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Hospital may permit more vaginal birth after cesarean deliveries

STORY BY MICHELLE GENZ (Week of May 13, 2021)
Portrait of Dr. James Presley of Florida Woman Care of Indian River County on Friday, May 7.

Dr. James Presley’s Army training included an important skill – how to guide a woman through having a baby vaginally after a prior cesarean section.

In his 40 years as an obstetrician, Presley estimates he has delivered as many as 200 babies in the practice known VBAC – vaginal birth after cesarean.

But the last deliveries by VBAC at the former Indian River Medical Center – apart from a very few deemed medically necessary – took place in 2007, state records show.

Now, Presley’s wish to deliver another baby by VBAC before his retirement next year may come true.

Monday evening, Cleveland Clinic Indian River issued a statement that appears to lift the virtual ban on VBACs. “Cleveland Clinic Indian River Hospital, Martin North Hospital and Tradition Hospital have the resources to perform VBACs for patients if it is clinically appropriate, if the patient meets criteria, and it is agreed to by the physician and patient.”

A policy statement from earlier in the day read that the hospital “currently does not provide VBACs unless clinically necessary for the safety of the patient and baby.”

Asked if the difference in terminology – “clinically appropriate” instead of “clinically necessary” – reflected a change in policy, spokesman Scott Samples said no, that the evening statement was an attempt to “clarify” the hospital’s position.

“It is definitely a chance in policy,” said Presley, adding that he would recognize a change if anyone would, as vice chairman of the department. “I applaud it. I’m glad they’re finally changing it.”

Only a week ago, a Cleveland Clinic physician told an OB patient – who happens to be a doctor – that there were no VBACs at Indian River.

“There are no VBACs, zero,” Presley said in an interview last Friday.

Though hospital officials refused to acknowledge it, the subject of allowing VBACs was on the agenda of an April meeting that included Presley and obstetricians employed by the hospital. Presley came away optimistic that change might be in the offing.

As officials parse policy, pregnant women with prior C-sections wanting a more natural delivery with their new baby are forced to contemplate a drive of nearly an hour to Holmes Regional Medical Center in Melbourne, or to Lawnwood Regional Medical Center in Fort Pierce, a half-hour away.

Presley has an arrangement with Lawnwood that allows him to see his patients right up until delivery, when they go through labor and delivery with whoever is on call at Lawnwood. Presley sends their records in advance.

It is hardly an optimal situation. “You’ve got an unmonitored baby” on those drives north or south, said Presley. There are risks to the laboring mother as well, in the rare event the prior C-section scar tears.

Until now, Cleveland Clinic Indian River Hospital has seemed OK with turning away pregnant women who have had C-sections but want to deliver vaginally, even though groups like the American College of Obstetricians and Gynecologists have urged physicians to spell out to women their choices in methods of birth.

Conversations about VBACs have been swirling since April, when Cleveland Clinic Indian River’s president was quoted in a Vero Beach 32963 article saying he supported VBACs when possible, and that patients were evaluated for them “on a case-by-case basis.”

If so, the hospital has turned all of them turned them all down – case by case – at least through 2019, according to records kept by the state’s Agency for Health Care Administration, or AHCA. They show the last VBACs in Vero in 2007, though hospital officials say there was one in 2020.

Presley has spoken with leadership in the mother-baby wing – Megan McFall, director of women’s health, and Mary Volsky, nurse manager. Both, he said, have signaled support for allowing VBACs.

When Presley spoke to his department in April on the matter of resuming VBACs at Indian River, the response was generally positive, he said. 

“I knew I wasn’t going to get anywhere with the old staff at the hospital, but when Cleveland Clinic came in, with a new administration, I thought hopefully we’ll get some traction on this,” said Presley.

That traction got off to a slow start. He spoke a year and a half ago with Cleveland Clinic Indian River’s chief medical officer, David Peter, as well as the head of anesthesiology about reinstating VBACs. They listened, Presley said, but his proposal “just died.”

Today, the receptive attitude Presley says he has encountered may be due to their recent successful effort to reduce low-risk C-section rates.

Those rates, in first-time mothers with the baby in the right position to deliver, dropped by 10 percent in 2020, though the rate appears to have risen since then, according to provisional data.

Hospitals faced new pressure to lower C-section rates when the Joint Commission, the national hospital accreditation organization, in 2019 said it would start flagging hospitals on its public-facing website if their low-risk C-section rates were over 30 percent. Indian River’s was 31 percent. With effort and training, McFall and her team brought that number down to 21 percent.

The overall C-section rate remains high, though. While VBACs are only a small percentage of that, they could chip away at the hospital’s 35.8-percent overall C-section rate so far in 2021. 

Presley says he and his fellow obstetricians at the hospital still need to review and possibly revise the old protocols that he says have not been updated since VBACs were last performed.

It would then be up to administrators to arrange for adequate coverage by anesthesiologists, he said. American College of Obstetricians and Gynecologists guidelines say facilities must be able to provide an emergency C-section “within an appropriate period of time, given the increased risk of uterine rupture in this setting.”

Uterine rupture is a life-threatening complication to mother and baby, but it is rare, occurring once in 200 VBACs on average.

Presley has never had a patient experience uterine rupture, and says he knows of none at the hospital since he started delivering babies here in the mid-1990s.

A VBAC – if the mother qualifies – typically carries lower risk than a scheduled C-section, and has a raft of benefits, including shorter recovery time, as well as lower risk of blood loss, infection and postpartum depression.

For the baby, a vaginal delivery can prepare the lungs to switch from being filled with fluid to filling with air. It can also impart added immunity by passing on beneficial bacteria present in the mother’s birth canal.

All those benefits are listed on Cleveland Clinic’s main website in an article by Dr. Rebecca Starck, an OB-Gyn who is president of one of the system’s Ohio hospitals.

“We encourage most women to consider and try a vaginal birth after a cesarean section,” wrote Starck.

Better yet, birth coaches like doulas are helping to bring down C-section rates, studies have shown.

“My passion is making sure their first birth is an educated one, and that a C-section results only from a true need,” said Erica Arsenault, owner of The Rising, a doula service that recently opened in downtown Vero. “We have to remind everybody: ‘I’m the boss of my birth.’”

“We’ve had a lot of women coming to our space that have had C-sections and they’re pregnant with their second or third children and their providers are saying they cannot have a vaginal birth,” said Arsenault. “They’re saying, ‘Is there any way around this?’ It’s like they’re ping-ponging between these options, then they get pigeonholed with a C-section.”

Becky Carraway, a Vero certified nursing assistant, had her third child by a VBA2C, shorthand for vaginal birth after two C-sections. She gave birth at Holmes in Melbourne, in what she described as a “quick and uncomplicated labor.”

“My doctor was absolutely amazing,” she said. “She sat in my room doing her paperwork so she wouldn’t miss my birth.”

It was a very different experience from the birth of her second child at Indian River.

After less than an hour of labor, Carraway pulled into the hospital parking lot already fully dilated. The baby’s head was down in the birth canal, where it needed to be for delivery. But because Carraway had had a C-section with her first baby, hospital protocol required her to have another C-section.

“The nurse/midwife was so mad at the situation,” Carraway recalled. “She said, ‘If I would have known you were going to stroll in here at 10 centimeters, I would have told you to lean the seats back and I would have delivered him in your car.”

Andrea Berry, CEO of the county’s Healthy Start Collaborative, refused to have her own options limited in her second pregnancy in 2013. She had a home birth after a futile search for a hospital willing to let her have a trial of labor after a traumatic C-section with her first baby.

She is hoping that Cleveland Clinic not only allows VBACs here but uses its renowned expertise to help guide women through the complicated decision process.

“It would be really great if Cleveland Clinic has a way to walk women through the risks and how to decide to do this, instead of losing women to different hospitals, different providers, or birth at home,” said Berry.