I realize that ton has been written on the subject of whether or when to offer a vaginal birth after cesarean section (VBAC). The NIH recently released a consensus statement on VBAC. For readers who are unfamiliar with the subject, women who have previously delivered a baby via c-section have a roughly 1% risk of their uterus rupturing if they are allowed to labor during subsequent deliveries. As uterine rupture is a potentially catastrophic event, elective c-section is offered to all women who have had a previous c-section. Some hospitals go even farther and refuse to deliver vaginally any woman with a history of a previous c-section. The long and short of the matter is, they can't do this. The International Cesarean Awareness Network has a pretty good Q and A for women with a previous cesarean who find themselves wanting to deliver vaginally at a hospital that "won't let them."
The question of whether or not to "offer VBAC" is one about which there seems to be little clarity. The bottom line is that doctors cannot refuse to offer VBAC because VBAC is not intervention. VBAC is what happens when doctors don't intervene. Doctors are free to recommend strongly against VBAC. Certain patients, particularly those whose c-section was due to arrest of labor and those who have vertical scars on their uterus, are bad candidates for VBAC. But VBAC is simply not in your doctor's toolbox of things to offer. Your doctor can either offer of decline to offer things like medications, tests, minor procedures and surgery. He or she can't "offer" a VBAC. VBAC is what happens when the patient declines her doctor's offer of a repeat c-section. I suppose if a woman presents in active labor and declines a repeat c-section, her doctor could say, "I'm sorry, I'm not comfortable managing this condition." They then have the choice of either kicking their patient to the curb or transfering her to the University Hospital, which does offer VBAC's but which is also 90 miles away. But this, of course, is nonsense as it would clearly expose them to more risk than simply managing a vaginal trial of labor.
Bottom line: there is no such thing as a refusal of VBAC.
I was looking back at an old post and happened to read this comment. In response, I wrote the following:
Thanks for the thoughtful response to my post, Parlancheq. You wrote it almost a year ago and I just happened to read it today :) Although I respectfully disagree with what you have to say, the one thing I will respond to is what you say at the end, "It seems docs should err on the side of screening rather than not screening." If this blog has any mission at all in life, it's to convince people that this is absolutely incorrect thinking. When there is no evidence to direct us one way or the other, doctors should err on the side of NOT screening. First do no harm, right? Do we believe this anymore? Every time we screen for something, we are giving ourselves an opportunity to intervene. And every time we intervene, we are giving ourselves an opportunity to harm our patients. First do no harm.
I thought it deserved to be its own post.
I was looking back at an old postand happened to read this comment. In response, I wrote the following:
Thanks for the thoughtful response to my post, Parlancheq. You wrote it almost a year ago and I just happened to read it today :) Although I respectfully disagree with what you have to say, the one thing I will respond to is what you say at the end, "It seems docs should err on the side of screening rather than not screening." If this blog has any mission at all in life, it's to convince people that this is absolutely incorrect thinking. When there is no evidence to direct us one way or the other, doctors should err on the side of NOT screening. First do no harm, right? Do we believe this anymore? Every time we screen for something, we are giving ourselves an opportunity to intervene. And every time we intervene, we are giving ourselves an opportunity to harm our patients. First do no harm.
I thought it deserved to be its own post.
Hopefully, readers of this blog clearly understand that I do not advocate screening for depression. But if you were going to screen your patient, you don't need a PHQ-9 or any other validated tool to do it. All you need is one question, "Are you depressed?" To be depressed is a completely nonspecific term which people use in a variety of different ways. But it is abolutely necessary for the diagnosis of, not just major depressive disorder, but of any sort of clinical disorder that includes depressed mood. Therefore, a denial of feeling depressed, rules out the disorder. An admission of "feeling depressed," however, does not mean that one has clinical depression, it just means you can't rule it out. In the case that the patient happens to answer, "Yes, I do feel depressed," then you need to ask more questions in order to make your assessment. Not that I advocate asking them in the first place; I don't. But if you insist on it, here's a way to make it easier.
BEEP! BEEP! BEEP
My pager had been quite all night. The sinking feeling that happens in the pit of your stomach whenever your pager goes off is typically pretty well ingrained after a week or two of intern year. And it's no wonder. Every time an intern's pager goes off, something bad inevitably happens:
BEEP! BEEP! BEEP -> Dr. Logan, there's a family member at the bedside of the cancer patient in Wonderland. They have questions and need you to come talk to them...(heart palpitations)
BEEP! BEEP! BEEP -> Dr. Logan, there's someone having trouble breathing in Purgatory. You need to talk to them, examine them, figure out what orders you need to write, write those orders and then write a 2-3 page note about them - hopefully finishing all of this before you get paged again. By the way, don't forget to go talk to the family member of that cancer patient when you're done...(heart palpitations)
BEEP! BEEP! BEEP -> Dr. Logan, there's a patient on the 8th floor of the Fog wing having chest pain. You need to go assess what's going on and maybe save her life. And you need to be pretty quick about it because there's still that patient in the ER and that family member waiting for you...(heart palpitations)
BEEP! BEEP! BEEP...(heart palpitations, in the absence of initial stimulus) I pick up the phone and dial a number I don't recognize.
ME: Hi. This is Dr. Logan, returning a page.
VOICE: (snorting and heavy breathing)
ME: Hello? (Dr. Logan wonders if he's just been paged by a wild boar)
VOICE: Hello.
ME: Who is this?
VOICE: (deep throated laughter) I'm surprised that you don't already know.
ME: What's this about?
VOICE: (chains clanking, snorts) We've met once before.
ME: You live under the hospital?
VOICE: (snorts now loader and shorter, more nearly resembling angry barks) I don't live under this hospital, I am this hospital. I am the irate family member in Wonderland; I am the old man who can't breathe in Purgatory; I am the diabetic lady having a heart attack on 8 Fog. It's all ME.
BEEP! BEEP! BEEP
I had set my pager to go off at 6am so I'd be able to get ready for 8am rounds. I recalled the events of the previous night:
1. Calmed a nervous daughter who demanded to know when her father with metastatic esophageal cancer and severe anemia secondary to a bleed at the surgical reanastamosis site was going to have radiation to the lesion in his brain.
2. Admitted a man with a COPD exacerbation.
3. Sent a woman with an ST elevation MI (heart attack) to the cardiac cath lab for emergency revascularization.
After that I had been able to sleep for about 45 minutes and seemed to recall having had the strangest dream. Upon getting home to my own bed in the late morning, I would halfway recall my attending having congratulated me for winning "...The battle."
