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For the Love of all things Natural

Saturday, March 5, 2016

VBAC in the Face of Denial

When I had my first child in 2011 I imagined a beautiful natural birth. What I got instead was an emergency C-section after an incredibly long and traumatic labor. While it was far from my ideal birth plan, at the time it was a necessary blessing and thankfully the hospital I delivered in made it as good a situation as possible. The day after my surgery, the OB who had performed the C-section stopped in and informed me that she had ensured a solid double closure suture with a low transverse scar, giving me the best chance for a vaginal delivery with my next child (a VBAC or vaginal birth after cesarean).

36 Weeks and Almost Ready to Pop!
During medical school I lost 4 pregnancies in the first trimester, each time immediately after stressful finals. My doctor and I did a full medical workup and could find no medical reason why I hadn't been able to carry the pregnancies, so it was blamed solely on stress and as soon as I graduated I again got pregnant and this time it stuck! Even through a stressful move, camping to wait for our house to be ready, and my board exams, I had a little life inside that was determined to make it. 

When I made it successfully out of the first trimester *sigh* I finally sought out a provider who I wanted to deliver my baby. The small town we moved to only had one hospital and as I soon found out, the hospital has a strict "no planned VBAC" policy. The only way to VBAC there is to show up in active labor, sign AMA (against medical advice) forms and "waive legal rights." I have spoken with a mama who did indeed have a successful VBAC at the hospital and her description of the whole situation made me cringe. Since VBAC is allowed under Oregon licensing for midwives, I sought out a midwife who would agree to allow me to VBAC in the town's only free-standing birth center. See the following for more on midwife license coverage for VBACs:  http://azdhs.gov/documents/licensing/special/midwives/committees/mspac/additional-resources/state-laws-chart-vbac-br-mg.pdf


Since I was so newly graduated and practicing, my income was and is low enough to qualify me for insurance coverage with Oregon Medicaid (Oregon Health Plan). In the past, as soon as you are documented to be pregnant you would be switched from your local CCO (coordinated care organization) to "Open Card" which meant you had a greater choice of providers. As my midwife was not on the local CCO, we immediately submitted my documentation and application for open card status. However, little did I know that Oregon was in the process of re-writing OHP regulations regarding "out of hospital" (OOH) birth which meant there would be an individual review of every open card application for an OOH birth. 

My initial application for open card was initially "pended" citing that I needed to have an OB sign off on the multiple miscarriages I had experienced. I complied readily and the OB gladly signed off on the miscarriages since I was well past the first trimester "danger zone." He also went over the options I mentioned above regarding VBAC or repeat C-section at our local hospital. Since by this time I had done my research thoroughly, my mind was firmly made up in favor of a planned VBAC over C-section for the reasons and statistics I will list at the bottom of this article. Again, my midwife and her staff sent in the documentation of my consult but my card application was still "pended" for a total of 3 months, meanwhile I was waiting impatiently, getting ever more pregnant and nervous about whether the cost of my birth would be covered. 

Finally, at the end of January I received my official "denial" for open card status with VBAC being the primary exclusion. As of January 1st, OHP now followed new Health Evidence Review Commission (HERC) guidelines which stated that OOH VBAC was a firm exclusion for coverage. For the full document see here: http://www.oregon.gov/oha/herc/CoverageGuidances/Planned-out-of-hospital-birth-11-12-15.pdf 

So now I was truly stuck in a hard spot. The closest hospital that supports VBACs is a 90+ minute drive away over a mountain pass which usually still has snow in March, not my ideal idea for a drive during labor. Heading over the hill ahead of time and staying for the few weeks around when I could potentially go into labor was also clearly not an option since it would mean the cost of a hotel, plus leaving my disabled father and 4 year old. I love my midwife and feel very well supported by her and her staff at the birth center. She has a 100% success rate with her mothers who have attempted VBACs under her care and it's close to home. This didn't seem fair! When I found other mothers on a local FB group who were facing a similar situation and complained I was contacted by a journalist for our local NPR station who offered to cover my story (http://ijpr.org/post/denied-vaginal-birth-after-cesarean#stream/0). She also hooked me up with a lawyer who specialized in women's rights in child birth. 

My amazing lawyer truly is an expert. Some of her findings to support my legal challenge include: 

1. ACOG (American Congress of Obstetricians and Gynecologists) not only supports a planned VBAC (also called TOLAC or "trial of labor after cesarean") (http://www.acog.org/Resources-And-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Obstetrics/Vaginal-Birth-After-Previous-Cesarean-Delivery), but also recognizes both hospitals and birth centers as the safest options to birth at (http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Planned-Home-Birth). 

2. It is illegal under federal law for state administered Medicaid to deny a birth center birth that is within the provider's scope of practice (http://www.acog.org/About-ACOG/ACOG-Departments/Government-Relations-and-Outreach/HCRImplementation/HRACMidwives). 

3. The newly implemented HERC guidelines actually self contradict in cases like mine since their 2014 guidelines clearly state that a previous cesarean is no guarantee for coverage for an elective repeat cesarean and recommend a planned VBAC in most cases! (http://www.oregon.gov/oha/herc/CoverageGuidances/Planned-Cesarean-11-13-14.pdf)

The even more confounding thing that has come up in discussion and research is that it seems to be only in the case of "worry regarding uterine rupture during VBAC" that hospitals deny a vaginal birth over concern regarding availability of an "emergency surgery team" to be ready for an emergent C-section should it be needed. 

Here are the statistics regarding this "concern" along with the stats for other situations requiring emergency C-sections:


Maternal mortality is 0.0038% with TOLAC vs 0.0134% with elective repeat C-section.

Uterine rupture risks:
-       With a low transverse scar- 0.2-0.5%, higher with vertical scar
-       Over-all VBAC risk with 1 prior c-section is 0.7%, with >1 prior C-section = 0.9%
-       Combined rupture+ neonatal death rate with 1 prior c-sec in women <42wks = 0.2%

Factors that increase risk of rupture
-       previous infection of scar
o   double closure decreases infection risk
o   cat gut increases infection risk
-       <24 months between prior C-section and VBAC
-       Induction by ANY method increased risk by 50%
-       Placental implantation over scar
-       >42 weeks gestation
-       > 1 prior C-section without VBAC
-       Macrosomia

Other reasons for emergent C-sections include:
-       Placenta accreta
o   Incidence (with no previous cesarean surgeries) of 3.3% with previa present and 0.03% without previa present.
-       Cord prolapse
o   0.1%-0.6%, with breech presentation the risk is slightly over 1%
-       Fetal distress
o   3.1%
-       “Failure to progress”
o   10%


Emergency C-sections obviously happen for more reasons than just uterine rupture (and far more commonly), yet it is only in these cases of concern over uterine rupture during VBAC that hospitals decline to assume the risk and enact planned VBAC bans. Why??? 

This is why I have decided to take a stand. This situation is not supported by medical science, law, or reason. My attorney has filed a formal appeal and request for administrative hearing. I am now 37 weeks and still plan to deliver via VBAC in our local birth center with my midwife. I have started a fundraising campaign to help cover my attorney fees (https://www.gofundme.com/xtmqxsk4). 

This is not just a fight for my birth to be covered, but will hopefully set precedent for other mothers who want (and deserve!) a VBAC and/or coverage for their out-of-hospital birth that is within their provider's scope of practice! Oregon, of all places should be setting the standard for progressive coverage and support of women's rights, not enacting restrictions that put mothers into an intensely stressful situation where they must put their own lives and their babies lives at increased risk to justify some legislative review or hospitals idea of "risk." 


Here are my other reasons justifying my choice of planned VBAC over repeat C-section:


Risks of C-Section to Mother

Most common:
-       Infection
-       Heavy blood loss
-       Blood clot in legs or lungs
-       Nausea, vomiting, severe headache (related to anesthesia and abdominal procedure)
-       Bowel problems such as constipation secondary to ileus
-       Organ injury- i.e. bladder or bowel damage secondary to surgical procedure

Long term risks, which increase with each subsequent C-section:
-       Uterine rupture
-       Placenta previa
-       Placenta accreta, placenta increta, placenta percreta
o   Least to most severe and which may lead to hemorrhage and may require a hysterectomy
-       Increased risk of ectopic pregnancy
-       Reduced fertility4
-       Increased risk of breech presentation in future pregnancies5

Risks of C-Section to Baby

Most common:
-       Injury during delivery
-       Need for NICU care
-       Immature lungs, breathing problems, poor temperature regulation, hypoglycemia
-       Delayed breastfeeding/bonding
-       Increased risk of neonatal death (within the first 28 days of life)
o   1.77 per 1,000 live births for C-section compared to 0.62 per 1,000 live births for vaginal birth3

Long term:
-       Increased risk of asthma2
-       Increased GI dysfunction secondary to altered gut flora6


Update on my birth!

Early labor started on March 18th around 9pm. I alerted my midwife and was able to sleep until 4:30am when active labor started getting intense. I went to the birth center at 6:30am and when she checked I was already 5cm dilated at 80% effaced. I labored for another two hours before my water broke spontaneously. I called my husband who came quickly to the birth center with our son. My mother arrived shortly after. By 9am I was ready to get into the tub as things were getting stronger. I started pushing at 9:35 and at 10:36 she arrived surrounded by my wonderful midwife and her team along with big brother, daddy, and grandma! Our healthy baby girl was 6 lb 7 oz and arrived with no complications and was absolutely perfect. She was placed immediately onto my chest and we waited until the cord stopped pulsating before cutting her free. I delivered the placenta with no complications. I ate lunch two hours later (pizza!) and after 6 hours of rest and recovery at the birth center we were deemed fine and able to leave. We gratefully went home to revel in our beautiful new addition. She has nursed like a champ and has already gained back much of the weight she lost in the day after birth and is doing absolutely beautifully.

I can't believe the night and day difference between my first birth experience and this one. Not only was labor and delivery relatively "easy" but delaying cord clamping allowed her to pink up and recover quickly. The bigger difference though has been in my recovery. After my C-section I was kept at the hospital for three days. That's three days of nurses waking up mama and baby hourly to check vitals, three days of essentially no sleep because in order for baby to stay on my chest I had to be awake, three days of having my every movement monitored and awaiting the dreaded "post C-section poop," three days of not being in my own comfortable home. Then after leaving the hospital it was two weeks of essentially being bed-bound except for diaper changes and bathroom trips. It was stabbing pain every time I thought about moving. It was weeks of pain medication just to be able to stand long enough to change a diaper. I fell into horrible postpartum depression and spent much of those two weeks crying in bed over my beautiful baby. My husband was at a total loss to help me, although he was wonderful about taking care of baby when I couldn't. My mother stayed for over a week to help keep the house running as I was at a total loss. It was six months before I could contract my abdominal muscles without feeling like I was being pulled apart. My belly had no tone and it took years to get anywhere close to my pre-pregnancy shape.

This time? I left the birth center six hours after delivery walking on my own two feet and feeling sore, but absolutely nothing in comparison to the pain I had the first time. I lost some blood, but it was a fraction of the gushing loss I had experienced the first time for days afterwards. I had my first postpartum poop without issue that same day. During labor I was able to move around and choose what positions were most comfortable. Given my history of back surgery this was key as being on my back with legs in stirrups would have been horrible. Instead I was in a tub of warm water and able to push at my own pace and allow my body to open up naturally. I was not drugged and out of it, but felt elated, victorious, and clearly conscious of the beautiful life I brought into the world. That first night I spent in my own bed, with baby on my chest, and actually SLEPT! By the next morning I was able to be up for short periods of time and move about comfortably to nurse in our sun-room surrounded by the beauty of nature. My mother stayed to help for a few days, but within a couple days I was feeling completely able to take back over the household duties. I have been baby wearing often and my body feels totally capable. My belly has already shrunk amazingly fast and I can move without pain! I have had incredibly minimal postpartum emotional changes, which I largely credit to sleep this time around along with feeling comfortable in my body so soon. All in all, this was a night and day difference compared with having a C-section.

I am so amazingly grateful to my midwife for supporting me in having the birth my body was designed for and so thankful for all the support I had in choosing to birth outside of the non-VBAC supportive hospital. Even if I had shown up in active labor and refused a C-section at the hospital, I know it would not have been anything like the beautiful birth I was able to have at the birth center. Instead of a cold medical procedure, my birth was comfortable, supported, and was a true spiritual transformation. After my C-section my husband swore he could never watch me go through birth again, but after this one he is already asking about another one! Pretty sure I'm good with two, but the fact that this one was good enough to want another speaks volumes! So here's my cheer for a successful VBAC!

Update on my OHP appeal hearing: My hearing is scheduled for early May, coincidentally the same day I was planning to go back to work. I will be spending my leave working closely with my lawyer to put together all our arguments, but I think the above story of triumph in the face of denial and the amazing difference in experience is the best argument why hospitals need to stop banning VBACs and Medicaid needs to cover birth center births that are within the provider's scope of practice and not force women into situations where their only locally covered option is a repeat C-section. Please share my story and encourage other mamas to make their voices heard and take a stand for their right to the birth of their choice!

Update on my Appeal 11/27/17
I haven't written in quite a while as, like all legal cases, things have been incredibly slow moving. My original hearing was cancelled by OHP on May 1st, the day before my hearing was scheduled to take place. They dismissed my case stating that, as I was not on the hook financially for my child's birth, that there was "no longer a hearable issue." Even though my whole case was never about the money, but about the ability of OHP to force women into repeat cesarean births when they could have a supported VBAC with a midwife under Oregon and federal law!

Being in this deep I was not about to give up, and with the help of my wonderful attorney, we filed an appeal with the Oregon court of appeals who have finally agreed to hear my case next month, December 14th, 2017. My daughter is 1 1/2 and I finally get my day in court to try and get this ridiculous system changed to benefit all Oregon mothers on Medicaid in allowing them to birth with the provider of their choice and avoid unnecessary and risky surgical procedures.

If you feel compelled to come and show your support, my hearing is scheduled for 1:30pm at the Oregon Court of Appeals, Supreme Court Courtroom, at 1163 State Street in Salem, Oregon. I would love to have a whole crowd of mothers and midwives who stand to benefit from my case. You are the reason I have pursued it this long and will not give up until justice is served!

After all, this is Oregon. This is a state that should be setting the standards in freedom of choice for families in choosing their birth providers, upholding federal mandates to protect this vulnerable population, understanding and supporting the desire to avoid unnecessary and risky surgical procedures, and to birth in a supportive environment!

References










10. C-section for fetal distress: http://www.ncbi.nlm.nih.gov/pubmed/12719676



13. C-section for placenta accrete: http://www.ajog.org/article/S0002-9378(10)01159-2/fulltext#tbl1