Special Circumstance Informed Consent/Informed Refusal ACDM Vaginal Birth After Cesarean
RE: Out of Hospital Labor and Spontaneous Vaginal Birth After Cesarean
Mother: T_____ W_________, gr 3, p. 2, (CS 1 ==> NSVD 1)
Father: ______ _________
This childbearing couple has received extensive information regarding risks and current medical criteria for managing VBAC (vaginal birth after cesarean), including a copy of a 1997 article published in a peer-review journal (Obstetrics and Gynecology) by Dr. Flamm on the controversies surrounding VBAC. Subsequent to full information as contained or documented in this Special Circumstance Informed Consent/Informed Refusal, these parents have declined prophylactic hospitalization & obstetrician care for labor and birth.
The mother is a gravida 3 who is free of pre-existing disease and has completed 37+ weeks of pregnancy without problem or complication. She is carrying a single fetus in a vertex position whose size and weight is average for gestational age. Her first child was born in the hospital by Cesarean Section after a failed induction and two days of labor. Her second birth was a normal spontaneous vaginal delivery of a 9 1/2 # baby boy after Mrs. W_________ labored at home (while attended by a midwife) and transferred to the hospital in advancing labor. There were no treatments or complications for either mother or baby.
The course of this pregnancy has been normal. Mrs. W_________ has declined the routine obstetrical panel of antepartum lab work and genetic screening including ultrasound. CBC performed on _____ and ______ reveals a very slight anemia improved by dietary measures.
After an appropriate informed-consent discussion of all known risks associated with both hospital and home-based maternity care, Mrs. W_________ has requested domiciliary maternity care (when appropriate "under the religious exemptions clause -- Article 3, Section 2063"). It was emphasized that, due to her prior cesarean surgery, her situation does not fall within the generally-accepted definitions of the lowest-risk category of pregnancy. The spontaneous labor and normal vaginal birth without complication for her second pregnancy reduces but does not totally eliminate the risks associated with the current pregnancy. In the presence of full disclosure of risks and absence of any promised outcomes or guarantees, the final decision properly belongs to the parents as current law recognizes the right of a mother to decline to bear an added risk to herself in order to reduce a theoretical or real risk to her fetus or infant (Gabbe 1991 obstetrical text, Legal & Ethical Issues in Perinatalogy, Forced Cesarean Sections, pages 1336 &1337).
These well-informed and responsible parents remain committed to home-based non-interventive midwifery care except in the event of a bona fide emergency or evident pathology of either mother or neonate. Actual intrapartal risk category is low with a low to moderate risk of complications, both in regard to her VBAC status and other risks associated with childbearing.
Historical Background Information on birth attendants,
various birth setting, and other circumstances:
Classically-speaking, maternity services to healthy mothers experiencing normal pregnancies were provided by midwives in the home of the childbearing parents. World-wide the standard for maternity care is still midwifery-based, with approximately 66% of all babies delivered by midwives. The countries with the best pregnancy outcomes have 70% (or more) of all births attended by midwives. Laws in many European jurisdictions require that a midwife be involved in all vaginal births (Germany, England), even when obstetrician care is being rendered. Midwives are recognized as guardians of normal birth and their care is acknowledged to be a direct factor in reducing the rate of Cesarean deliveries (by 40% or more) and other interventions such as episiotomy (Rosenblatt, 1997). In most European countries the majority of births now occur in a clinic, free-standing birth center or hospital under the care of midwives. However, the Netherlands which uses midwifery care as its standard for normal birth has the distinction of having more than 30% domicilairy birth rate (highest among the developed countries) in combination with one of the best records of maternal-infant outcome in Europe.
The customary provision of intrapartum care in the United States has departed quite drastically from these historical and cultural norms. We now have less than 5% of births attended by midwives and the US rates at near bottom in perinatal mortality (23rd out of 25 first-world countries). Beginning in the early decades of the 20th century an active campaign was undertaken to replace all midwives with physicians, to move the location of birth from the home to acute care hospitals and for births to be attended by surgical specialists (obstetricians) whenever possible. This was based on the untested theory that physician-attended births were safer. The obstetrical ideal for parturient women, as expressed by Dr. DeLee in1911, included the use of many different drugs during labor and anesthesia, episiotomy and forceps for delivery.
These interventions were purported to spare both the mother and the baby from the ordeal of a "risky" pathological process which was how childbirth was viewed by the medical profession. There was no scientific basis for this assumption and in fact it has been proven wrong by evidenced-based research. Following the implementation of this policy nationally (between 1910 & 1930), maternal mortality and birth injuries rose in some places by 15% per year and the United States had the third highest maternal mortality in the industrialized world. It was not until the medical discoveries accompanying the Second World War (antibiotics, blood typing, improved anesthetics agents) that the number of maternal deaths and birth injuries began to fall, as these discoveries made it possible to treat the many problems caused by the over-medicalization of healthy mothers with normal pregnancies.
In contemporary times, the routine hospitalization of all childbearing women, attendance of all normal births by obstetricians and a fairly extensive list of regularly used interventions such as confining the laboring mother to bed, prohibiting oral intake of food and water and use of IV fluids instead, lack of privacy, imposition of arbitrary time limits, augmenting labor with drugs, use of narcotic pain medications and anesthetics were never subjected to RCT (randomized controlled trials -- the "Gold Standard" of medical science) or other rigorous scientific scrutiny before becoming "customary". Once they were accorded the status of "usual and customary procedures" in a community, a physician who failed to employ these "customary standards" (even though it was not evidenced-based) was considered to be negligent and could be accused of malpractice.
However, data available from many other sources (national perinatal statistics and scientific research conducted in other jurisdictions such as the Cochrane Data Base, M. Enkins Guide to Effective Care During Pregnancy, publications by M.Tew, and work of Peter Schlenzka, 1999) all fail to confirm the safety or efficacy of these standard obstetrical policies. Reputable research points to the conclusion that the "Usual and Customary" practices of hospital-based obstetrics does not improve the outcome for healthy mothers enjoying normal pregnancies. Some studies postulate that these now common practices actually increase the risk to both mothers and babies. (Tew & Winstra-D). The value of high-tech obstetrics lies primarily in addressing evident ill health (for example maternal heart or kidney disease), complicated pregnancies (bleeding, infection, multiple gestations) and prematurity. Another important contribution of obstetrical medicine is patient preference for physician care and/or her desire to use pain medications during labor and anesthesia for delivery.
Contemporary Obstetrical Practices in the US
for management of VBAC labor and delivery:
Uterine rupture can occur in unincised uteri, either spontaneously or as a complication of oxitocin use (either Pitocin or cervical ripening agents) or following obstetrical manipulations (forceps, etc.) [Gabbe, p. 668] Spontaneous ruptures of this sort are frequently catastrophic.
Post Cesarean pregnancy itself (separate from the issues of labor and delivery) carries a greater risk compared to an unincised uterus. While the over-all incidence of rupture and wound dehiscence (silent, asymptomatic separation of the uterine scar which does not cause major clinical problems) is small (less than 1%), some authors have identified 50% of uterine ruptures to occur before the onset of labor. For that reason, obstetricians have recommend for the past 55 years that elective cesareans be performed several weeks before the end of the pregnancy (37 or 38th week).
The risks associated with elective cesarean before spontaneous onset of labor (SOOL) are increased in iatragentically-caused premature births with respiratory distress syndrome and occasional neonatal mortality. Also the risk of maternal mortality subsequent to Cesarean is 2 to 4 times than vaginal birth. Liliford et al identifies maternal mortality subsequent to vaginal birth (including those with maternal disease and complicated pregnancies) to be 6 per 100,000. Maternal mortality for Cesarean are identified by them as 31 per 100,000. Gabbe's obstetrical text (1991 & 1994) states that expected mortality is much higher, at least l death per 1000 surgeries (100 per 100,000).
For comparison, deaths from automobile accidents (women 14 to 34) is 20 per 100,000 and deaths from breast cancer are 26 per 100,000. For this reason, the American College of Obstetricians and Gynecologists recommended in 1985 that post cesarean mothers labor and give birth vaginally when possible. In recognition of these risks ACOG further liberalized their guidelines in 1988 to further reduce the number of repeat cesareans. However, in October of 1998, those liberalized guidelines were replaced with very stringent guidelines that again typlify VBAC pregnancies and labors to be extremely high risk, citing a rupture rate of approximately 1 out of every 200 VBAC labors. According to one study, rupture can be detected by EFM due to a sudden fall in the unborn baby's heart rate. Perinatal death or permanent damage can usually (but not always) be prevented if emergency cesarean is performed in 17 minutes from first symptoms of rupture (fetal bradycardia).
The new ACOG guidelines generally recommend that VBAC moms be immediately hospitalized for active labor with IV line in place, continuous electronic fetal monitoring, close supervision by L&D staff, immediate availability of an obstetrician (or obstetrical resident) with immediate access to the services of an anesthesiologist, scrub technicians, and continuously available operating room. If this criteria cannot be met, ACOG guidelines recommend that a scheduled elective cesarean be preformed instead of permitting spontaneous labor, due to the risks of uterine rupture when labor occurs in any setting in which a CS cannot be immediately performed.
Risks of Vaginal Birth After Cesarean
The major risk associated with laboring subsequent to Cesarean Section is uterine rupture. Benign dehiscence (asymptomatic separation of uterine scar) is considered to be 1.5 % (Gabbe, p. 668), many of which are only discovered after the birth and which do not influence the course of event or require any treatment. However, in those rare occurrences of catastrophic rupture, the major complication is profound fetal distress resulting in neurological damage (which may be permanent) and includes the possibility of perinatal death. Reported rates of fetal mortality vary with different studies. Fetal risk is defined in Gabbe obstetrical text (1991, p. 668) as no higher than that of patients delivering by elective repeat Cesarean, (which typically 2 to 3%).
Permitting a post-cesarean mother to labor and/or give birth vaginally may also risk her health via hemorrhage subsequent to uterine rupture. It may also risk her future reproductive status due to the necessity to perform an emergency hysterectomy and risk her life due to failure to diagnosis the rupture in a timely manner, unsuccessful treatment or unforeseen complications (anesthetic accidents, reactions to blood transfusions and/or post-operative infection). Gabbes obstetrical text reports a study of 6,258 women who attempted VBAC with 86% success rate (5,356), no maternal mortality and 5 fetal/neonatal deaths (ratio 1 to 1251). All births reported in this series occurred in hospitals.
Benefits of prophylactic hospitalization in a major medical center are immediate access to operative delivery should symptoms of profound fetal distress or other signs of uterine rupture be observed. Maternal benefit of hospitalization for labor and delivery are identified as prophylactic IV fluids with immediate accesses to intravenously administered oxytocin, plasma-expanders and blood transfusions.
Risks of prophylactic hospitalization are increased in the use of interventions (pitocin, narcotics, anesthesia), increased rate of cesarean for various non-VBAC reasons and exposure to the whole spectrum of iatragenically-caused complications and hospital-acquired infections. Also, hospitalization does not prevent the development of many common complications of childbirth unassociated with post-cesarean status. In event of a uterine rupture it may not be possible to save the life of the baby even in the hospital (Informed Consent, Dr. Bruce Flamm)
Known risks associated with hospitalization for normal childbirth include the increased use of oxytocin augmentation of labor resulting in iatragenically induced fetal distress, increased ratio of operative delivery, particularly cesarean section; nosocomial infections of mother and/or babies; medication errors, drug reactions, anesthetic accidents; surgical mistakes such as inadvertently cutting of bladder or bowel, tying off a ureter, surgical laceration of baby or a uterine artery necessitating emergency hysterectomy; neonatal respiratory distress; wound infection; operative or post-operative maternal hemorrhage necessitating blood transfusion with concomitant risk of allergic reaction/shock and exposure to diseases carried by blood products (hepatitis, HIV). This latter category of complications can put fathers, siblings and other family members at risk due to their communicable nature and untreatable status.
Neonatal complications of hospitalization includes acquired neonatal sepsis, routine admission to the NICU for septic work of babies who mother's had an epidural-associated fever in labor (87% of septic work-ups and 86% of antibiotics administration in neonates are post-epidural anesthesia). Mix-up of babies or abduction of a neonate, while rare, are an additional risk associated with hospitalization. Within the last year 25 different strains of Vancomycin-resistant staph has emerged in addition to a potentially deadly mutation of pseudomonas and Group A strep (both common hospital pathogens). Vancomycin-resistant endoccocus (VRE) have been cultured in 100% of the hospitals tested in the greater Bay Area. Maternity patients are particularly at risk for acquiring hospital "super bugs" (new strains of antibiotics-resistant bacteria). Hospital-acquired infections from these antibiotic-resistant pathogen have proved fatal to a small number of mothers and babies.
Hospitalization for normal childbirth does not prevent or reduce the incidence of many common maternal-infant complications such as failure-to-progress, malposition of the fetus, cord accidents, respiratory distress, infection, genetic defects, cerebral palsy or the rare complications of childbearing.
However, more immediate intervention or treatments of some of the conditions listed above is available in acute care hospitals and is statistically associated with improved outcomes in those cases - in some instances reducing neonatal mortality by as much as 3 times over non-intervention or non-medical care.
In spite of being fully informed of the specific risks associated with VBAC labor in locations other than a level three hospital (includes most community hospitals and all OOH birth centers or client homes), a few families decline prophylaxic hospitalization. Typically these mothers hold strong beliefs that the original Cesarean was due to inappropriate hospital interventions or policies which hampered their ability to labor spontaneously such as mandatory IVs, use of continuous EFM, prohibition of oral nourishment, lack of access to shower or tub bath and other non-drug comfort measures (i.e., absence of midwifery-based management of labor) and the imposition of arbitrary time restraints during the labor associated with routine obstetrical management. There is some evidence that the use of pitocin in post-cesarean mothers increases the risk of uterine rupture (one study 15 of 16 post-cesarean rupture had received Pitocin stimulation of labor). Lack of non-drug comfort measures and one-on-one labor support due to staffing shortages increases the likelihood that narcotic pain meds and/or epidural anesthesia will become necessary. Pain medication and use of anesthetics increases the need for pitocin augmentation thus increasing the risk of uterine rupture. Post-cesarean mothers are often very aware of this vicious cycle, which unfortunately, is reinforced by the most recent ACOG guidelines that mandate these very interventions as standard of care.
The dilemma facing post-cesarean families is that there are no risk-free options or perfect solutions. Once the uterus has been incised in the original Cesarean, a permanently difficult situation is created. In order to avoid all risks of late pregnancy uterine rupture, elective repeat Cesarean would have to be performed before 38 weeks. However, both mother and baby are thereby exposed to the risks of unnecessary surgery, prematurity and hospital-acquired infections. Another imperfect solution is for the mother to be immediate hospitalized at the first sign of labor. The longer a mother is in the hospital before she gives birth, the greater the rate of interventions and the lower the rate for spontaneous birth. Early hospitalization exposes her and the baby to the risks associated with medical interventions, increased Cesarean Section rate and hospital acquired infections. To avoid this some non-physician authors writing on the topic of VBAC have recommended that the mother stay at home until the labor is well established and advancing spontaneously at which point she is transport by family car to the hospital for delivery. The imperfection in this plan is that a goodly proportion of significant ruptures occurs either before onset of labor or in the early stages. Except for obstructed labors, statistics suggest that the actual birth itself (delivery) is not any more "risky" than either the pregnancy or first half of labor, and perhaps lessens as full dialation of the cervix relieves the intrauterine pressure on the surgical scar.
The known risks of Cesarean surgery for both mother and baby are statistically equivalent or greater than those of VBAC so efforts to reduce Cesarean surgery through vaginal birth, even if involving "experimental" methods (those not supported by published studies or currently unresearched) appear to have merit. For many women, the imperfect method they have chosen from a spectrum of unperfected options is to labor at home under the care of a midwife and if the labor progresses normally to remain out of the hospital and permit the baby to be born spontaneously at home. If or when labor ceases to be normal and progressive they agree to seek out hospital-based medical care. This is the choice make by [name of family]
Management Plan for this Family is as Follows:
1) Prophylactic hospitalization in the presence of an identified medical complication.
2) Due the potential complexity of a VBAC labor, the presence of second experienced midwife is planned. Parents live within 5-7 minutes of a major medical center and there are no physical barrier to their home nor inclement weather or road conditions that would delay emergency transport. Mrs. __________ will not be exposed to the additional hazards of an oxytocin-augmented labor while she remains out of the hospital.
3) Criteria for domiciliary birth defined as SOOL of a briskly progressive nature, accompanied by progressive dilation of cervix and normal decent of fetal head. Absence of indicators of normalcy will result in intrapartal transfer to hospital.
4) Criteria for elective transfer of care or emergency transport by EMTs are (but not limited to) the following: inadequate forces of labor, non-progressive labor, other standard indications of diminution of fetal or maternal wellbeing, such as antepartal bleeding, neonatal respiratory distress, retained placenta or excessive postpartum bleeding
Parents have agreed to abide by these criteria and precautionary measures.
Prayer requested by parents for: __________________________________________________
Continued normalcy, timely and spontaneous onset of a briskly-progressive labor, normal birth of baby, speedy expulsion of the placenta with no excessive postpartum bleeding
Prayers by practitioner for:
Good outcomes for mother and baby and practitioner guidance regarding management of the situations present during the intrapartum, and wisdom in carrying out caregiver functions
Mother: __________________________________ Date _______________
Father: __________________________________ Date _______________
Midwife: _________________________________ Date _______________
Outcome: Mother delivered at NSVD
at home, after a 9 hr labor
click the Pic to return home