Monday, March 29, 2010

VBAC (Vaginal Birth After Cesarean Section) and Informed Consent

VBACs (Vaginal Birth After Cesarean Sections) have received a great deal of attention in the media recently. Chicago Tribune Article by Julie Deardorff. The issue is whether enough VBACs are attempted or if patients are being adequately informed of the risks and benefits.

AMA code on informed consent states; "The patient's right of self decision can be effectively exercised only if the patient possesses enough information to enable intelligent choices. The patient should make his or her own determinations on treatment. The physician's obligation is to present the medical facts accurately..."

So let's look at some medical facts as presented by ACOG (American Congress of Obstetricians and Gynecologists);
  • What are the risks and benefits associated with VBACs?
"Neither elective repeat cesarean delivery nor VBAC is without risk. Generally, a successful VBAC is associated with shorter maternal hospitalizations, less blood loss and fewer transfusions, fewer infections, and fewer thromboembolic events than cesarean delivery. However, a failed trial of labor may be associated with major maternal complications, such as uterine rupture, hysterectomy, and operative injury, as well as increased maternal infection and the need for transfusion. Neonatal morbidity also is increased with a failed trial of labor, as evidenced by the increased incidence of arterial umbilical cord blood gas pH levels below 7, 5-minute Apgar scores below 7, and infection. However, multiple cesarean deliveries also carry maternal risks, including an increased risk of placenta previa and accreta...
Uterine rupture (incidence less than 1%) has been associated with fetal death, as well as severe neonatal neurologic injury."

For those of us who counsel patients on their treatment options regularly, reciting a laundry list of the risks and benefits is rarely ever the end of discussion. Understanding risk is a complex issue. 1 in 200 chance of uterine rupture with VBAC? How many patients or physicians understand what that means? Is it ever an understandable concept without context?

What provides context is how important the risk is to the patient and the provider. A mother who truly believes in the importance of vaginal delivery may perceive the risk as small. Another, who may have had a long painful labor followed by a cesarean section during her first delivery may feel otherwise. Family, friends and coworkers all help to provide context.

And how about the providers? Perhaps we all agree that an experience with a bad outcome should not taint consent discussions with a patient. But how can we escape the reality of these experiences whether they were as a result of a VBAC or too many cesarean sections? Incorporating these into our counseling while avoiding bias is a delicate balance.

Then there's the media.

"Experts point out that although the attempt (VBAC) carries a risk of uterine rupture, the chance it will happen is relatively low: 0.5 percent. Meanwhile, C-sections carry all the risks of a major surgery. Compared with having a vaginal birth, a woman delivering by C-section experiences more physical problems, longer recovery and more emotional issues on average, studies show. Research also has found babies born by cesarean are less likely to be breastfed and more likely to experience breathing problems at birth and asthma as they get older."

This is a paragraph from the Chicago Tribune article I quoted earlier. I have highlighted two areas comparing the risks of VBACs to repeat cesarean sections. The way the information is presented is neither complete nor true to the spirit of informed consent. Clearly I realize that the media is not held to the same standards. I would also consider irresponsible highlighting the disagreement between a patient and her provider that in this case led to a good outcome. Those outcomes are statistically more common and they should not be represented as an endorsement of one treatment plan over another. And I would have protested as strongly if the only case discussed was of a uterine rupture that led to a baby's injury.

A couple of weeks ago I was giving my son advice on how valuable "time" was and how it was one of the most precious things in life. He looked at me, shook his head and pronouncing each word slowly said, "Oh daddy... you and your legends!"

I think he meant that I should stop blethering.

And so I shall cease my rants and give ACOG the final word:
"After thorough counseling that weighs the individual benefits and risks of VBAC, the ultimate decision to attempt this procedure or undergo a repeat cesarean delivery should be made by the patient and her physician."

Sunday, March 7, 2010

Weight Loss- Channel Beowulf

My son's class has been learning about myths and legends and so our homework has been following a similar theme. Yes! OUR homework. I've always been an enthusiastic proponent of parental participation in children's education but this appears to require committment in par with at least a part-time position. By the time I have researched the subject on Wikipedia so as not to appear foolish and redirected his attention from a Nintendo created product we are both exhausted and ready for bed.

Recently however, thanks to our homework I learned about Beowulf. An important work of poetic literature written in 700AD. It depicts the life and battles of the heroic Beowulf against various monsters and demons. This is a quote from this poem:

"O flower of warriors, beware of that trap.

Choose, dear Beowulf, the better part, eternal rewards. Do not give way to pride.

For a brief while your strength is in bloom but it fades quickly; and soon there will follow

illness or the sword to lay you low, or a sudden fire or surge of water

or jabbing blade or javelin from the air or repellent age.

Your piercing eye will dim and darken; and death will arrive, dear warrior, to sweep you away."

Uplifting it may not be but wonderful advice none the less in any battle involving us and our demons. As you become more self assured and start to lose some weight, you must remain vigilant. There are many forces out there and deep within you ready to pull you down. "O flower of warriors, beware of that trap."

Over the past three posts we’ve tried to look deeper at what makes us not achieve and maintain our goal in weight loss. I hope that some of the examples that I wrote about hit home and gave you some insight into what might derail your efforts. Now knowing what they are, feel prepared and we can start.

Let’s set a realistic goal first. If you’re BMI is between 25-30, our aim would be to lose about a 1lb per week. If the BMI is higher, about 2lbs per week. Your first target date should not be more than 5 weeks away. So you’re looking at 5-10lbs in the next 5 weeks.

1) Dietary intervention: You are going to log in or a similar site everything you eat and you will enter your daily weight, daily.

It is important for you to get in a habit of doing this everyday. If you have eaten too many calories for a day or two, it is not the end of the world or this program. You need to talk to your family, friends or other support group. They will make sure that you stay strong.

2) Physical exercise: Exercise alone is not a good method for weight loss but studies have shown that it is extremely effective in long-term weight management and improved health. Remember, you have looked within yourself and you know why you want to lose weight and what your specific barriers are. Exercise puts a different face to this challenge. You need to practice affirmations that will make it a positive experience. Your mantra should be to say over and over to yourself. "I enjoy exercise" "Exercise makes me feel alive", "I feel better, I breathe better, I look better after I exercise".You can see more on I am not gonna bore you with what you should not say to yourself because I am sure that you are very familiar with those!

3) Behavior modification: What this is based on is that being overweight is the result of having learned incorrect eating and exercise patterns and the good news is that these can be re-learned and modified. The first part involves self monitoring (keeping food diaries and activity records) which you will be doing on

The second part is stimulus control. Some eat to comfort themselves. Is that the case? We need to find what specific things trigger that feeling and find different comforting measures. Do you eat more or lose self control after you drink too much alcohol? Don't worry I'm not gonna suggest you stop drinking altogether but for this to work you have to know how it affects your resolve and eating habits.
100% honesty. That's our contract. Maybe you don't even know everything that is going to try and trip you up. We need to be vigilant.

Finally lets get back to the beginning. Before starting this challenge go to your health care provider and first get a medical clearance. Second, make a demand for help losing weight. Your family, friends and your healthcare provider are the cornerstone of the support you will need.

Let me leave you with another quote and feel free to use it as your war cry;

"I am Ripper... Tearer... Slasher... Gouger. I am the Teeth in the Darkness, the Talons in the Night. Mine is Strength... and Lust... and Power! I AM BEOWULF!"