The Trouble With Repeat Cesareans

For further information, contact Melissa Maimann at Essential Birth Consulting. Link to article

By Pamela Paul Thursday, Feb. 19, 2009 To avoid another C-section, Barton has to drive 100 miles to deliver in Los Angeles. For many pregnant women in America, it is easier today to walk into a hospital and request major abdominal surgery than it is to give birth as nature intended. (It's often the same in Australia, unless you have a private midwife or doula with you) Jessica Barton knows this all too well ... her first child ended up being delivered by cesarean section, she can't find an obstetrician in her county who will let her even try to push this go-round. And she could locate only one doctor in nearby Ventura County who allows the option of vaginal birth after cesarean (VBAC). But what if he's not on call the day she goes into labor? ... in order to give birth the old-fashioned way, Barton is planning to go to UCLA Medical Center in Los Angeles.

Much ado has been made recently of women who choose to have cesareans, but little attention has been paid to the vast number of moms who are forced to have them. More than 9 out of 10 births following a C-section are now surgical deliveries ... the International Cesarean Awareness Network (ICAN) ... found that 28% of [hospitals] don't allow VBACs ... ICAN's latest findings note that another 21% of hospitals have what it calls "de facto bans," i.e., the hospitals have no official policies against VBAC, but no obstetricians will perform them ...

Why the VBAC-lash? ... The risk of uterine rupture during VBAC is real--and can be fatal to both mom and baby--but rupture occurs in just 0.7% of cases ... only 1 in 2,000 babies die or suffer brain damage as a result of oxygen deprivation.

After 1980 ... more women began having VBACs. By 1996, they accounted for 28% of births among C-section veterans, and in 2000, the Federal Government issued [a] ... report proposing a target VBAC rate of 37%. Yet as of 2006, only about 8% of births were VBACs, and the numbers continue to fall--even though 73% of women who go this route successfully deliver [vaginally].

So what happened? In 1999, after several high-profile cases in which women undergoing VBAC ruptured their uterus, the American College of Obstetricians and Gynecologists (ACOG) changed its guidelines from stipulating that surgeons and anesthesiologists should be "readily available" during a VBAC to "immediately available." ...

Some doctors, however, argue that any facility ill equipped for VBACs shouldn't do labor and delivery at all ...

Part of the answer has to do with malpractice insurance. Following a few major lawsuits stemming from VBAC cases, many insurers started jacking up the price of malpractice coverage for ob-gyns who perform such births ... 26% [of OBs] said they had given up on VBACs because insurance was unaffordable or unavailable; 33% said they had dropped VBACs out of fear of litigation ...

Of course, the alternative to a VBAC isn't risk-free either. With each repeat cesarean, a mother's risk of heavy bleeding, infection and infertility, among other complications, goes up. Perhaps most alarming, repeat C-sections increase a woman's chances of developing life-threatening placental abnormalities that can cause hemorrhaging during childbirth. The rate of placenta accreta--in which the placenta attaches abnormally to the uterine wall--has increased thirtyfold in the past 30 years ...

... while many obstetricians say fewer patients are requesting VBACs, others counter that the medical profession has been too discouraging of them ... 57% of C-section veterans who gave birth in 2005 were interested in a VBAC but were denied the option of having one.

... "the pendulum has swung too far the other way," So how to reverse the trend? For one thing, patients and doctors need to be as aware of the risks of multiple cesareans as they are of those of VBACs. [Concern arises that perhaps doctors will forget how to do VBACs.]

- Well, fortunately, you "do" a VBAC the same way you "do" a natural birth. By supporting the natural processes that women's bodies are designed to perform. In this country, VBAC rates are between 10% and 16%. In some private hospitals, the rates are as low as 1%. In homebirth, the rates of VBAC are at least 80%. And it is a numbers game, so put yourself where the numbers are stacked with you, not against you. Plan a home birth for your VBAC, or employ a private midwife for a hospital birth.

Melissa Maimann, Essential Birth Consulting.