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.

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.