Looking for info about VBACs and AMA

[egoldber]

AMA, as in "against medical advice". Sorry, this post is a little long.

While I am not pregnant yet, DH and I want to start trying for #2 this year. Since I had a C section with Sarah, I have been thinking and weighing whether or not to do a VBAC (vaginal birth after cesarean) or ERCS (elective repeat C section). I have been doing a lot of reading about this topic. One of my problems with a LOT of what I have read is that they describe C sections SO negatively and my C section experience was VERY positive. The doctor and nurses were great, very warm and understanding, I had a great bonding experience in the hospital, my recovery was VERY fast with very little pain.

Anyway, I recently had my yearly exam, so I was asking the OB a lot of questions about VBAC. To her credit, she was very straightforward about her practice's policies. They will "support" VBAC, but their policy is that if you haven't gone into labor spontaneously by 39 weeks they want to do a ERCS.

I asked what if I REALLY wanted to wait to go into labor on my own, and she sort of reluctantly said they MIGHT wait for 40 weeks, but that they NEVER let ANYONE go longer than 41 weeks due to increased infant morbidity after 41 weeks. I straight out asked her if this was their policy because of insurance issues since there is ALWAYS some risk with ANY labor and delivery. She virtually admitted that their policy was due to their insurance and if I was adamant they would have to document all over my chart that I was doing things AMA.

So I guess my question is, if I do decide to wait and have that documented as AMA in my chart, is my insurance going to cover me? My "bill" for Sarah's delivery was WELL over $10,000 (including everything and also Sarah's bills) and that is not something I would want to pay out of pocket!

Of course, this could all be moot. But if I want to change OBs then I would want to start looking and researching now. I really do like my OBs, they are very nice, and I am not sure that changing OBs would really help since from what I have read, my OBs policies sound pretty standard with what most OBs are doing these days. And while I know many people do home VBACs, that is really not for me. The chance of uterine rupture in my situation is around .5% (1 in 200), and the statistician in me would call that "infrequent" but not "unlikely".

Any thoughts or insights would be appreciated.

Thanks!

[flagger]

Let me disect this a little bit as an independent observer.

>While I am not pregnant yet

Concentrate on getting pregnant first.

>One of my problems with a LOT of what I have read is
>that they describe C sections SO negatively and my C section
>experience was VERY positive. The doctor and nurses were
>great, very warm and understanding, I had a great bonding
>experience in the hospital, my recovery was VERY fast with
>very little pain.

Maybe you should stop reading so much if you had such a good experience the first time.

>They will "support" VBAC, but their policy is that if you
>haven't gone into labor spontaneously by 39 weeks they want
>to do a ERCS.

Again you are not even pregnant yet, and you are worrying about something 39 weeks in the future?

>So I guess my question is, if I do decide to wait and have
>that documented as AMA in my chart, is my insurance going to
>cover me? My "bill" for Sarah's delivery was WELL over
>$10,000 (including everything and also Sarah's bills) and
>that is not something I would want to pay out of pocket!

Well the baby would be coming whether it cost $25,000 or $5,000. I personally think the finances would be the furthest from your mind at the moment of truth.

>Of course, this could all be moot. But if I want to change
>OBs then I would want to start looking and researching now.
>I really do like my OBs, they are very nice, and I am not
>sure that changing OBs would really help since from what I
>have read, my OBs policies sound pretty standard with what
>most OBs are doing these days.

If you are very happy with the OB's why change and add
more stress in your life when you aren't even pregnant?

>The chance of uterine rupture in my situation is around .5%
>(1 in 200), and the statistician in me would call that
>"infrequent" but not "unlikely".

The chance of us having a child with Down Syndrome is higher because of the mother's age at time of delivery too. We refused several of the tests because we want this child so much. The worry and the stress before the Level II US was bad enough.

From someone who doesn't know you from Eve and the fact that you asked for thoughts, my thought is to STOP READING! Put down the keyboard. There is nothing like worrying about events that will never happen and being only stuck with worry in the end.

[mama2be]

Beth,

I don't know the answers to your questions...but...

I think the parents place board has a whole board on vaginal birth after c-Section. I would go check and pull it up and post the site BUT I for some reason crash my computer everytime I go on their boards...let me know if you can not find it and I'll pull it up. I've never been on it BUT remember the topic over in the right hand column I think....

I'm sure someone here will know what to tell you, but thought if you didn't know about that board you might find it helpful.

[ddmarsh]

Hi - I am having my 4th section on Tueday, the only one I have had that has been scheduled. I am with a new OB but my last one had told me that the risk of rupture did not rise significantly until after 3 sections, which is why I labored fully with each of my other 3 (they all ended up sections for different reasons). My new OB has stated that he does not typically allow VBACs after only 1 section - I'm not sure if the statistical information has changed since I had my last child (he is 4) or whether this OB is more conservative. There was a great book out called " Vaginal Birth After Cesarean" (I'm pretty sure I have the title correct) but I don't know how recently it has been updated to reflect more recent research. At any rate, for me after 3 it was out of the question this time but if I were in your situation I would look more fully into it and make my determination from there.

BTW, I had a doula with my last birth b/c their literature indicated a greater chance of success with VBACs with the presence of one. It didn't work that way for me but it may be worth considering for yourself.

Good luck -
Debbie
(panicking now that I have less than 48 hours left to being mom to 4 :))

[KathyO]

Hi Beth -

I wish I could be more helpful (the only VBAC candidate I know ended up c-sectioning the second time due to lack of progress in labour, which had nothing to do with her c-section history), but another statistic you might want to check out and throw into your mix is the odds of the baby coming a little earlier the second time. If (as I understand) the odds of early labour are increased on second children, you might feel better about taking the chance on "early" or "right on time".

Would your current OB consider inducing labour rather than ERCS if the agreed-upon deadline (whatever it is) arrives? Sometimes getting the waters ruptured is all that it takes; or even (undignified but true) a fleet enema.

I disagree on the question of "reading too much" - for some of us, excessive knowledge does only contribute to the mental churn... but for others (including myself), knowledge is power!!! And since the good OBs book up very rapidly (I lucked onto mine by getting in practically at the moment of conception!), now IS the time to do the research on whether to change and to whom, rather than once the ball is rolling.

Cheers,

KathyO

P.S. - DH and I are in exactly the same space where you are, second-child wise. Funny, how it goes. We got "lucky" the very first time the last time around; now it's been (egads!) THREE WHOLE MONTHS and I'm fussing that something must be WRONG!!! :P

[egoldber]

Neve, I have looked at the VBAC board on ParentsPlace. Unfortunately, my post sort of got lost in the shuffle there. I will try again later. But it seems like almost all of those women end up getting talked into a repeat C by their OB or do a home VBAC.

I guess my question is more about AMA. If I stick with these OBs, and want to do a VBAC, then I may very well end up having to do a VBAC AMA. I am OK with that, but not if my insurance won't pay for it in that case. That thought had never even occured to me until I saw a post on another thread about AMA.

If I need to find another OB, I would rather do it now than wait until I am already pregnant and "on the clock".

Thanks,

[egoldber]

Thanks Kathy! My OBs do not induce at all with VBACs due to the increased risk of rupture that comes with induction. I would also be a little reluctant to be ruptured since that puts you on the "24 hour clock" to deliver.

I may be worrying for nothing, because I had Sarah at 36 1/2 weeks (ruptured early, failed to progress beyond 1 cm within 24 hours, even on maximum Pitocin). And my mom had all 4 of us between 1 and 3 weeks early. So I am as likely a candidate as anybody to go early.

I am also the kind of person who needs the time and space to think and chew on these things. And as you say, finding a good OB is NOT an easy thing to do. And I also worry if getting pregnant will be so "easy" the next time. The first time, after two months of "not preventing" we ended up pregnant. For the next time, we are plannig around DH's travel schedule. If our time frame "slips" (YIKES!) more than two months, it will be a real hardship at work for him, so we would then likely have to delay trying again for a few months. Talk about pressure! :) :)

[egoldber]

Wow! Good luck with #4!

And you are right, another reason I feel the need to do a VBAC this time is that if I have a third (and we are seriously considering it), after 2 sections it would be virtually impossible for me to VBAC.

Not that you aren't really busy with other things right now, but I am curious if all your secitons were similar in terms of recovery time. As I said, mine was very "easy" but I have heard that susequent sections are not always as easy.

Thanks!

[mspacman2]

Have you asked your insurance company whether they would pay for an AMA procedure?

[Rachels]

You can probably guess what my position on this is going to be. 40 weeks is an AVERAGE. Most babies are born somewhere between 38 and 42 weeks, and both extremes are both safe and normal. This is the only country in the world where we don't allow women to enter labor spontaneously after 40 weeks, and, as I've said before, we're shamefully far down the worldwide list in terms of good outcomes for mothers and babies.

My thought is that birth is so sacred and wonderful, regardless of how it happens, that the issue really isn't only quality of experience. I think good surgical birth experiences are possible. My concern is for what is safest for you and your baby. Surgery carries vastly more risks than vaginal birth. Elective cesareans are done or recommended many times because there is a very small risk of uterine rupture after a previous cesarean. You have to weigh that and decide what you want. For me, it would be worth it to try everything I could to avoid a repeat cesarean, because the risks that go with choosing surgery-- for both mothers and babies-- are MUCH higher percentage-wise than the risk of rupture.

No doctor is ever going to say to a mother, "We want to do an unnecessary cesarean." ALL surgical births are going to be presented as necessary. But the reality is that 25% of births or more in this country are done by c-section, and there is absolutely no medical justification for that. Every single country with lower morbidity rates has a cesarean rate of 10% or less, and a 10% rate is the MAXIMUM recommended by the World Health Organization. What we do here is driven more by litigation than research, unfortunately. There is no research anywhere which suggests that elective surgery is safer than allowing a healthy pregnancy to continue past 39 weeks.

If you want to take a look at some of the literature on this, check out Henci Goer's book *Obstetric Myths vs Research Realities*. She summarizes dozens of studies, but also lists all the references together so you can easily go check them out for yourself if you'd prefer. Her work is very comprehensive.

I don't blame you at all for thinking about this now. While people do change providers mid-stream, it's hard, and more stress than you need. Better to look around now if you decide VBAC options are important to you.

-Rachel
Mom to Abigail Rose
5/18/02

[Rachels]

Beth, forgot to mention that if you find a VBAC-supportive doctor, it won't be AMA. Same is true of midwives, who typically have much higher VBAC rates and often practice in hospitals (if that's where you would feel safest). You could avoid the whole AMA thing that way.

-Rachel
Mom to Abigail Rose
5/18/02

[mama2be]

I am familiar with AMAs in the ER and they are just a generic form and just know staff always said, "Let 'em sign it if they want to go...they're insurance will probably not pay for their visit"...so I mention the insurance thing based on hearing that a good 100 times a day....:)....so I never saw a "denial" form etc...

I wonder if you emailed Julie directly (the one who responded about AMA having actully worked for an insurance company) if she could shed a better light on it.

But I was also thinking any contract you are ever presented with you can alter and initital, and if you discuss this with the OB ahead of time (your concern about insurance) she'd probably let you do that somehow, or even know the loop hole around it. She just wants to cover her derrierre it's not like she doesn't want your insurance to take care of your bill. So maybe her AMA statement is more of a consent to save her vs. a true "against medical advice" form....does that make sense??? And if her form is not like that maybe you two can have a meeting of the minds and make up something that is in both of your best interest. Also she'd be soemone who knows first hand if she has ever had trouble with insurance companies based on the signing of one (keep in mind she wants that insurance mula too)...

I know you know this already so I don't even have to say it...BUT you are of course VERY VERY VERY wise to stay near the keyboard, research and figure out how to pull off what you want!!! And it is of course not ever to early to start that process...And if I had to pay some $25,000 or whatever for a birth and was insured it would not be the furthest thing from MY mind...yikes...that's a lot of money all over a signiture on a piece of paper...Anyway I know you know that but had to give my 2cents...

Please keep me posted I'd be curious to know how this turns out...again i suspect the MD can also help you with the loop holes here. It sounds like you liked her. Also patient relations at Fairfax might be another way to go, they would know if people have had problems with AMA forms vs payment. If you call their main number and ask for "patient relations" they might also be a good source of info.

UGHHHH insurance!!!! and it is only getting worse!!!!

[sweetbasil]

Beth,
I know how you feel...I carried DS 2 weeks late and was induced, to find out the cord was wrapped around him and I ended up with a C-section after laboring all day. My mom had 2 sections, so it was really all I knew, and wasn't a devastating thing for me...but once DS was born, I knew I'd like to at least TRY for a VBAC next time. So we've decided that we'll let the pregnancy progress and if I'm not dilating or effacing when the time comes, I'll go ahead and have a c-section. I've heard that scheduled sections are much easier than having one after a day of induced labor, as mommy's body isn't exhausted prior to surgery. Like you, my recovery was quick, and DS getting tangled was probably what kept him from coming out on his own, both of which help our odds.

Also I've read that the direction of your uterine incision (which, you probably know, is different from the scar on our stomachs) plays a big role in the success rate of a VBAC- I wonder if presenting your personal info on the uterine cut to insurance would help your case any?

Good luck! :)

[darebear]

I agree that location of the uterine incision does play a big part. I am dealing with that now. I had a c-section with DS, he was 3 days late, but he ended up at 10 lb. 1 oz. and 23 in. We moved recently and the first ob I went to said definately another c-section since chances are the next one would be big and he would not let me deliver anything over 9 without a section. so he would have to induce early and he will not induce since I already had a previous section. I went to another doctor a couple of weeks ago and he is waiting to get my records from my OB in Florida to see where the cut was and then he said we can discuss it. So I am waiting. I do not want another section because my recovery was AWFUL!!! My incision opened and then I had an infection and ended up back in the hospital 4 weeks later.

Allison

[ddmarsh]

Beth - In answer to your question above I personally found the first section to be the worst. I think I have felt that just knowing that you have to get yourself up and moving sooner rather than later really helps alot. I labored with each one and then had a section, so perhaps this time with no labor it will be a bit easier.

I too am a research/reading nut, so I completely understand your need to gather all of the information now. I hope you can make it work :).

Debbie

[suribear]

Beth, i think you are wise to look around now. i found a wonderful practice with two wonderful midwives and a doc. the hospital is not our local one, which doesn't do vbacs currently.

i did have a negative c/s experience so i was motivated to try vbac, plus i want to avoid having major surgery. from what i have read (which is a lot :)) the risk of rupture goes up mainly with inductions, prostaglandin in particular. i wouldn't feel comfortable using them, even if i wasn't vbac-ing.

btw, i found out about this midwife/ob practice through the ICAN mailing list. i don't remember how i joined, but it should be on the net.

if you go with a vbac friendly provider, ama should not be an issue. if you really want to vbac, imo, it's worthwhile finding a provider who is truly supportive. as you know, there are definitely benefits to waiting until the baby is ready to come out :) do go back to the parentplace group, too, and try reposting there!

good luck!
Kris

[jubilee]

Beth, I am so sorry to bring up this can of worms! I did not work in claims analysis (where they decide on whether to pay a claim or not) so I don't have all the answers on this issue... and this info probably changes from insurance company to insurance company anyway. Two things I am aware of about going against medical advice:
1. Your doctor will probably have you sign a waiver, protecting them from malpractice in the event something awful happens.
2. Your insurance will ONLY know that you went against medical advice if your doctor or hospital tells them. Insurance companies, althought they have the right to your medical records, don't get them on routine visits. They do get them on surgeries, and maybe other major proceedures, to check for medical necessity. (I was in surgical preauth division at Blue Cross, but didn't handle OB issues.)
So... if your doctor is warning you that he/she will make an issue of the VBAC, and already is saying it's "against medical advice", it's likely they will have you sign a malpractice waiver (if such waiver exists in your state) and might raise a stink with the insurance. It might be worth calling around and finding out if an OB in your area does support VBAC. Your birthing experience is important, so maybe a change of doctor will give you the options you want. But at least ask your current OB what ramafications there might be if you do VBAC. HTH,

[KM]

Regardless of what anyone on this board advises, you must find out what your specific insurer says about coverage for an AMA procedure. My guess is that the AMA designation is really for malpractice protection rather than insurance coverage, but your insurer will tell you for certain. As you said, the dollars involved here are large...you'd hate to say 'the people on the message boards said it would be OK', Im sure you realize the only certain answer can come from the insurer.

That being said, let me offer that i had a WONDERFUL second cSection experience (first was after full day of labor, baby was face up, cord wrapped around neck and over 9 pounds). When discussing options for second baby, my doctor did admit practices are changing quite rapidly due to insurance pressure. As little as a few years ago i would have been encouraged to do a trial of labor on the second baby. Now they enourage ERCS for certain profiles. I guess they have identified that certain circumstances are more likely to end in repeat C after trial of labor, and for an insurer, its cheaper to go straight to the surgery rather than all day labor followed by surgery. This isnt the way it should be, but the almighty dollar rules in the insurance world.

Some examples my doctor posed...if first baby was breech, they wouldnt push ERCS on second baby, because this is a circumstance that is no more or less likely the second time around. If first baby was delivered to a younger woman (say 18 or 19) who planned on having 5 more kids, they might encourage VBAC because that many C's would be dangerous. Im in my 30s, only plan on having the two kids, and would likely end up with a very large baby again (head circumference was 95% percentile). The decision was entirely up to me (no threat of AMA designation), but i chose the repeat C route. I respect everyones choice, this was just the right one for me.

As for the experience, both my C's were great (which i think has lots to do with the hospital staff). Because there is no labor with the ERCS recovery is much easier (the analogy used was its the difference between being hit by a truck and then having major surgery compared to just having major surgery without the truck!!)

There were other factors that tipped the scales for us, so do your research and trust your intuition (unlike other posters, i think you are very smart for starting your research early instead of waiting til the last moment) I know what you mean about all the numbers involved...Im an actuary and believe me I did a lot of weighing of the figures thrown my way (25% of first babies are C...if youve had a C on first baby you are 50% likely to C again...but if you fall into a certain niche that second C rate can be anywhere from 25% for things like breech presentation to 80% for things like very large babies and small pelvis. Given that i was 80% likely to go down that road again, we scheduled the C)

Good luck!

[darebear]

KM- was your second baby big also? My DS was born 10.1 and 23 in also with 95% head circumference. I have been told by my ob/gyn that chances are the next will big also.

Allison

[KM]

Im not sure comparison is fair b/c csection was scheduled (10 days before expected due date) so no telling what size would have been if waited til labor commenced. First baby was 7 days early and 95th percentile on head, 90th percentile on weight and length. 2nd baby, at 10 days early was 8lbs 5 oz, so still quite big size and i believe was 75th percentile on all measures (weight, length, head).

Like you, I was told this is a trait that tends to repeat.

Also, i see from your previous post you had a relocation...this was also a factor in our decision. We had relocated and had no one we felt comfortable to call at 2am to watch the todller if i went into labor (no family close by, no really close friends other than coworkers who we wouldnt ask to take a day off of work, didnt live in the same suburbs as us, etc) so the ability to schedule in advance was a bonus for us. Drop baby #1 at daycare, report for scheduled delivery. It made it much easier. (while convenience is NOT the reason to schedule a C section, it was really a bonus for us)

[Shirale]

This whole thread is so interesting...I also had a C for Amira, after 24 hrs of labor (after my water broke at home)and she was 2 weeks late, I had meconium in the water, and it pitocin only made my blood pressure go crazy (I had Pre-eclmapsia)....and I am not quite thinking about trying for #2 yet, but am curious as to the options. (I like to research as well!) My Ob said that she is definitly in favor of VBAC, but I am not sure what I personally feel about it. My recovery was very difficult b/c I was so worn out from the labor (not that I ever got to pushing, but I waiting qquite a while for my epidural and the contractions were exhausting, and I had been having contractions for a full week b/4 my water broke) and I wonder if it would have just been better to have had the C earlier and then I wouldn't have gotten into the trouble with needing Magnisuim Sulfate after dilvery, etc. I wasn't able to be with Amira for a while...anyhow, it is (as always!) a lot to think about.