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."

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 dailyburn.com 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 meisalus.com. 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 dailyburn.com

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!"

Weight Loss- Marathon Style

A few years ago I ran my first marathon. It was the second time I had signed up. The first time I didn’t make it to the starting line as my son was born about a month before. If you read one of my previous blogs (“life after baby” August 2009), you’ll know why!


My first marathon was in Cincinnati in 2002. “The Flying Pig Marathon”. The irony is too obvious to comment on.

I arrived at the starting line scared but excited. This was going to be the real deal. The chip around my ankle documented, both officially and electronically, the transition from being a couch potato to … something else. I hesitate to use the words “runner” or “athlete” as they may conjure up images that are not quite aligned with reality.

I crossed the finish line that day with tears in my eyes and on such an incredible emotional high that it is difficult for me not to recommend running and racing as tools for personal growth if not for physical health.

I told you about my emotions at the start and the finish lines but it’s not as easy or pretty to talk about the 26.2 miles in between. Suffice it to say that at various points during the race the desire to stop was overwhelming. As I would put one foot in front of the other I could almost hear the angelic and the evil Eden on my shoulders. “Your family will still love you. Just Stop!” “It’s too hot anyway. No one will blame you if you stop” “Maybe there is a medical emergency around here and they need your expertise”.

But alas no calls for emergency pap smears and no one having a baby by the side of the road.

The reasons for my perseverance had little to do with my strength of character and more with having heard it all before. Even though on that day I did not heed the calls to quit, I had done so on many other occasions during my training runs. I knew what to expect.

Your many attempts over the years to lose weight were your training runs. It is important for you to know and acknowledge what it was that made you stop. I know that you have a great deal of insight into what is going on in your head when it comes to this issue.

Is your self esteem in tatters? Do you sometimes feel that you intentionally sabotage some of the efforts because you're afraid? Does the mountain to climb seem too high and so you give it a good effort but just as things heat up you trip yourself up? Do you do just enough to get people off your back for a while? Not trying to preach but you and I know that you don't believe that it will succeed so why put yourself through all of this.

What is it that makes you put road blocks on the way? What are you afraid of? You know what they are and you must acknowledge them before we can move on.

This is race day and we’re on the starting line. You’re pumped, excited, scared.

You know what comes next. Be prepared.

We’ll celebrate at the finish line.



Go to meisalus.com and click on inspirational videos. Under weight loss, watch and listen to meditations and affirmations. Also try the relaxation videos and don’t forget to use headphones.

Weight Loss Motivation: Look In The Mirror And Say "Damn You's A Sexy Person!"

I know that there are many of you out there who have given up on losing weight. You know what I’m talking about. That feeling deep inside that tells you that you will always be overweight. Once in a while you may make an attempt to change. You say things like “I’m really gonna try” or “I’ll do my best. That’s all I can do”. It doesn't sound like you believe.


That’s one part of your life that you don’t like to talk about because it reminds you of that sense of defeat. Or may be you talk about it everyday! You are constantly on a diet. People roll their eyes up when they hear about your latest attempt and they don’t even hide it from you anymore.

You are successful at work, have wonderful friends and a loving family but cannot conquer your inner self.

What motivates you to want to lose weight? Is it to be healthier? Is it to look good? Appear more attractive to potential partners? Maybe your family members are nagging you? Does your doctor bring it up in passing and try to guilt you into eating healthier and going to the gym?

I think the greatest motivation is to look in the mirror one day, not at the shape of your body but deep into your own eyes. Knowing that you have control over your mind and your body. After achieving what was seemingly insurmountable, you will feel like you can take on the world. No matter what it throws at you.

Motivation refers to the psychological forces or energies that impel a person towards a specific goal. Everything that we have mentioned so far falls under the category of extrinsic motivation. What that means is that we start to restrict our calories and physical exercise because we want to achieve weight loss and everything that we think will come with it, and not because we are particularly fond of eating healthier or going to the gym.

That’s a great way to start but as we move through this journey, we will explore ways to incorporate tools to achieve intrinsic motivation. We hope to be in a place that we derive satisfaction and enjoyment inherent in healthy living habits.

I am inviting you to start believing again.

I would like to introduce you to a recently started internet service. Someone described it once as a personal spa for the mind! At this time we will use it for its meditation and affirmation tools. Go to meisalus.com and click on inspirational videos. Under the weight loss tab watch and listen to some of the featured videos. Listen with headphones for full effect. Keep yourself motivated daily.

Remember! Until next time keep recording what you eat. It’s a crucial aspect of self monitoring.

"Lose Weight The Easy Way" and next week "Get Rich Quick, Doing Nothing"

The hunger center in my brain wasn’t very active when I was a child. It didn’t need to be. I gave it everything it wanted and more. Way more. It would only be time to leave the dinner table when the stomach pain overtook the desire to consume more food.
This along with an innate dislike of too much physical activity led me down an inevitable path which was to be known as the chubby one throughout my childhood. I know, the story is sad and you are probably trying to hold back tears but let them flow because there is more. Even now as I am in my early forties, kind relatives remind me at every opportunity of my childhood fondness for all things edible.

Any lesser man would have been left with a life long sensitivity towards his weight. But not me. No sir.

I have however, purely for professional growth had the opportunity to study and observe various weight loss measures. I have seen some amazing success stories that have proven the most reasonable approach to be the right one.

This approach is based on consuming fewer calories than you expend which is an elaborate way of saying eating less than you burn off. This is GUARANTEED! to cause weight loss. I wish that what I just said was as profound as I tried to make it sound. The importance of my statement is not that it offers a new way to lose weight but its promise to be an equal opportunity method. No matter who you are if you consume less than you expend, you must and will lose weight.

Our task for today is to find out as much about ourselves as possible;

First lets see who is at risk for complications of being overweight and obesity and needs to consider weight loss. Go to BMI Calculator and by inputing your height and weight calculate your Body Mass Index (BMI). A BMI of 18.5-24.9 is considered normal. If your BMI is less than 18.5 you are considered underweight. The following are the various stages of being overweight and and their corresponding BMIs and risks of medical complications such as type2 diabetes, high blood pressure and heart disease;

Overweight: BMI 25.0-29.9, Increased Risk

Obesity(Class I): BMI 30.0-34.9, High Risk

Moderate Obesity(Class II): 35.0-39.9, Very High Risk

Extreme Obesity(Class III): >40.0, Extremely High Risk

Realizing that you are overweight or obese is not going to be the best news that you've had today but burying your head in the sand is not the solution either. Recognizing the task at hand is the first step towards resolving it.

Second, are you ready to get started today?

Are you ready to tackle this issue once and for all? Why do you want to lose weight? What are the things that make it hard for you to start? Can you commit to 15-30 min a day to this process?

Third, we need a very clear idea of what we are eating before we can think about modifying it. There are online calorie counting sites available with smartphone applications. The one that I like is dailyburn.com.
Sometimes just realizing how many calories you are ingesting is enough to start the process of modification. Before we talk again you must become religious about tracking how many calories you are eating. The site has thousands of food item entries including ones from restaurants. You must be careful as we tend to underestimate our portion sizes. This time, stay true to this endeavor and you may be surprised at the results.


We will base our approach on the American Gastroenterological Association Medical Position on Obesity. You will need a medical evaluation before we can proceed from this point. This may include history taking, physical examination and possible lab tests which may elicit obesity related health risks. You must notify your medical provider of your intention to embark on a dieting regimen involving calorie restriction and increased physical activity.

I saw an ad for a smoking cessation aid that said "never quit quitting" and something similar needs to be our moto. Despite the title of this post, this journey will be hard and at times you will falter. It doesn't mean that your body is immune to this way of life. It means that we regroup and start again. Not in six months, or next new year's day but tomorrow or in a week.

Over the next couple posts I will try to go in a little more detail about the different aspects of this approach. Feel free to comment and even help us come up with a slogan or a name.

Mammograms, Evidence Based Medicine, Media, Politics,...

In 2002 the researchers of the WHI (Women's Health Initiative) held a press conference to announce to the world the results of their study. This was before any of their peers had a chance to review their results. They told us that they had prematurely halted the study on Hormone Replacement Therapy (HRT) because they had found a significant increase in the risk of heart disease, breast cancer and stroke in the treatment group.
The radio, TV and the internet were ablaze with outraged women that felt betrayed by their physicians who had obviously given them these poisonous pills for years. Many of my patients called our office to inform us that they were stopping their HRT. More than a few however called back a couple of months later to tell me that they were restarting them as life was unbearable with constant hot flushes, night sweats and mood swings.
Fast forward a few years and now these wonderful and informative studies have had a chance to be peer reviewed and a consensus has emerged.
There is no increased risk of the conditions mentioned above for about the first five years after menopause starts. The recommendation now is to only prescribe HRT to alleviate menopausal symptoms and at the lowest dose and for the shortest period of time (usually three to five years). These guidelines for some reason did not grab any headlines. If only we could convince a celebrity to say you could have wonderful sex, all day long if you take HRT according to these recommendations.
It appears that the history is repeating itself. The U.S Preventive Services Task Force (USPSTF) has recently issued its recommendations for screening for breast cancer. You cannot escape the headlines on TV, radio and newspapers. Blogs are also of course full of opinions on the matter. The fact that the American Cancer Society, American College of Obstetricians and Gynecologists and surprisingly! American Society of Radiologists have come out against these recommendations has only added fuel to the fire.
The major changes to the current practice are;

1. For women aged 40-49 individualize decision to begin biennial (every two years) screening according to the patient's context and values (family history, other risk factors, patient's desire, ...)
2. For women aged 50-74 screen every two years.

Again, as was the case with the WHI study the USPSTF have done a great job in studying the merits, risks and benefits of a very common screening program. Where this effort has failed, through no fault of its own is that it never had a chance to be appropriately peer reviewed and a consensus to be reached. This should have been done before the media had a chance to make a mockery of it and the Congress to feel obliged to step in.
A screening program must meet the following criteria;

1. The disease in question should constitute a significant public health problem, meaning that it is a common condition with significant morbidity and mortality.
2. The disease should have a readily available treatment with a potential for cure that increases with early detection.
3. The test for the disease must be capable of detecting a high proportion of disease in its preclinical state, be safe to administer, be reasonable in cost, lead to demonstrated improved health outcomes, be widely available, as must the interventions that follow a positive result.

Adequacy of a screening test should not be based on anecdotal evidence or questionable expert opinions. Everyone can remember an uncle or a grandfather that lived to be ninety despite smoking a pack a day. It doesn't make smoking safe. This brings me to my favorite Hippocrates quote;
"There are in fact two things, science and opinion the former begets knowledge, the latter ignorance."
My patients have started asking me about these new recommendations and for now I'm telling them that I'll wait for the dust to settle and for knowledge to overcome ignorance.

How Can I Get Pregnant?...NOW!

The glint in the husband’s eyes is unmistakable as I explain the frequency with which the couple needs to have sex to increase the likelihood of getting pregnant. My patient on the other hand looks a little more skeptical. It is as though she wants to make sure this is not the result of some male conspiracy or that her spouse didn’t call me before the appointment to arrange for this advice!

For numerous patients, planning a pregnancy is a conscious decision that usually leads to behavior and lifestyle modifications. It is however unlike most other conscious decisions in our lives in that we have less control over when it may happen.

“Finish college at 21. Take a year out and travel before graduate school. Get married at 26. Get stabilized at work and married life for one to two years. Get pregnant around August so can have baby in Spring and not be pregnant when it is too hot outside!” This is how many of us try to plan our lives and for the most part we manage to stick with the agenda until it comes to the last item on the list. This lack of control can lead to anxiety and feelings that something must be wrong.

The scenario can be a familiar one. The first month is all very exciting. The couple have sex as they are advised. They both try to delay doing the home pregnancy test until at least an hour after she would have expected her period to come. Most however can’t even wait that long. They start a day or two before. Squinting their eyes as they look closer at the test strip for any faint positive signs. Then they reassure each other that they tested too early. I bet one or both of them later goes and retrieves the test strip from the garbage can just to make sure. The disappointment is clear when her period starts.

By the third month, the excitement of having sex prescribed by your doctor is all but gone. Instead, having sex is about achieving results. It is about ovulation kits, temperature spikes and the consistency of cervical mucus. All of which are, no doubt, very well known aphrodisiacs!

Anxious thoughts and insecurities begin to creep in. She feels less of a woman and him less of a man. “Maybe you need to relax. You’re too stressed.” “Maybe you need to take this more seriously". "What if something’s wrong?"

Most pregnancies happen during the first six months of trying to get pregnant. Overall, after 12 months of unprotected sex, approximately 85 percent of couples will become pregnant. Over the next 36 months, approximately 50 percent of remaining couples will go on to conceive spontaneously. This entire group is considered to have “normal fertility”. The approximately 10% that are remaining may need evaluation for decreased fertility.

Having this knowledge doesn’t necessarily make dealing with disappointments any easier. It is important for a couple to sit down before they start and discuss their approach and their goals. Having a strong foundation built on communication and mutual support will certainly help. It is important to include your healthcare provider in your discussions. He or she can make sure that you are in optimal physical and emotional health before starting on this very exciting journey.