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SATURDAY January 24, 2004 - Subscribe - Contact Us - Rate Card Valley&State Backpage O&E Sports Archives Classifieds Faith&Beliefs Obituaries Revels December 16, 2003 Birthing option to disappear By Susan DeRosia Ashland Daily Tidings For women who had their first baby by Caesarean section the first time and would like to try a vaginal birth the second time, the window of opportunity is closing. According to Dr. Bryan Sohl, director of Maternal Fetal Medicine at Rogue Valley Medical Center, on Monday morning the medical executive committee, representing the joint medical staffs of Rogue Valley Medical Center and Providence Medical Center voted to implement a moratorium on vaginal birth after Caesarean section. For Dr. Linda Harris, "It's tragic." Harris is a practicing obstetrician and gynecologist. "It's very sad because it's a very reasonable medical alternative that has been taken out of our reach by attorneys and lawsuits," she said. Harris said that since she came to the Rogue Valley 18 years ago, she and other doctors have offered the option for vaginal birth after Caesarean section (VBAC) to patients who fit the criteria for the procedure and with very few exceptions, the outcomes were successful deliveries. A swinging pendulum That option hasn't always been available. The history of offering the option to mothers who had an initial Caesarean section has swung back and forth during the past 90 years. In a report given by Bryan Sohl to the Oregon section of the American College of Obstetricians and Gynecologists (ACOG) in April 2002, he outlined both the rules and the exceptions about the procedure through the last century: In 1916, Dr. Edwin B. Cragin, coined the phrase, "Once a Caesarean, always a Caesarean." Cragin admonished physicians that "no matter how carefully a uterine incision is sutured, we can never be certain that the cicatrized uterine wall will stand a subsequent rupture." Nevertheless, Cragin went on to describe a patient who reported to him that she successfully delivered three children following her Caesarean section. While Cragin's dictum became the standard of care, many physicians continued to offer VBACs with many reports of success. In 1981, the National Institutes of Health issued a report stating that by selecting patients who met certain criteria, a trial of vaginal birth should be permitted in hospitals with appropriate facilities. In 1982, ACOG came up with a set of guidelines for the procedure which included that the previous C-section incision had been "low transverse" (horizontally across the lower part of the uterus). In the 1980s the pendulum swung the other way, in some parts of the country, insurance companies insisted that a mother attempt a VBAC. Here in the Rogue Valley, until recently, the decision has been left up to the woman and her physician. Sohl explains that through the '80s and '90s, obstetricians have learned to distinguish which mothers were the better candidates for VBAC. The standard was that a trial of labor could be attempted if the patient met the conditions and the hospital offered the capability of beginning an emergency C-section within 30 minutes of the decision to operate. 'Litigous society' "Traditionally, the 30-minute rule was what we went by," said Sohl. "But we currently live in a highly litigious society, and recent lawsuits have changed all that. Now, if you want malpractice insurance you can't offer or participate in a VBAC unless you can guarantee that a C-section is immediately available. That means an operating room, an obstetrician and an anesthesiologist, an OR crew, including a scrub tech and a circulating nurse. All available immediately." A trial of labor could last hours, and keeping an operating room open means that no other procedures could be scheduled during that time. For anesthesiologist Dan Fiddler of RVMC, a trip in October to the American Society of Anesthesiology Meeting brought the sobering news that more and more hospitals and medical centers are discontinuing VBACs. Fiddler said that during the conference several different presentations were made and hours of discussions were dedicated to the topic. The resolution came back to the language in the ACOG guidelines. Where it had been previously understood that the hospital needed to have the team "readily" available, it changed to "immediately" available. He describes what the switch from "readily" available to "immediately" available means. "The option to do a C-section has to be available not just near the time of delivery, but any time during the labor. That presents a very different position," he said. "You would have to shut down a room and cancel elective surgeries, call the patients and say, sorry, you can't have your surgery today. Call the surgeon and cancel heart surgeries, lung surgeries. You'd have to choose one room to keep it empty during the entire day." Adding fuel to the fire is the fact that since 1999, when tort reform was repealed by voters in Oregon, the cost of malpractice insurance in Oregon has skyrocketed. Sohl, who is a a specialist in high-risk pregnancies, cites figures. "My insurance premium has gone from $25,000 a year to $98,000. A general OB/gyn's insurance might go from $28,000 a year to $62,000," he said. The decision to discontinue to perform VBACs was implemented earlier this year in both Mearle West Hospital in Klamath Falls and at Sutter Coast Hospital in Crescent City, Calif. DailyTidings.com Home Page Valley&State | Backpage | O&E | Sports | Archives | Weather | Classifieds Columnists | Faith&Beliefs | Obituaries | Revels | Subscribe | Contact Us Copyright 2004 Ashland Daily Tidings and Ottaway Newspapers All Rights Reserved Site Search: .:Advertisements:. 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