Who Speaks for Maria?

The hospitals in Ventura County where I used to admit patients continue their de facto ban on vaginal birth after c/section. There is no appealing to the clinical evidence, ACOG and NIH recommendations or even their sense of fairness. Today I saw a patient whose story must be told.

Maria R. is a Gravida 5, Para 4 hispanic female. Speaking to her via an interpreter today convinces me she is educated and well informed of her birthing options. For you see, she had a c/section in Mexico with her first baby and has had 3 successful VBACs all in Mexico since. I saw her early in pregnancy as a consult and reviewed her options including her right to have a vaginal birth at the hospital of her choice. No one can force her to have surgery. She does not want a c/section. She knows the risks to her are much greater with a repeat c/section that with a vaginal birth. She knows the likelihood of a successful VBAC for her is greater than 90%.

Maria is now 39 weeks. She is schedule for a "unelective" repeat c/section in 6 days. She came in today thinking she might be in early labor. She was concerned about having to have surgery against her wishes but is not the type to raise a stink. My associate, much to her credit, has contacted the hospital and anesthesia department on Maria's behalf and has been told that a planned VBAC is not an option. If she were to arrive at the hospital without time to wheel her into the operating room she would then be "allowed" to deliver vaginally. My associate, who is currently on vacation, is afraid to stand up for this patient's safety and rights because she is aware of my story and the hospital's history of how they deal with conscientious dissenters. Her last labor was so fast she barely made it to the hospital. I told her that she has the right to refuse surgery should she show up too early. She would be a great candidate for a home birth but her family lacks the means and her insurance does not cover that option.

Maria and I spoke for a while during her visit. When she left, my nurse and I shared our feelings. A combination of anger and frustration would best describe them. Why should this woman be forced into such a situation? Clearly, there is no one who can argue on clinical grounds that she is not the ideal VBAC candidate. Clearly it is safer for her to deliver vaginally. Clearly it should be her informed choice. And I wonder, should she suffer a complication from an unnecessary surgery who is responsible? Will hospital administrators, OB and anesthesia committees stand up and say its their fault?

ACOG and other organizations have written much about the ethics of home birthing. Dr. Nicholas Fogelson and I had a letter to the editor published in the August 2011 Green Journal responding to Dr. Chevernak's rigid stance against it. Where do the ethicists stand on this one? Who speaks for Maria? The silence is deafening! Dr. F