For more than 10 years the UC Davis Health System’s Center for Perinatal Medicine and Law, organizationally within the Department of Obstetrics and Gynecology, has conducted a series of grand rounds presentations that focus on current and often controversial clinical, legal, ethical and policy issues in obstetrics and gynecology. These grand rounds periodically incorporate mock legal proceedings, including attorney-client interviews, depositions and judicial hearings, as well as interdisciplinary panels through which students, residents, faculty and practicing health-care professionals from the community gain insights into challenging clinical concerns. The grand rounds in June addressed a particularly current and contentious issue among obstetricians – vaginal birth after cesarean section (VBAC) procedures.
The high rate of cesarean deliveries
Recent medical literature reflects an intense debate about the risks and benefits of offering pregnant women who previously underwent one or more cesarean section procedures the option of a trial of labor (TOL) in subsequent pregnancies. The issue has become increasingly compelling because of the significant increase in women who have previously undergone a cesarean. When first noted in 1965, the national rate of cesarean deliveries was 4.5 percent. By 2008, it had risen to 32.3 percent. A recently published study in the official journal of the American College of Obstetricians and Gynecologists (ACOG) noted that cesarean section has become the most common surgical procedure in the United States, with nearly 1.5 million deliveries each year. The conventional view of "once a cesarean delivery, always a cesarean delivery" set the stage for a vicious cycle of ever-increasing cesarean delivery rates. cesareans disproportionately account for about 50 percent of childbirth-related expenses of hospitalization ($7.8 billion annually), thus making their frequency a national health policy concern as well.
The issue of defensive medical practice
Some observers argue that the exponential increase in cesareans in the United States is attributable to defensive medical practice. The proliferation of large damage awards in "bad baby cases" following complications during labor and delivery has noticeably decreased the threshold for shifting from routine labor and delivery, even in pregnancies not deemed high risk or otherwise problematic. An ACOG poll published earlier this year revealed that 29 percent of its members were performing more cesareans out of fear of lawsuits.
A New York Times article on the phenomenon identified another factor: physician responsiveness to expressed preferences of women. The procedure has become so common that physicians have difficulty convincing patients that VBAC-related risks of uterine rupture have been greatly exaggerated, and that a cesarean delivery is major abdominal surgery that is inadvisable without clear indications that it is medically necessary. Only then do the risks of a cesarean to the woman (infection, blood loss, blood clotting and anesthesia-related risks) and to the baby (injury during delivery, possible NICU admission) warrant this much more invasive and costly approach.
Adherence to such clinical criteria would invalidate performance of a cesarean simply because the patient wishes to deliver on a particular date (a reportedly common request), or in order to accommodate the desire of a visiting relative to see the new baby before returning home.
The clinical data on VBAC
Although a 1980 National Institutes of Health Consensus Conference report declared VBAC a reasonably safe and medically appropriate means of reducing the cesarean section rate, subsequent practice patterns shifted only slightly and briefly.
Widespread fears persisted within the clinical community about the risk of uterine rupture with VBAC and associated liability risks. These fears spread so intractably into the patient population that pregnant women commonly demand a repeat cesarean. A survey of women published in an Australian bioethics journal revealed that their adamant demand is often driven by their perception that VBAC increases risks of uterine rupture during labor.
The position of many respondents could be characterized as "Don’t try to confuse me with the facts, doctor, because I’ve already made up my mind." When asked if their physician had discussed with them the comparative risks and benefits of VBAC versus elective cesarean, many respondents said they preferred to decline such conversation. They indicated a preference instead for psycho-social support for their already firm decision in favor of a repeat cesarean.
Ethical quandaries for the clinician
Demonstrating respect for the principle of individual patient autonomy seemingly requires disclosure of all relevant and significant information about the benefits and risks of any recommended or alternative treatment or procedure that would be within the standard of care for the patient’s medical condition. But what is the clinician’s responsibility if the patient declines the information necessary to make an informed decision about treatment options?
Patient autonomy includes the right of a patient with decisional capacity to refuse information and thereby assert a right to make an uninformed decision about medical care. A clinician may seek to persuade a patient that in such instances ignorance is not bliss, but rather that knowledge is power, and to encourage the patient to consider pertinent information that is necessary for a truly informed judgment. Ultimately, however, the patient may choose to cultivate her ignorance or to cling to a prior decision based upon inadequate or erroneous information.
Shared decision-making, the gold standard of a highly functional physician-patient relationship — strongly recommended when genuine uncertainty about the optimal approach arises — cannot take place when the patient opts out of the process. In such instances, the clinician must decide whether she is willing and able to continue in the care of such a patient.
Restrictive guidelines and institutional policies
A March 2010 NIH expert panel report on VBAC by the Agency for Healthcare Research and Quality concluded that "VBAC is a reasonable and safe choice for the majority of women with prior cesarean. The occurrence of maternal and infant mortality for women with prior cesarean section is not significantly elevated when compared with national rates overall or mortality in childbirth."
Nevertheless, the report notes that many women are unable to seriously consider this otherwise reasonable option because of provider, hospital, insurance or medico-legal factors that mandate repeat cesarean. Such mandates appear to have their genesis in ACOG guidelines from 2004 stating that "VBAC should only be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care." Some ultraconservative interpretations suggest that adherence to this guideline requires not only 24/7 obstetrical coverage but also a neonatal intensive-care unit. Narrow and conservative interpretations of the ACOG guidelines have shaped institutional and practice protocols as though such guidelines set the standard of care.
As a consequence, VBAC is not available in many settings, particularly smaller or rural communities, even for women who might benefit from a trial of labor. A 2006 survey reported that more than half of the women interested in a trial of labor were denied that option due to characteristics of their caregiver, the delivering hospital or – much less frequently – the circumstances of their pregnancy.
Ideally, clinical practice guidelines, institutional policies and protocols, and the custom and practice of most clinicians will closely correlate with the most current and reliable clinical data. The culture of clinical practice will reflect a strong disposition toward showing respect for individual patient values that are reasonably informed by competently and sensitively provided clinical information. In most instances the result will be a transparent and trusting therapeutic dyad that creates a supportive environment for shared decision-making.
Clearly, with respect to VBAC, we have a very long way to go to achieve this ideal.
The need is significant. More than 81 million Americans over age 20 have one or more types of cardiovascular disease such as high blood pressure, coronary heart disease or congestive heart failure. Peripheral vascular disease is estimated to affect up to 10 million Americans. UC Davis Health System is improving cardiovascular health through state-of-the-art patient care, cutting-edge research, education and outreach.