Hospital births: In Chicago, a physician or a certified
nurse-midwife may attend hospital births. As you decide which is
right for you, there are specific questions to ask:
Alternative birthing center: Practitioners at West Suburban
Hospital's alternative birthing center use a telemetry unit to
monitor fetal heart rate and encourage alternative birthing
methods. A vertical Cesarean scar, more than two previous Cesareans
and carrying past 42 weeks are risks that prevent women from
delivering at the center.
Home birth attended by a certified nurse-midwife. Many certified
nurse-midwives have discontinued their VBAC practices, because
their collaborating physicians are hesitant to allow the procedure
away from the hospital.
Home birth attended by a direct-entry midwife. Though the home
birth model is proven safe, certified professional midwives and
direct-entry midwives do not have hospital privileges or
collaborating physicians if an emergency occurs.
International Cesarean Awareness Network www.ican-online.org
Citizens for Midwifery www.cfmidwifery.org
Illinois Families for Midwifery www.iffm.lovesbaby.com
Doulas of North America www.dona.org
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.
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
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
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
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
"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
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
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
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."
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
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
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