Vaginal birth after caesarean section is an option - and here's how to fight for it
Wednesday, October 06, 2010
Gina Crosley-Corcoran could feel the ghost of a knife slice her lower abdomen as she gave birth to her first child by Cesarean section. Even the healthy birth of her oldest son, Jonas, couldn't erase that haunting memory.
"Just lying on the operating room table and feeling what was being done to me was a very traumatic experience," says the Brookfield mother and pre-law student. "So when we decided to get pregnant again, I knew that I wanted to have a vaginal birth."
Crosley-Corcoran's feelings aren't uncommon among women whose doctors say they need to have emergency C-sections, often after hours of labor. C-sections account for 31.8 percent of births in the United States and the rate has risen more than 50 percent in the past 11 years.
That contrasts sharply with the World Health Organization's recommendation that C-sections should account for no more than 15 percent of births in low-risk women. The numbers can be disheartening for women who know C-sections are major abdominal surgeries that come with all the risks of any major surgery-and they're being performed for reasons that have nothing to do with a disease or medical condition.
"Birth is something we're all designed to do," says Crosley-Corcoran, who started and leads the DuPage County chapter of the International Cesarean Awareness Network. "It's not the way it is on TV shows. It's not sensational. It's normally very healthy."
However, Crosley-Corcoran's battle to have a vaginal birth after Cesarean, often referred to as VBAC, may be less common-if only because many women don't know they have the option of fighting for a VBAC.
New recommendations offered
In response to the heightening conflict, the National Institutes of Health last year held a VBAC consensus conference. Many women hoping to avoid repeat Cesarean sections are being deprived of the choice, the conference panel announced. Though the independent panel of health care providers and policy makers emerged from the conference with new recommendations, those recommendations are still largely left open to interpretation.
The issue remains a subject of hot debate between women who don't feel they should be forced into surgery and doctors and hospitals that say the risks of VBACs-including uterine scar rupture during labor-outweigh those of repeat C-sections.
"We certainly support the concept of people having choice and are happy to have people undergo a trial of labor, but I think also we want to convey to them what the risks and benefits are in their individual circumstances," says Dr. William Grobman, a specialist in maternal fetal medicine at Northwestern Memorial Hospital. "At the end of the day, what we want to be doing is taking care of people, and I think we need to make the decisions that are most about the patient."
The American Congress of Obstetricians and Gynecologists has set guidelines "useful in identifying candidates for VBAC," including the immediate availability of a physician and anesthesiologist should an emergency C-section become necessary. Some hospitals that can't meet this recommendation have opted not to provide VBACs.
Yet critics argue hospitals that can meet these recommendations are still banning VBACs, despite the high success rate of VBAC births in the United States, consistently between 60 and 80 percent, according to the National Institutes of Health. They also cite the extremely low risk of uterine scar rupture, which they say occurs in less than 1 percent of women.
Some health care professionals believe key risks involve legal as well as medical issues.
A clash of values
After insurance issues hampered her attempts to switch doctors during her second pregnancy, Crosley-Corcoran, 31, prepared for a struggle.
"(My doctor) wasn't going to support the things that needed to happen for me to get my VBAC," she says. "I saw myself going back down this road where I was just going to end up with another C-section, and I knew I had to get myself informed and get myself a really good support system."
Crosley-Corcoran began educating herself about birth, hired a doula and even learned how to read a fetal heart rate monitor. All were choices that helped her during the birth of her second son, Jules.
When her contractions started at work one May morning in 2008, she immediately took a taxi to her doctor's hospital.
Crosley-Corcoran says she fought throughout her 38-hour labor with doctors and nurses who said she needed another C-section.
"They kept trying to tell me that Jules' heartbeat was becoming (too fast). Well, I knew what that was and I could see the fetal monitor and it wasn't," Crosley-Corcoran says. "To me, the most inappropriate behavior was the scare tactics."
Dr. Melissa Dugan-Kim, an OB-GYN at the Northwestern Specialists for Women and Northwestern's Prentice Women's Hospital, says in the last five years she has done nearly 300 C-sections and 200 vaginal deliveries.
Dugan-Kim, who also does VBACs, attributed the rising number of C-sections to an increase in assisted reproductive technology, which leads to a increase in twins and multiples.
"Everyone thinks they're going to get pregnant, have an easy pregnancy and take home a healthy baby. That's not always the case," says Dugan-Kim.
Jamie Grumet knew having a baby would be painful. But she didn't realize how hard it would really be, she says.
"I thought you have a baby and it's so exciting," Grumet, 31, says.
She arrived at Northwestern's Prentice Women's Hospital late one evening in September. Things were slow to progress. A nurse had to break her water early the next morning, and it wasn't until mid-day when Grumet's doctor gave her the go-ahead to push.
"I was all excited," she says. But after an hour of pushing, the baby wasn't moving.
Grumet's doctor told Grumet she needed an emergency C-section because if she continued to push, she could risk breaking her narrow pelvis.
"That 20 minutes between the time they prep you for the C-section and you actually go into surgery was probably the worst, scariest, most awful 20 minutes of my life," she says. "I knew I was in good hands. It's just that I was so alone and they lay your arms out on the table literally like Jesus on a cross."
Just 20 minutes after she was wheeled into surgery, baby Ellie was born. Although Grumet understands her C-section was necessary, she says her birthing experience didn't go as she had hoped.
Grumet's doctor told her any subsequent deliveries must be via C-section, which has become such a common practice that 90 percent of women who give birth that way once will do so again, according to the Illinois Department of Public Health.
"My doctor says for the next baby it'll be a lot different because I'm having an elective, scheduled C-section. You can have your Starbucks in the morning and have your baby in the afternoon," she says. "I think I would be mentally prepared, knowing I was going into surgery, so I'd be OK with it."
A tangled web
More than 24 hours into Crosley-Corcoran's VBAC, her doctor became more insistent that she needed a C-section. She continued to resist.
Situations like Crosley-Corcoran's stem from a complex web of causes.
"I think it speaks to the many different pressures in our health care system," says Grobman, who spoke at the NIH's recent VBAC conference. "It has to do with regionalization of health care. It has to do with, probably to some degree, the professional liability climate. It has to do with societal attitudes toward Cesarean and vaginal delivery."
It's a situation that makes it easy to blame the doctors and hospitals that ban VBACs or pressure women to have C-sections. But Grobman says that may not be a fair reaction.
"It's not that those hospitals are being mean per se, but they're constrained by guidelines and circumstances. In that sense it's not really necessarily their fault," he says. "It's really system-wide change that people need to make … if people feel this is an important thing."
Playing the card that's dealt
While Grumet understands it's safest for her to have a repeat C-section, she says she's still sad.
"I'll never be able to experience the way women have been having babies forever and that's so sad," she says.
Crosley-Corcoran's experience turned out differently. For her, the struggle was completely worth it.
"After my C-section, I felt like there was this thing as a mother that I should have experienced, that I should have been able to go through," she says. "Getting my VBAC and knowing that I did it … it's just the most miraculous and powerful, unbelievable feeling."