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Comment and Controversy

VBAC: Let’s end the semantic games

September 2004 · Vol. 16, No. 9
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To the editor:

Although I appreciated the April article on VBAC by Drs. Thomas D. Shipp, MD, and John T. Repke, MD (“Preserving the VBAC alternative: 8 pearls”), it failed to address the real reason VBAC is declining—at least in smaller hospitals.

At my rural hospital, both my liability insurer and the facility’s insurer decided it was no longer acceptable for the anesthesiologist and operating room team to be available within 15 minutes. Instead, they must remain physically “in house” along with the pediatrician and obstetrician during the entire duration of the patient’s labor.

This did not present a problem for me, as I have been in the habit of staying in the hospital for these patients all along, but it essentially ended the ability of the hospital to offer this service. A small rural hospital such as mine does not have sufficient numbers of personnel to ask them to sit in the hospital for 8 to 12 hours—sometimes longer—for what may turn out to be a successful vaginal delivery.

While the change in policy has certainly not impacted my lifestyle negatively (it is always easier to come in and do a repeat cesarean than to sit with a patient through a long trial of labor), the people it certainly hurts are the women in my community. These women now are asked to make a choice between travel to the nearest large urban center (1-1/2 to 2 hours away by private vehicle), an unwanted major surgery, or a home birth with one of our local lay midwives, who are happy to labor these patients in birthing centers and private homes an hour away from emergency cesarean services.

In essence, we have taken 1 obstetric emergency (uterine rupture) and singled it out for a different standard of care. The same requirements for in-house personnel are not in place for the rest of our obstetric patients, who may come in with cord prolapse, abruption, severe hemorrhage, or fetal distress at any time—all of which mandate emergency cesarean.

If we as a profession want all the women of the United States to receive high-quality obstetric care, we should ask the American College of Obstetricians and Gynecologists to support the 30-minute “decision-to-incision” rule and stop playing semantic games with phrases such as “readily available” and “immediately available.” Our counterparts in the legal profession and insurance industry have used these phrases to insist on an impossible standard of obstetric care for rural America, effectively driving many patients into the arms of rural lay midwives, sometimes with disastrous consequences.


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