A 31 year-old Gravida 6 Para 5 (6 pregnancies, 5 births) at 40 weeks gestation arrived at her local hospital with ruptured membranes and uterine contractions every 3-5 minutes. On exam by the nurse, the mother was 5 cms dilated, 75 percent effaced, cephalic presentation at -2 station. The amniotic fluid was clear and the fetal heart tone tracing was Category I (normal). She denied any significant health history or major surgeries, including prior cesarean births.
While the nurse was completing the assessment, the unit secretary located the patient’s prenatal records and found a letter discharging the patient from the practice. The reason for the discharge was that she had a prior cesarean birth and was planning a vaginal birth after cesarean (VBAC) and the provider does not offer trial of labor after cesarean (TOLACs) or VBAC services as an option. The local hospital also does not offer TOLAC/VBAC services due to hospital size and provider/operating room team availability.
The nurse then asked the mother again if she had ever had a cesarean birth in the past. Initially, she remained quiet. But after a time, she reported that she did have a cesarean birth with her second child because the baby was breech (buttocks or feet first). Her three subsequent births had been normal, uncomplicated vaginal births. The patient stated that she did not want a repeat cesarean birth. The on-call obstetrician was contacted and updated on the situation. The obstetrician requested that the nursing staff have the patient sign a refusal to permit cesarean birth.
The nurse informed the patient and her husband that the doctor was not currently in-house and that refusing a cesarean might be dangerous as a uterine rupture could occur during labor. The patient stated that she understood and still did not want a cesarean birth. Both she and her husband agreed to sign any forms required for her to refuse the repeat cesarean birth and proceed with TOLAC. The patient and her husband also made it clear that a cesarean birth would be an acceptable option should complications arise during the labor that might jeopardize the health and well-being of the mother or the baby. The patient signed the forms for the refusal to permit medical treatment. The obstetrical provider was called when she was 8 cm dilated, 80 percent effaced and -1 station. Shortly after the provider arrived she had a normal spontaneous, vaginal birth of a healthy baby girl.
Perhaps the most striking element in this case is that the mother felt she had to hide her obstetrical history from her care team. From the details provided in the case, the mother did so out of concern for her well-being as well as that of her unborn baby. She had a supportive partner and was willing to consider a cesarean should it become medically necessary but wanted to have a TOLAC. Entering the clinical data from the case into the VBAC calculator for use at the time of admission, and assuming a BMI of 35 and no hypertensive disease of pregnancy, the patient had a predicted chance of a VBAC of between 90 and 95 percent (depending on maternal ethnicity). She was thus an excellent candidate for a TOLAC with a high likelihood of a successful VBAC. The high likelihood of success is based, in part, on her cervical dilatation at the time of admission. However, had the clinician run the VBAC calculator designed for use during the antenatal period, she still would have been an excellent candidate for a TOLAC with a predicted chance of VBAC of between 84 and 91 percent.
Given that the patient was a good candidate for TOLAC, both in the clinic and at the time of admission, perhaps a better alternative to discharging her from the practice would be to apply the recommendations from the ACOG Practice Bulletin on Vaginal Birth after Cesarean for women planning to give birth in smaller, lower resource facilities. The document states the following:
“When resources for emergency cesarean delivery are not available, ACOG recommends that obstetricians or other obstetric care providers and patients considering TOLAC discuss the hospital’s resources and availability of obstetric, pediatric, anesthesiology, and operating room staffs.”
“Respect for patient autonomy also dictates that even if a center does not offer TOLAC, such a policy cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery.”
Since the patient decided that transfer to a tertiary care center was not the best option for her, the hospital did the right thing by engaging her in a discussion of the risks of giving birth at that particular facility and determining when a cesarean would be an acceptable option. However, had the clinic and hospital policies been built with the guidelines in mind, the woman likely would not have been discharged from the practice and likely would not have felt the need to conceal her obstetrical history.
Not allowing women to choose how they will labor and give birth serves to impair the patient-provider relationship which may result in care avoidance (such as leaving against medical advice [AMA]) or lying to the provider to hide her history, each with potentially catastrophic consequences. In the CHPSO database, women often left AMA when the hospital insisted on a cesarean delivery.
Similarly, there could have been a catastrophic outcome as a result of this mother hiding her history. With the care team assuming that they were caring for a low-risk, multiparous patient, she may not have had continuous fetal monitoring to allow for detection of critical changes in the fetal heart rate often seen with a uterine rupture. The timely response to such changes are critical for avoiding a potentially catastrophic outcome for mother, baby, or both.
In recent years we have seen obstetrical providers and hospitals alike come under fire when women are denied their autonomy in care planning and decision making with regard to childbirth. Recently, a woman in Staten Island filed a lawsuit alleging that she was forced to have a cesarean birth with her third child. The hospital in question had a policy in place that allows providers to override maternal refusal of treatment. However, the policy would appear to be in conflict with the ACOG recommendations regarding a woman’s right to refuse medically recommended treatment. Citing reasons including prognostic uncertainty and women choosing not to seek care due to the undermining of the patient-physician relationship, this committee opinion states that “Pregnancy does not lessen or limit the requirement to obtain informed consent or to honor a pregnant woman’s refusal of recommended treatment.” In fact, in an article addressing the rights of pregnant women, Minkoff and Paltrow (2004) argue that “…stripping mothers of their authority in this regard will be the sundering of the relationship between women and the health care system, an eventuality to be feared by all who cherish the well-being of mothers and children.”
Women giving birth in small, low resources facilities should still have the same right to informed, autonomous decision making that women have in larger, higher resource facilities. The difference is that the informed consent process must include a discussion of the risks associated with that choice which she would not encounter should she choose to/be able to transfer her care. According to Minkoff and Paltrow (2004) informed consent and maternal empowerment regarding birth choices must be at the cornerstone of obstetrical care because “…the best protection for a fetus lies in the protection of the rights of the individual best positioned and most highly motivated to defend its interests: an informed and empowered mother.”