By Ted Peskin, M.D.
A recent article in this publication by Jill Raznov commented on the desire of women with previous Cesarean Sections (c-sections) to deliver their subsequent baby vaginally at Hilo Medical Center (HMC).
As an obstetrician/gynecologist who now practices office gynecology only and as Medical Director for Acute Care at Hilo Medical Center, I am pleased to address the policy of the hospital and its affiliated physicians regarding c-section and vaginal births after c-sections (VBAC).
For every OB physician, the safety of the mother and her infant is our highest priority. In my nearly 4000 deliveries, I will never forget the women who ruptured their uterus during labor without any warning signs. In a split second, the mom who trusted me with her welfare and the life of her baby were at risk of dying. Only very fast action on the part of multiple specialists (anesthesiologists, obstetricians, and pediatrics) prevented catastrophe.
The National Institute of Health, a U.S government research agency, states that “unfortunately, there is no reliable way to predict who will have a uterine rupture” and the risk of uterine rupture is 35 times higher in a woman in labor with a previous c-section compared to a woman in labor with no previous c-section. In addition, between 14% and 33% of women with a uterine rupture require an emergency hysterectomy which is a more dangerous operation for the patient than a non-emergency hysterectomy.
In addition, according to the American College of Obstetricians and Gynecologists (ACOG), the risk of the baby dying during labor or in the first month after delivery is 13 times higher with vaginal delivery after c-section as compared to a repeat c-section after a previous c-section.
Because of these risks, both ACOG and the American Society of Anesthesiology recommend that vaginal deliveries only occur in institutions equipped to respond to obstetrical emergencies where the physicians (anesthesiologists and obstetricians) are “immediately available.”
Luckily, my patients who ruptured their uterus were in two Massachusetts hospitals that had round the clock in-hospital physicians in these specialties. If that had not been the case, I believe there is a high probability that some of the mothers and babies might have died or been permanently harmed.
So, why can’t Hilo Medical Center simply have these specialists in the hospital or immediately available around-the-clock 365 days per year? The number of births at HMC is at the crux of this issue.
The two hospitals that I was affiliated with in Massachusetts had 3000 deliveries (an average of 8 deliveries per day) and 5000 deliveries (an average of 13-14 deliveries per day). These numbers were high enough to justify clinically having obstetricians, anesthesiologists, and pediatricians physically present at all times. HMC has about 1200 deliveries per year (an average of 3 deliveries per day). There are several reasons why this lower number of births, coupled with the need to allocate finite resources to programs throughout the hospital, have resulted HMC’s current policy, as well as the desire of practicing OBs to have their patients who desire VBACs deliver in a safer setting on Oahu.
The number of births at HMC is too low to enable the hospital to pay needed specialists to be in the hospital at all times so they would be available if a patient with a previous c-section were in labor (or if a woman in labor enters the emergency room and request a VBAC).
To have these specialists on standby for VBACs is simply not practical or financially feasible giving the periodic nature of the service. It would be extremely expensive for the hospital to pay for these additional services, and the money would have to be taken from other vital services to the people of East Hawaii. Patients suffering from heart attack, stroke, cancer, trauma, and other conditions would have less of a relatively finite pool of resources to help them.
Furthermore, with an already limited number of specialists in our community, this would stretch these doctors beyond capacity. It has been difficult to recruit physicians in any specialty to the Big Island, but requiring these specialties to be physically present during labors averaging eight hours would make recruiting additional doctors even more difficult.
Fortunately, there are other options that allow patients to fulfill their wish to avoid a c-section if at all possible while providing the patient and their infants with the safest possible care.
Kapiolani Medical Center in Honolulu has the volume to justify having these specialists physically present in the hospital every hour of the year. Patients seeing a HMC affiliated obstetrician are told that it would be safer for the patient to spend the last few weeks in Honolulu if they would like to have a vaginal delivery after a previous c-section. The Hilo based obstetricians are happy to provide prenatal care until that time.
In addition, all of the Hilo Medical Center affiliated obstetricians have agreed and have written a policy stating that a patient who shows up in labor with a previous c-section will be allowed to delivery vaginally as long as they understand and accept that that the obstetricians and anesthesiologists cannot promise to be in the hospital and be “immediately available” during the labor, and that this situation could increase the risk to them and their infants if they were to have an unpredictable uterine rupture. The obstetricians understand that this policy might encourage some patients to say that they plan on having a repeat c-section and then request a vaginal delivery when in labor. Despite this possibility, they felt it was important to give the women the ability to choose the vaginal delivery option if the patient truly planned on a repeat c-section and then had a change in circumstances.
Some in East Hawaii may say that it is too inconvenient and expensive to go to Honolulu for a few weeks prior to delivery in order to increase their safety in case they have a ruptured uterus. There is no doubt that living on an island and the expense and emotional toll of an extended stay on another island is a barrier to achieving this higher level of safety.
However, the Ronald McDonald House in Honolulu has helped alleviate the financial burden for women choosing to deliver at Kapiolani by allowing them and their family, including other children, to stay at this house for extended periods of time for $20 per day. In addition, they provide free transportation, and free access to their food pantry. If the Ronald McDonald house is full, they refer patients to the YMCA-Fernhurst which has a similar program, or to the Ohana Hotel which has a special rate for pregnant women needing prolonged stays.
The crucial question for mothers-to-be and their partners is whether they would want to take a chance of the mother or the infant’s death or disability in order to avoid the expense and emotional tool of spending the last few weeks of their pregnancy in Honolulu.
The obstetricians who are affiliated with Hilo Medical Center want to make sure that every pregnant patient and their infant have the safest and best outcome possible. I am hopeful that readers will now better understand the significant risks to the mother and the infant of vaginal delivery, the options available for a successful VBAC, and the multiple factors resulting in our policy.
Ted Peskin, MD is an Obstetrician/Gynecologist and Medical Director for Acute Care at Hilo Medical Center.