Vaginal birth after Cesarean an uphill battle, but still possible

Suzanne Davis of Bethany Beach, after having twin boys and her third son – all delivered by cesarean section – always felt like she had missed out on something. With her twins, she went into labor early and had an emergency c-section at just 29 weeks gestation. Because of that first c-section, when she became pregnant for a second time, she was told she would need to have a repeat surgery. A previous c-section continues to be one of the main reasons why women have a c-section.

Coastal Point Monica Fleming: Suzanne Davis is pictured here with her daughter. Davis gave birth vaginally last fall after having had two previous c-sections. VBAC numbers have been dwindling in the past decade as c-sections have risen dramatically.Coastal Point Monica Fleming
Suzanne Davis is pictured here with her daughter. Davis gave birth vaginally last fall after having had two previous c-sections. VBAC numbers have been dwindling in the past decade as c-sections have risen dramatically.

“I did feel like I had missed out on the whole woman-pushing-it-out thing,” said Davis. “I would’ve been completely fine if it was medically necessary [to have another c-section] and I know some people are perfectly happy with it, but if someone wants to not have major surgery…”

After switching providers and educating herself, Davis did achieve a vaginal birth after a cesarean – five years after her youngest was born, when she gave birth to her only daughter, last fall.

“I definitely wanted a VBAC [vaginal birth after cesarean] the second time, but everybody was like, ‘Absolutely not,’” continued Davis. “They said it’s too much of a risk, and they are doctors, so I believed them. They looked at me like I was crazy, and they said, ‘You and the baby will die’ [in the event of a uterine rupture].”

Davis’ story has become familiar, as more and more hospitals – especially small community hospitals – are outright banning VBACs. An independent study done by the International Cesarean Awareness Network (ICAN) recently found that more than 800 U.S. hospitals either ban VBACs outright, or have “de facto” bans, where it is not “banned” per se, but there is no physician available who is willing to assist a mother in her choice to labor and deliver naturally after a cesarean.

ACOG guidelines focus on ‘1 percent policy’

Because of a change in the guidelines of the American College of Obstetricians (ACOG) — which describes itself as a voluntary, non-profit membership organization and the nation’s leading group of professionals providing health care for women, with more than 52,000 members — in 1999, stating that a physician, an operating room and anesthesia had to be in-house and immediately available, many hospitals see anything but a repeat c-section as too risky. (Earlier guidelines stated that availability of those people and facilities in les than 30 minutes was acceptable)

Often, the risk doctors are referencing is the less-than-1-percent chance that the post-cesarean uterus will rupture during labor, which can be catastrophic in some cases. The chance of a rupture is about .32 percent (or about 3 in 1,000) and the overall risk for “serious adverse perinatal outcome” (stillbirth, hypoxic ischemic encephalopathy, neonatal death) is about .27 percent or 106 out of 39,049, as concluded in a 2007 study.

That study, “Risk of Uterine Rupture and Adverse Perinatal Outcome at Term After Cesarean Delivery,” was done for the National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. The study looked at 19 different maternity centers over four years and studied women with a single-term gestation (pregnant with one full-term baby).

The same report, in which a total of 39,117 women were studied, also found that those same adverse perinatal outcomes occurred in women without uterine rupture about half of the time, and “adverse maternal outcomes such as maternal death occurred more in women undergoing elective cesarean delivery without labor and without an indication.”

In the article “The Folly of 1 Percent Policy,” written by Dr. Eugene Declercq, a professor of maternal and child health at the Boston University School of Public Health and Judy Norsigian, executive director of Our Bodies, Ourselves, the authors liken the view taken on c-sections (and subsequently VBACs) as being perfectly parallel to former Vice-President Dick Cheney’s “One Percent Doctrine” – the title of Ron Suskind’s 2006 book on post 9/11 national security policy.

They write, “[The doctrine] perfectly captures an approach to decision-making in American medicine that misallocates resources and undermines primary care. By focusing maximum resources on preventing an extremely rare but potentially disastrous outcome over necessary preventive care, this model has shaped healthcare decision-making in areas ranging from hysterectomies to coronary bypasses. One shift – the rapidly rising Caesarean rate – exemplifies this problem.”

The article goes on to outline that the U.S. has one of the highest c-section rates (averaging 30 percent) of industrialized nations, behind only Italy (with 37 percent) and South Korea (with 35 percent).

The report states that c-sections are becoming safer than ever as obstetricians are more skilled at performing them, but “they are not without negative consequences. When they are performed as elective surgery on mothers with little or no medical risk, these harms outweigh the benefits.”

“Yet caesareans are advocated as necessary to avert potential disasters that might occur,” they continue.

“At a 2006 meeting sponsored by the National Institutes of Health, one doctor captured the 1 percent (or in this case 1/30th of 1 percent) doctrine when he described rare conditions and noted the benefits of a 100 percent caesarean rate (you read that right) in avoiding these outcomes in 3 in 10,000 cases.”

“Likewise, a 2006 position statement from the American College of Obstetricians and Gynecologists states that ‘Labor and delivery is a physiologic process that most women experience without complications,” but then goes on to emphasize the one percent doctrine: ‘…serious intrapartum complications may arise with little or no warning, even in low risk pregnancies.’ The statement and the doctor’s claim are true, of course – anything can occur – but does that mean that society benefits when every birth is handled as a disaster (or, worse yet, a lawsuit) waiting to happen?”

VBAC statisticsClick to see a PDF version of the table.
Risk of lawsuits influences doctors’ availability

Still, the justification many women are getting in the doctor’s office is not that the doctors themselves are leery of being sued, but that vaginal birth after cesarean is just too risky – and a repeat c-section is offered as the only viable choice.

As c-section rates continue to hover at their highest ever — about 30 percent of births nationwide, with Delaware about average, this is something that is affecting more and more women every day. And all too often, the risks associated with c-section and repeat c-section – which can include everything from anesthesia complications for mother and baby to placental abnormalities, such as placental abruption, placenta previa and placenta accrete – are downplayed.

Dr. Richard Derman – chairman of Christiana Care OB/GYN in Newark, to which many downstate mothers wishing to try vaginal birth after cesarean are referred – said there are risks no matter what women choose, but, ultimately, they should have the choice.

“Women should be counseled and given an option,” he said. “There are risks associated with VBACs, and there are risks associated with multiple c-sections. C-sections place the patient at much greater risk of an emergency hysterectomy.”

In addition to that, potential risks to babies include everything from low birth weight to prematurity to respiratory problems and lacerations. Other potential risks to women can hemorrhage, infection, surgical mistakes, re-hospitalization, dangerous placental abnormalities in future pregnancies, unexplained stillbirth in future pregnancies and increased percentage of maternal death.

Derman added that about 75 percent of women with a previous cesarean are able to give birth vaginally, and women and doctors need to discuss the reason for the first c-section when deciding what the options are although there are “no absolute predictors” of who will be successful and who will not.

“We live in a litigious society,” sad Derman. “Plus, nationally, there are some concerns about bad outcomes and being named in a lawsuit. Obviously, you want the right thing for the mother and the baby. But, when the right things are about equal, the potential for a costly litigation comes into play.”

He said it would be interesting to see what the numbers were in states where tort reform is accepted. Tort reform would change how malpractice cases are handled and how monetary awards are figured.

A 2005 Journal of Defensive Medicine article concluded after surveying 824 physicians at “high risk of litigation,” such as in OBGYNs, that 93 percent admitted they practiced “defensive medicine.”

“Forty-two percent of respondents reported that they had taken steps to restrict their practice in the previous three years, including eliminating procedures prone to complications, such as trauma surgery, and avoiding patients who had complex medical problems or were perceived as litigious. Defensive practice correlated strongly with respondents’ lack of confidence in their liability insurance and perceived burden of insurance premiums,” stated the report.

Derman said that Christiana oversees about 7,000 births each year and averages around a 30 percent c-section rate, which is lower than the national average and lower than the average of the nation’s 10 largest hospitals. In 2006, the latest year for which the state of Delaware Division of Health and Social Services has data available, Christiana Care had 6,151 births; 33 percent were surgical and 67 percent were vaginal. Of the vaginal births, 81, or .02 percent were VBACs.

Derman’s prediction is that c-section rates will continue to go up, VBACs will continue to drop and complications from c-sections will rise. He added that, especially for women planning to have large families, it is very important to get counseled on all the options.

“If women want a big family, it is really important to counsel them on a trial of labor,” he explained. “For something with a 75 percent success rate, it might make the most sense to them.”

Written and de facto banks keep VBACs rare

The problem with that, according to Pam Udy, president of ICAN, is that many women who have already had a c-section are simply no longer being offered any counseling or any options besides a repeat c-section.

At the recent Controversies in Healthcare Conference, she noted, the fact that more than 300 hospitals nationwide now ban VBACs was referenced, but she emphasized that those were 2007’s numbers.

“Now, there are over 800 hospitals where there is a written ban,” she explained. “We are not talking about hospitals that discourage it or doctors that are uncomfortable but actual written policies banning them. That is a huge increase in one year.

“Women are being denied this option and are not even aware. They are saying, ‘My doctor says I need a repeat c-section. There must be a medical reason why.’ It’s frustrating, because there’s not always a medical reason. They are putting the pocketbook ahead of mothers and babies, and that is really not OK.”

Udy emphasized that hospitals do not have to have a written policy for them to have low VBAC numbers.

“There’s a whole attitude of discouragement, and they are very good at picking out your fears and your history and using them as reasons for repeat surgery,” she said.

Udy got involved after having her first two children by scheduled cesarean section at 38 weeks. After reading extensively, interviewing many care providers and hiring a doula, the third time around, she gave birth vaginally in a hospital. She went on to have two more children vaginally, with one being born at home.

“That’s the only reason I got a vaginal birth after a cesarean,” she said about her work to educate herself. “It was amazing to me that I could ‘choose’ major abdominal surgery and yet I had to cite I don’t know what [statistics] to get a VBAC. It’s sad.” She added that the reason she went on to have a homebirth was specifically to avoid a fight in the hospital about how she would deliver.

Both Udy and Davis – mothers with two c-sections and no prior vaginal births – are in the minority even by VBAC standards. ACOG’s guidelines for physicians and hospitals that do “offer” VBACs state that the best candidates for them are mothers with only one prior c-section done for a non-recurring reason (such as a breech baby). According to ACOG, if a mother has had more than one cesarean in her history, she could still be considered, but only if she also has a prior vaginal birth in her history, thereby limiting the pool of “acceptable” VBAC candidates even further.

“I didn’t want to fight,” added Udy, of her decision to eventually go for a homebirth. “I just wanted to find somebody who believed I could do it.”

Patients battle for VBAC option

This is something that happens often, as Davis can relate. It was only after researching doctors, talking to a lot of friends and asking around (plus a serendipitous change in insurance companies) that she found a doctor willing to help her. Although she was told by many people that her only option was Christiana Care in Newark, a two-hour drive, she persevered and eventually delivered her daughter at Beebe Medical Center in Lewes.

“When I went, I could tell that he was interviewing me, too,” she said of her doctor. “We were going over my history, and I’m young, active and healthy, there really was no reason for the first or second surgery — well, really no reason for the second — and he was honest about all the risks.”

She added that another OBGYN she saw was not as supportive and simply told her she would have to go to Christiana if she wanted a VBAC.

“That was my low point. She was on a mission, and was just like, ‘You cannot have a VBAC at Beebe. It’s dangerous. There’s no anesthesia.’ She was so matter of fact about it, and then she just left the room, and I was like, ‘Wait, I have other questions about my pregnancy!’”

Davis said she didn’t really have any second thoughts, but signing the consent form, which laid out all the “what-ifs,” was still nerve-racking.

“It basically said, if anything happens, they were not responsible,” she explained, saying the form was almost too much for her husband, but by then, she was determined that her positive thinking could get her through anything and she was comfortable with the fact that 99 percent of the time, things work out, so she signed the form.

Because Davis was already at 42 weeks gestation, she and her doctor had scheduled a c-section just in case she did not go into labor soon. Her c-section was scheduled for a Wednesday, and she went into labor the day before.

“I walked in and they were like, ‘Aren’t you scheduled for a c-section tomorrow?’ and I said, ‘Yeah, but I’m here now!’

Davis purposefully waited at home as long as she could after labor began and was 5 centimeters dilated when she arrived at the hospital. She quickly progressed and had her baby – a 7-pound, 1-ounce girl – unmedicated and vaginally, about four hours later.

“The nurses were not happy about it,” she said. “And when I left, the one charge nurse said, ‘You really had us scared. I’m glad it went well.’”

Davis added that the recovery from the vaginal birth and the recovery after her previous c-sections bore no comparison.

“They told me to take a shower that day, and I was like, ‘I can’t do that,’ but I did and it felt great.”

VBACs rare at area hospitals

Wallace Hudson of Beebe Medical Center Corporate Affairs said that, although Beebe does not have a formal written policy banning VBACs, if a woman came in and wanted to have a vaginal birth after a cesarean, such as what happened with Davis, she is required to sign a consent form that points out the risks to both her and the baby.

“It states the risks to her and the baby, in the event of a uterine rupture, and the increased risk of death to the child, and states that we, as a hospital, do not meet the ACOG requirements for a VBAC, which is anesthesia, physician and an operating room being immediately available,” he explained.

“If the form is looked through and all the items are checked, and they have released the hospital from any risk or liability, we can go ahead with them,” said Hudson of VBACs at Beebe. In 2008, including Davis, Beebe Medical Center recorded seven VBACs. They had 1,036 total births, of which about 34 percent were c-sections.

The question for Davis, and many women, is what would happen at such a hospital in a true emergency birth, without immediate availability of anesthesia, physician and operating room. What if a woman happened to need an emergency c-section at 3 a.m. at a small community hospital that didn’t have on-site anesthesia or a 24-hour operating room? What about a heart patient that needed emergency surgery?

Hudson said that, to meet ACOG guidelines to be able to perform c-sections, hospitals have to have those three things – anesthesia, a physician and an operating room – available within 30 minutes, as opposed to the “immediately available” requirement to do VBACs per ACOG guidelines. He said the 30-minute timetable is a guideline they can meet.

In addition to the questions of whether a hospital has a 24-hour operating room and 24-hour anesthesia in-house, or whether the patient should agree to release a hospital from liability, there is another question: What if a woman cannot find a provider that believes in her ability to birth and is willing to sit with her while in labor?

At Peninsula Regional Medical Center in Salisbury, Md., there were 2,235 births and six VBACs in 2008. While PRMC’s c-section rates have gone down from 2007’s rate of 36.6 percent, to 32 percent in 2008, their VBACs were fewer than at Beebe – a smaller hospital with a 1,000 fewer births.

Kent General, a hospital that saw 1,855 births in 2008, had a 27 percent c-section rate, and in the same year, there were 29 VBACs. They, Christiana Care in Newark and St. Francis Hospital in Wilmington all meet ACOG’s guidelines for VBACs, as does Peninsula Regional Medical Center.

Milford Memorial, another local, small hospital that currently does not comply with the anesthesia/OB/operating room guidelines of ACOG, had 435 births in 2008; 37.7 percent were c-sections, and they had no VBACs. Nanticoke Memorial in Seaford, which has enjoyed being considerably lower than other area hospitals in terms of the c-section rate, had 983 births in 2008; 24.7 percent of which were c-sections and four of which were VBACs.

Because Nanticoke does not have 24-hour in-house physicians, operating room and anesthesia, either, those four VBACs, according to Director of Maternal and Child health Nancy Orely, represent women who either came in fully dilated (giving them no time to be prepared for a c-section) or who refused to have a c-section.

Locally, shift is away from VBAC, natural birth

Ronnie Kopek, director for Women and Children’s Services at Bayhealth (emcompassing Milford Memorial and Kent General in Dover), said that there are lots of differences on the maternity wards here than in Vermont, where she was located for 10 years.

“In Vermont, people were a lot more touchy-feely. The women were more educated. There were more midwives. And it was a different kind of delivery,” she said.

She noted that she had been surprised to learn that there were no bathtubs for women to labor in – an increasing request, as many say laboring in the water makes labor and birth easier and less painful – at Kent General. She added they are “working on the anesthesia” issue at Milford Memorial.

“It could be the culture, or the age range. Older women tend to be more educated on natural childbirth,” she said. “And with the advent of technology, we tend to use what we have, and we have the tendency to want to intervene, to have more control, and we forget that babies will come regardless.”

She added that, years ago, it used to be, the more VBACs hospital did, the better.

“We were happy to do it and moms wanted it,” she said, but she added that, at least in new England, a “huge lawsuit” impacted they way hospitals looked at vaginal birth after cesarean, and the times have since changed.

“It’s a cycle,” said Nanticoke Memorial’s Orley. “It’s interesting how we have changed over time. We might get back to a time where there’s more natural childbirth. I’ve been doing this 30 years, and it always seems to cycle. Who knows where we’ll be in 10 or 20 years?’

Patients’ voices can make the difference

In the future, Kopek said, Bayhealth intends to use more focus groups to see what it is the women actually want.

“We can say what’s good for the patient all we want, but if we don’t ask the patient, we won’t really know.”

For many women, the 30 minutes in the revised ACOG guidelines or the lack of physician cooperation, or an outright ban on VBAC, can make the difference between the right to choose to have a vaginal birth and being coerced into a repeat surgery, and the patients themselves may be the only ones who will change it.

“There have been some reversals of bans,” said Udy. “And that comes from women saying, ‘We want this option and, if it is not available, we will go somewhere else.’ The c-section has become the be-all, end-all cure to any pregnancy complaint or complication, when there are a lot of alternatives to surgery. If more of us raised our voices, we’d get this option restored. We are all moms, and time is limited and resources are limited, but our voices are so strong.”

ICAN encourages women to speak out and to take the time to interview doctors seriously because, many times, the deciding factor in whether a women successfully gives birth vaginally after a cesarean is the attitude of the care provider she chooses – a notion Davis understands all too well.

Davis added that women need to be strong, and need to be educated, and need to be willing and able to fight for what they know is right for them, even if they feel alone doing it.

“I called a girlfriend who works in labor and delivery, and she was adamant I not do it,” Davis noted. “I talked to a lot of friends, and they said, ‘What if something happens to you?’ It’s a lot of responsibility, they all kept telling me no, but I just kept thinking about my doctor. He looked at me like an individual, not like ‘textbook, this is how we do it.’ He was like my beacon of light, and I felt like it was the right thing to do.”

“If you really want it, go for it. It’s sad that it’s not even an option, or it’s one that has to be done covertly. But you have to be an advocate for your own body.”

For more information on the International Cesarean Awareness Network, and what to do if a hospital has a VBAC ban — either written or de facto — visit ican-online.org. For more information on the pregnant patient’s rights and information regarding informed consent, contact National Women’s Health Alliance at www. http://www.nwhalliance.org and click on “pregnancy info.”