Your right to a vaginal birth: What you should know before making a decision
Saturday, November 01, 2003
An unprecedented 26.1 percent of babies - that's one in four - born in the United States last year arrived via Cesarean section, according to a report released in June by the Centers for Disease Control and Prevention.
In Illinois, the figure was only slightly less troubling; 23.9 percent of babies were born by surgical procedure rather than vaginal delivery. Both the state and national numbers are far higher than the Cesarean rate the World Health Organization recommends-10 percent-and the 15.5 percent level the U.S. Department of Health and Human Services believes should be the limit for Cesarean sections by 2010.
On one level, any birth that results in a healthy baby-be it vaginal or Cesarean-is the best birth possible. But on another level, this trend is disturbing because it seems that the surgeries are based on convenience and cost rather than a woman's right to choose the birth that is right for her.
"Vaginal birth is the gold standard," says Jo Anne Lindberg, president and founder of BirthLink, an Evanston-based birth counseling network. "It's the empowerment factor-it makes you feel like you can do anything."
"Women have fear about child birth and a lot of [practitioners] have a fear of being sued," says Anne Gallagher, a certified nurse-midwife with Parteras Women's Health in Oak Park.
VBACs versus cesareans
A Cesarean birth can be disappointing for new mothers expecting a vaginal birth. And at its worse, it can spark trauma and grief that is difficult to overcome. The idea that they can deliver subsequent babies vaginally often helps those mothers heal.
But women increasingly are finding it difficult to even attempt vaginal birth after a Cesarean, or VBAC.
The federal government recommends doctors shoot for a 37 percent VBAC delivery rate by 2010-a goal endorsed by the American College of Obstetricians and Gynecologists [ACOG]-but the rate has fallen steadily over the past three years.
But while ACOG makes this recommendation in theory, in practice it's guidelines thwart VBAC deliveries.
ACOG provided a copy of its VBAC practice guidelines, as well as its most recent recommendations for Cesarean delivery for this story.
Chicago Parent made more than ten calls to the organization's obstetrics practice and cesarean delivery task force representatives and scheduled several interviews. Not only did many calls go unreturned, but each interview effort was subsequently rescheduled due to physician unavailability.
Common in the mid-20th century, the rate of VBACs first began to decline in the 1970s, coinciding with a rise in malpractice lawsuits. There was a strong movement in the 1990s to increase the number of VBACs, thanks in part to birth groups and the support of the medical community. But the gains were short-lived.
The CDC reports that approximately 60 percent of women with previous Cesareans attempted a VBAC in 2002, but only 12.7 percent succeeded-23 percent less than in 2001.
Obstetricians and midwives directly attribute this to the July 5, 2001 New England Journal of Medicine. The study in the journal warned of increased risks with VBACs.
Although the study was quickly criticized by birth advocates and physicians alike, the mainstream public and media seized on the idea that VBACs alone caused the increase in uterine rupture.
"The take-home message that people came away with was that VBACs were bad because you could have a uterine rupture," says Hillary Kieser, a certified nurse-midwife with West Suburban Midwife Associates in Oak Park. "But when you looked at the research, it wasn't that accurate of a study. And the risk [of uterine rupture] was still so small."
Researchers reviewed the charts of 20,095 VBAC women and found that uterine rupture occurred in less than 1 percent of most cases-0.16 percent of women who underwent a scheduled, repeat Cesarean with no intention of delivering vaginally and 0.52 percent of women whose labor began spontaneously suffered a uterine rupture.
Critics note the more important finding of the study was ignored: An even more alarming uterine rupture rate (2.45 percent) occurred among women induced with synthetic drugs such as Pitocin. These and other drugs commonly used to speed up labor seem to increase risk of uterine rupture independent of VBAC status.
VBAC candidates in the Chicago area have options.
Pregnant with her first child Charlene Branda, 35, knew she would need a Cesarean. Her boy was in a breech position. "I remember when I first found out that [it] was likely; I started feeling some sadness," she says. "I wanted my son to be healthy, but I thought to myself, 'This doesn't seem like what a birth should be.'"
Branda's doctor, on staff at Northwestern Memorial Hospital, assured her after her son's birth there was a good chance she'd be able to deliver vaginally. Her healthy baby girl arrived by VBAC just 3½ months ago.
"It was so exhilarating," Branda says. "I felt more attached to the birth experience--I was in a euphoric state for two days."
Though Branda's doctor remained supportive throughout her pregnancy, Branda had to continually repeat her commitment to the idea. Initially, her obstetrician mentioned many women repeat Cesareans as a matter of convenience. And when it seemed as though Branda might pass her due date, the C-section was raised again.
"I just made it very clear that I wanted to try a VBAC," she recalls. "I let her know that I was very motivated." Branda is convinced her doula, Pam Hays, played a major role in the vaginal birth of her second baby.
"How relaxed you are about the birth experience will influence the outcome," Branda says. "Pam made sure there was no pressure."
"The biggest thing is having someone there to give you confidence," says Hays, adding that a physician's reluctance or bias toward VBAC can diminish that confidence.
"A lot of it is semantics," she notes. "Initially a doctor says, 'We're going to try for a VBAC.' But as the pregnancy progresses, the language starts changing to a 'trial of labor' and talk about the strength of the Cesarean scar. All sorts of restrictions come up. 'You have to have an IV. There will be continuous monitoring. No water in case there's need for a section at the end.' That puts doubt in a woman's mind."
Lower risks, fewer options Outside Chicago or any urban setting, the chances of a woman being able to have a VBAC decreases.
In July 1999, prior to the New England Journal of Medicine study, the American College of Obstetricians and Gynecologists revised its VBAC practice guidelines. The group began recommending an obstetrician and an anesthesiologist be available to perform a Cesarean during VBAC attempts. Previously, a surgical team was advised to be "readily available" within 30 minutes of the hospital.
On the upside, the revision reduced the small yet valid risk of uterine rupture during VBAC by ensuring immediate surgery, protecting doctors and hospitals from liability.
On the downside, it increased the chances women would have another Cesarean rather than a vaginal birth. According to Jude Wrzesinski, a certified nurse-midwife with HomeBorn Health in Cherry Valley, Ill., only the Level One trauma centers in nearby Rockford have the luxury-or the budget-to staff an anesthesiologist 24 hours a day, seven days a week.
"If a woman wanted a trial of labor at [a smaller hospital], they would have to call someone in to sit around just to see if his services were required," Wrzesinski says. "If he isn't needed, who's going to pay for his time? The hospital isn't going to want to, the patient isn't going to want to and her insurance company isn't going to want to."
As a result, smaller hospitals are either drastically reducing the number of VBACs they perform-the rate at Rockford's Swedish American has dropped from 50 percent two years ago to less than 10 percent, Wrzesinski says-or the hospital refusing to offer the procedure at all. Like many home birth midwives, Wrzesinski was compelled to stop offering VBACs when her collaborating physician's community hospital discontinued them.
"If the smaller hospitals stop offering VBACs, everyone gets a C-section," she says. "Maybe there is an OB available who still wants to do them, but there's no anesthesiologist. It's so sad to turn these women down. My collaborating physician feels the same way."
It's never too late Doula Hays insists her VBAC clients do their homework and ask potential practitioners specific questions: What is your VBAC rate? What kind of restrictions do you place on your patients? What kind of restrictions does the hospital operate under? If a soon-to-be mother is uncomfortable with any of the answers, it is never too late to change practitioners, she says.
Dr. Jennifer Lucchesi, a naturopathic physician and holistic midwife with a private practice in Chicago, agrees.
"You can't open up and labor with someone who you know is going to create a friction or tension with your beliefs or your needs," she says. "I sometimes meet women 38 or 39 weeks along whose doctor shrugged off their birth plan. I say, 'What are you still doing with that person?'"
Julie Lambert has taken that sentiment to heart. She learned in the 32nd week of her first pregnancy that her daughter Madeleine was breeched and did everything she could to convince the baby to turn-exercises, acupuncture, somersaults in the pool. She even tried to startle Madeleine into flipping with an electric toothbrush. Yet, she still had a Cesarean.
"I see labor and delivery as a rite of passage in becoming a parent and a mother," she says. "I feel cheated out of that." Now, 1½ years later, Lambert has just had another chance at vaginal birth. Her second daughter, Annabel Rose, was born at Evanston Northwestern Healthcare on Oct. 5 after 40 hours of labor, 36 of which were spent at home with Lambert's doula and husband.
"It was a successful VBAC with no drugs," Lambert says. "Everything went just the way I wanted it." But the opportunity didn't come without hard work and difficult decisions.
Early on, Lambert met with BirthLink's Lindberg, who explained the VBAC options available in Illinois. Lambert could labor at West Suburban Hospital's alternative birthing center, have her baby at a regular hospital with a pro-VBAC obstetrician or a nurse-midwife or try home birth.
Lambert read volumes of literature on VBAC and studied the information available on the International Cesarean Awareness Network Web site. Then she went to see her doctor.
"I felt really comfortable with [my OB], but I really needed to talk to her about whether she saw VBAC as normal labor and delivery," Lambert says. "I asked very specific questions about monitoring the baby and what would happen if I needed to be induced, and I soon realized we were not on the same page."
Making the right choices
Lambert's doctor advised continuous internal monitoring (as do most hospital-based obstetricians) to detect fetal heart rate deceleration, an early sign of uterine rupture. But internal monitoring involves attaching an electrode to the baby's scalp in utero, a process that Lambert found far too invasive.
"In [the doctor's] mind, [internal monitoring] is a safer way because you'll know sooner if there's a problem," Lambert says. "You have to decide as a mother what you feel comfortable with. I knew I would have an overall safer labor if I was supported and encouraged in my decisions. I don't think my OB steered me toward a C-section, but I knew her perspective wasn't going to change in three months, and that I would continue to second-guess what she was doing."
Extensive research and playing an active role in her birth plan readied her for any outcome. Although she did not have a cesarean, Lambert was much more prepared for any eventuality this time around, she said just weeks before Annabel was due.
"I think it will be different this time because of the people I've surrounded myself with. I've given myself the best team possible; if I have to have a second C-section, I'll know it's because it had to happen."
Most VBAC advocates agree that with continued education for both expectant mothers and physicians, the pendulum will once again swing in favor of vaginal birth after Cesarean.
"What we do is a combination of art and science," says certified nurse-midwife Gallagher. "'First do no harm'-that's a really good place to start."
Women must understand that there are risks in any birth. Then, they should decide what role they as mothers want to play when they give birth. Do they want to call the shots? Do they want the doctor to decide? Do they want a midwife?
"I think that consumers have to say, 'I'm willing to accept a certain amount of risk. I understand that [a physician or midwife] can't guarantee any outcome.'"
Eryn McGary is a Chicago-based writer. She can be reached at ESMcGary@hotmail.com.