One of things that really, really perturbs me is the use of rates of VBACs and rates of c-sections as performance measures. I think that these measures might have been well-intentioned but are terribly flawed indicators of maternity care. In short I think that efforts to 'keep down the rate of c-sections', or 'increase the rate of VBACs' are bad policy, for a lot of very good reasons.
1. It places a value judgement on how birth occurs - in short by having a publicly stated goal to reduce the c-section rate or increase the rate of vaginal births after c-sections - it sends a message to moms. That message is "physiological birth is superior to surgical birth" - in short many women get the message that they have failed if they have a c-section or do not attempt/succeed with a VBAC. Birth no longer is about bringing home a healthy baby and a mom who is in the best physical and emotional health as possible - it becomes about how the birth occurred. It's time to realize that a c-section is not a failure and that a vaginal birth is not an accomplishment. A healthy mom and a healthy baby is an accomplishment - as is a process that facilitates that outcome and respects the emotional and physical needs of both mother and baby.
2. The unintended consequences of this focus might be really, really ugly. When the focus shifts to how birth occurs, inevitably there are trade-offs. The trade-off of having a low c-section rate might be an increase in the number of births that are assisted by forceps and vacuum. The trade-off of having a low c-section rate might be a decrease in the rate of inductions after 40 weeks and an increase in the number of still births. The trade-off of having a low c-section rate overall might be an increase in the number of emergent c-sections that occur when delivery with 30 or 20 minutes is critical to avoiding long-term disability. The trade-off of increasing VBACs might be an increase in uterine ruptures. The trade-off having a low c-section rate might mean more 3rd and 4th degree tears. The trade-off of a low c-section rate might be an increase in the rate of severe birth traumas. The trade-off might mean putting the process of how birth occurs ahead of the genuine desires and needs of the patient.
Are these trade-offs ones that we really want to make?
3. These are not indicators that tell us anything meaningful about the quality of care or appropriateness of the care received by maternity patients. By focussing on these measures, and actively seeking to reduce c-section rates or increase the rates of VBACs - we are not measuring what matters or moving closer to achieving the goal of maternity care that is actually better. Effort needs to be made to find the measures that really reflect good quality care and to report on those things.
It's time to quit focussing on reducing the cesarean rate or increasing the rate of VBACs - these measures and goals should be immediately scrapped. Yesterday wouldn't be soon in enough in my opinion.
Mothers and babies deserve better - they deserve quality care that places genuine outcomes that matter ahead of the specific mode of delivery.
Showing posts with label VBAC. Show all posts
Showing posts with label VBAC. Show all posts
Wednesday, April 4, 2012
Thursday, November 24, 2011
Cojocaru versus BC Children and Women's Hospital Goes to the Supreme Court of Canada
Giving birth has risks, giving birth after a previous c-section has additional risks. Vaginal birth after c-section (VBAC) carries with it a 1 in 200 risk of uterine rupture. What this means is that the baby is expelled into the mothers abdominal cavity during labour and deprived of oxygen. If a c-section cannot be performed immediately, there is a danger of permanent brain damage.
This is what happend during Eric Cojocaru's birth at BC Women and Children's hospital in 2001. According to the information in the original judgement and the appeal judgement (found at http://canlii.ca/t/2336k and http://canlii.ca/t/fl1nt ), Eric's mother, Monica, arrived in Canada pregnant and went to an OBGYN in Vancouver. Monica was told by her doctor in her home country that any future deliveries should be done by c-section. Monica told her OBGYN in Vancouver she wanted a c-section. The OBGYN offered Monica a VBAC indicating that it was successful in most cases (70 to 80 percent), and that the risk of uterine rupture was small. Monica, whose first language is not English, believed that she had to go through a trial of labour to get a c-section.
Monica's labour was induced when she was 10 days overdue by way of vaginal insertion of a prostaglandin gel. It is noted in the appeal judgement that the unchallenged evidence was that the Hospital had four operating rooms (“OR”s) but only one anaesthetist and one OR team on duty at any given time throughout the day that Mrs. Cojocaru was induced. Anticipating these conditions, the Hospital had scheduled no caesarean sections for the day, as it would have on a normal day. Rather, the operating room was taking only statim (urgent, emergency) caesarean sections. The undisputed evidence was that the waiting list that day for caesarean sections designated “urgent” was one to two hours long and that they were given priority. A bradycardia was detected at 6:18pm, Monica was assessed at 6:22pm and found to have signs of a partial tearing or rupture of the uterus, an attempt to attach a scalp electrode to the fetus was unsuccessful and a stat c-section was ordered. Monica arrived at the OR at 18:29, the c-section was started at 18:30 and Eric was deliveried at 18:41 (23 minutes after the initial bradycardia was detected). The evidence, unchallenged and uncontradicted, was that the only anaesthetist and OR team at the appellant Hospital were engaged between 18:00 and 18:30 in performing an emergency caesarean section; that the decision to call in a second anaesthetist was for the anaesthetist at the hospital to make; and that, had the on-duty anaesthetist called for them, it would have taken 20 to 30 minutes for a second anaesthetist and OR team to be assembled to perform an emergency caesarean section on Mrs. Cojocaru. It was found that the bradycardia detected at 6:18pm was caused by a uterine rupture and complete placental abruption. In order to avoid brain damage, a baby must be delivered within 10 to 15 minutes of a placental abruption (by 6:28pm and 6:33pm, which due to resource constraints would not have been possible). Eric Cojocaru suffers from a form of cerebral palsy and has many physical disabilities, as well as impairments to his ability to think, learn and develop social skills. The orginal judgement awarded the Cojocarus $4 million dollars and found that there was negligence in regards to "informed consent" and "malpractice".
The decision was reversed on appeal and will be heard by the Supreme Court of Canada.
I am struck that a woman, attempting a VBAC would be induced on a day when the hospital is short-staffed and at risk of being unable to provide timely access to medical care (a c-section within 10 to 15 minutes) should they be needed. There was only 4 ORs and 1 anesthetist on duty that day. A back up anesthetist would take 20 to 30 minutes to arrive. There was a 1 to 2 hour wait for urgent c-sections. How is it that a woman, who was at risk of a uterine rupture (1 in 200) was allowed to be induced and proceed to a Trial of Labour when, should she need a c-section the wait would likely exceed the 10 to 15 minute wait that would avoid brain damage? Does the hospital not have a responsiblity to ensure that such services are available if a known high-risk patient is labouring? Why wasn't a second anesthetist at the hospital on that day, given the prevailing conditions (a full high-risk ward, a 1-2 hour wait for urgent c-sections)? Was the risk of being unable to access timely medical care communicated with the patient at the time the induction was started? Under the circumstances should Monica have been offered a repeat c-section that day instead of a trial of labour?
I wish the Cojocarus the best under the circumstances, and hope that the Supreme Court of Canada will uphold the $4 million award of damages - it seems to me that the system failed to deliver quality care to the Cojocarus and that Eric's injuries were entirely preventable. I will be watching this case with interest.
This is what happend during Eric Cojocaru's birth at BC Women and Children's hospital in 2001. According to the information in the original judgement and the appeal judgement (found at http://canlii.ca/t/2336k and http://canlii.ca/t/fl1nt ), Eric's mother, Monica, arrived in Canada pregnant and went to an OBGYN in Vancouver. Monica was told by her doctor in her home country that any future deliveries should be done by c-section. Monica told her OBGYN in Vancouver she wanted a c-section. The OBGYN offered Monica a VBAC indicating that it was successful in most cases (70 to 80 percent), and that the risk of uterine rupture was small. Monica, whose first language is not English, believed that she had to go through a trial of labour to get a c-section.
Monica's labour was induced when she was 10 days overdue by way of vaginal insertion of a prostaglandin gel. It is noted in the appeal judgement that the unchallenged evidence was that the Hospital had four operating rooms (“OR”s) but only one anaesthetist and one OR team on duty at any given time throughout the day that Mrs. Cojocaru was induced. Anticipating these conditions, the Hospital had scheduled no caesarean sections for the day, as it would have on a normal day. Rather, the operating room was taking only statim (urgent, emergency) caesarean sections. The undisputed evidence was that the waiting list that day for caesarean sections designated “urgent” was one to two hours long and that they were given priority. A bradycardia was detected at 6:18pm, Monica was assessed at 6:22pm and found to have signs of a partial tearing or rupture of the uterus, an attempt to attach a scalp electrode to the fetus was unsuccessful and a stat c-section was ordered. Monica arrived at the OR at 18:29, the c-section was started at 18:30 and Eric was deliveried at 18:41 (23 minutes after the initial bradycardia was detected). The evidence, unchallenged and uncontradicted, was that the only anaesthetist and OR team at the appellant Hospital were engaged between 18:00 and 18:30 in performing an emergency caesarean section; that the decision to call in a second anaesthetist was for the anaesthetist at the hospital to make; and that, had the on-duty anaesthetist called for them, it would have taken 20 to 30 minutes for a second anaesthetist and OR team to be assembled to perform an emergency caesarean section on Mrs. Cojocaru. It was found that the bradycardia detected at 6:18pm was caused by a uterine rupture and complete placental abruption. In order to avoid brain damage, a baby must be delivered within 10 to 15 minutes of a placental abruption (by 6:28pm and 6:33pm, which due to resource constraints would not have been possible). Eric Cojocaru suffers from a form of cerebral palsy and has many physical disabilities, as well as impairments to his ability to think, learn and develop social skills. The orginal judgement awarded the Cojocarus $4 million dollars and found that there was negligence in regards to "informed consent" and "malpractice".
The decision was reversed on appeal and will be heard by the Supreme Court of Canada.
I am struck that a woman, attempting a VBAC would be induced on a day when the hospital is short-staffed and at risk of being unable to provide timely access to medical care (a c-section within 10 to 15 minutes) should they be needed. There was only 4 ORs and 1 anesthetist on duty that day. A back up anesthetist would take 20 to 30 minutes to arrive. There was a 1 to 2 hour wait for urgent c-sections. How is it that a woman, who was at risk of a uterine rupture (1 in 200) was allowed to be induced and proceed to a Trial of Labour when, should she need a c-section the wait would likely exceed the 10 to 15 minute wait that would avoid brain damage? Does the hospital not have a responsiblity to ensure that such services are available if a known high-risk patient is labouring? Why wasn't a second anesthetist at the hospital on that day, given the prevailing conditions (a full high-risk ward, a 1-2 hour wait for urgent c-sections)? Was the risk of being unable to access timely medical care communicated with the patient at the time the induction was started? Under the circumstances should Monica have been offered a repeat c-section that day instead of a trial of labour?
I wish the Cojocarus the best under the circumstances, and hope that the Supreme Court of Canada will uphold the $4 million award of damages - it seems to me that the system failed to deliver quality care to the Cojocarus and that Eric's injuries were entirely preventable. I will be watching this case with interest.
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