cartman36

      Don’t you find it ironic that women on babycenter who claim to be mama bears and fierce protectors of their children can in the same breath talk about how wonderful homebirth is.

      • anh

        it’s always the same women who go on and on about how much a mother’s choice matters in labor but if she chooses not to breastfeed she’s a shit bag

        • Cartman36

          I guess you only get a choice when the choice is in line with the NCB philosophy. I quit BBC when I realized the level of crazy and stupid. Sensible opinions seem to get drowned out by the NCB crowd.

          I was so naive before kids. I didn’t know home birth was even a thing people did in the 21st century except for maybe the amish.

          • Bugsy

            …and the Duggars.

          • Cartman36

            Oh snap!!! that is true. I am a HUGE sister wives fan and when Christine (wife # 3) had their last baby she had her first hospital birth and said if she had known how nice hospital birth was she wouldn’t have done homebirths. I was like GO GIRL!

          • Bugsy

            Awww…I always enjoyed Sister Wives!

          • Cartman36

            Thank you! My husband thinks I am crazy but I LOVE Sister Wives!

          • Kazia

            Did you know that one of the older girls (Jill) was pursuing lay midwifery? Now she’s 9 months pregnant and going to have a homebirth with a midwife, almost certainly a CPM. Her mom had mostly hospital births.

          • Bugsy

            Yeah, my mom is addicted to the show (and is currently visiting us, so we’ve been watching it). It is interesting that the mom mainly had hospital births…she definitely seemed to go the OB route as she aged. Did she have any at home with a midwife?

        • Hannah

          Your choice is only valid if it’s the one they’ve chosen for you.

          • Bugsy

            Yep. The pro-midwife mommies didn’t like my suggestion that an OB could be as *caring and wonderful* as a midwife, or the notion that my OB-attended birth last time was an absolutely delightful experience.

        • Cobalt

          Because breastfeeding, which can be a physical, medical, financial, logistical, or emotional nightmare dragging on for months is the “least you can do for your baby”, never mind if the baby goes hungry until ALL possible avenues for breastmilk have been shown to result in malnourishment.

          Spending 24 hours in L&D, however, with access to lifesaving technology at the first sign of trouble, is just too much to ask. You might be offered pain relief, or given an IV, and no mother should have to suffer that just for the sake of a healthy baby.

    • Amy M

      How many of those women are first time mothers? I would expect the more experienced ones to have some inkling that births don’t always go to plan. I mean, sure you can stay home and avoid prenatal care and a birth attendant all you like, but you still can’t control 1)when labor begins, 2)how long it will take 3)what position the baby will be in 4)how the baby will tolerate labor 5) the size of the baby 6)whether or not some complication will arise. All they can really control is the setting, and who does or does not attend. It’s amazing to me how many women don’t seem to realize that.

      • Bugsy

        A lot of them, but there are a surprising number of experienced moms touting the all-natural route. There’s one who is encouraging another mom to do all of her prenatal appts herself – “you can get a book to teach you how to do it.” Then there’s the mom who’s encouraging other moms to decline when the GD test. When I said that, as a mom who was surprised to be diagnosed with GD last time – I wouldn’t dream of it, her response was the canned “Well, have you READ what’s in glucola?”

        It scares the crap out of me how much these bozos are alarming other mommies and spreading lies. They really don’t seem to realize how blessed we are to have modern medicine.

        • The Bofa on the Sofa

          “Well, have you READ what’s in glucola?”

          Let me guess….glucose?

          (the thunk you just heard was my head hitting the desk)

          • demodocus’ spouse

            and nasty orange flavoring

        • Cobalt

          Sometimes, NCB doesn’t have a bad outcome. Everything turns out fine, which reinforces the belief that good results come from NCB (not in spite of it), anecdotes become anecdata, and converts are made. The world needs more skeptics.

          • Who?

            This is the key I think. It went fine for 10 people, why wouldn’t it go fine for me? And it might well. But on the off chance it doesn’t-which off chance is greatly increased by no pre-natal care-well then that’s bad luck/lack of effort/failure to follow correct protocol. And lucky you were at home so you didn’t have to deal with any judgy doctors.

            There have been a couple of posters over the last week or two who ended up in NICU with babies due to be born at home, overwhelmed by the kindness and empathy of NICU staff, having been led to fear and expect judgement and blame.

            These ‘midwives’ are a piece of work.

  • Grooosss. Gross gross gross.

    If these babies had died of malnutrition because their parents forced a vegan diet on them, chances are that they’d be charged with some form of neglect, at the least. When you reach that far in the pregnancy, making stupid, dangerous decisions resulting in death has to be considered child endangerment.

    • Therese

      If these babies had died in the womb because mom was eating an insufficient vegan diet, than no, she wouldn’t be charged in that case either.

      • Indeed, because these are fully ripe, viable fetuses and infants that are not only ready to be born but are either in the process of birth or its immediate aftermath.

        When dumdums insist upon their newborns being vegan and aforementioned newborns inevitably starve to death, the dumdum parents are legally responsible.

        When children die or suffer needlessly from injuries or illness without proper hospital care, the parents are legally responsible.

        When newborns die because they were at home with an inept midwife instead of a hospital with staff and medical equipment on hand, the parents ought to be legally responsible.

        • Therese

          If the parents don’t seek needed medical attention once the child is born, then, yes, they can absolutely be charged. There was a couple charged for letting their 32 week preemie die because they did nothing to seek medical attention. But the equivalent to feeding an infant a vegan diet would be not seeking medical care when your infant needs it. The equivalent to having a homebirth that results in the fetus dying would be eating a crappy diet while pregnant that results in the fetus dying. Basically, if you can legally do it to your body while your not pregnant, you still have the legal right to do it while pregnant.

          • To be redundant; attempting to rear an infant on a vegan diet, to the point of death, is criminal. As is not seeking medical attention when confronted with some other obvious distress unrelated to starvation.

            The baby veganism is an anology, but not the medical neglect.

            Upon labor, it’s a human being with a right not to be born with brain injuries due to lack of oxygen. It is done cooking, ripe, fully formed. If we cannot abort it unless the situation is dire, then it has rights.

            I’m all about pro-choice. I worked in NARAL for years. But when people make selfish decisions that end up permanently harming or killing their children, it pisses me off.

  • Cartman36

    Heartbreaking. Just heartbreaking. I had a c-section due to heart decels and it is so SAD to think that my sweet baby could have died had we not had access to first world medical care. I cannot understand a mother than would gamble with her baby’s life just to avoid a c-section or hospital birth.