Hospital VBAC?


Ruby Wales holds her newborn, Carson. Her first doctor worried more about the risks of vaginal delivery than of cesarean, so she found a different one.

After an emergency cesarean with her first baby, Ruby Wales was holding out for a vaginal birth with her second one.

With a toddler underfoot, the 33-year-old Mission Viejo woman wanted a faster recovery. But finding a physician to deliver her second child wasn't easy. Her first obstetrician turned her down flat. "She said, 'No -- no way,' " Wales recalled.

Once reserved for cases in which the life of the baby or mother was in danger, the cesarean is now routine. The most common operation in the U.S., it is performed in 31% of births, up from 4.5% in 1965.

Same stats as we have in Australia ....

With that surge has come an explosion in medical bills, an increase in complications -- and a reconsideration of the cesarean as a sometimes unnecessary risk.

It is a big reason childbirth often is held up in healthcare reform debates as an example of how the intensive and expensive U.S. brand of medicine has failed to deliver better results and may, in fact, be doing more harm than good.

"We're going in the wrong direction," said Dr. Roger A. Rosenblatt ... "in which more intervention, such as cesareans, is linked with declining outcomes, such as neonatal intensive care admissions ..."

... Because spending on the average uncomplicated cesarean for all patients runs about $4,500, nearly twice as much as a comparable vaginal birth, cesareans account for a disproportionate amount (45%) of delivery costs ...

... The cesarean rate in the U.S. is higher than in most other developed nations. And in spite of a standing government goal of reducing such deliveries, the U.S. has set a new record every year for more than a decade.

We have the same situation in Australia: every year, the CS rate only goes up.

The problem, experts say, is that the cesarean ... exposes a woman to the risk of infection, blood clots and other serious problems. Cesareans also have been shown to increase premature births and the need for intensive care for newborns ...

Inducing childbirth -- bringing on or hastening labor with the drug oxytocin -- also is on the rise and is another source of growing concern. Experts say miscalculations often result in the delivery of infants who are too young to breathe on their own. Induction, studies show, also raises the risk of complications that lead to cesareans.

Induction may also fail. The majority of failed inductions end in caesarean.

Despite all this intervention -- and, many believe, because of it -- childbirth in the U.S. doesn't measure up. The U.S. lags behind other developed nations on key performance indicators including infant mortality and birth weight.

And in at least two areas, the U.S. has lost ground after decades of improvement: The maternal death rate began to rise in 2002, and the typical American newborn is delivered at 39 weeks, down from the full 40 ...

... "Cesarean birth ends up being a profit center in hospitals, so there's not a lot of incentive to reduce them," said Dr. Elliot Main, chief of obstetrics for Sutter Health, a Northern California hospital chain.

But there is a lot that hospitals can do to reduce them ... Among California hospitals, cesareans range from 16% to 62% of births.

NSW caesarean rates vary from 15% to 46%. The average is 29%, two to three times that recommended by the World Health Organisation.

Such variation means a lot of women are getting unnecessary cesareans, Main said. "There's no justification for that kind of variation."

Physicians ... have been blamed for failing to make women fully aware of the consequences of cesareans, and for promoting them for convenience.

But change is underway. The Institute for Healthcare Improvement's Strategic Partners program trains hospitals to implement a set of guidelines, such as the careful use of oxytocin, and a ban on elective deliveries before 39 weeks. In four years, 60 hospitals have signed on.

... 48% of newborns admitted to neonatal intensive care units were from scheduled deliveries, many of them before 39 weeks.

... After being notified of the correlation, the physicians changed their practices and reduced neonatal ICU admissions by 46% in three months.

The rise in avoidable first-birth cesareans has had a multiplier effect. Most U.S. physicians discourage vaginal deliveries after a cesarean because of some widely publicized cases several years ago in which the uterus split disastrously along the prior incision.

That's why Ruby Wales' first obstetrician refused.

"She said it was because there is a 1% chance of a uterine rupture," Wales said. "And I thought that was weird because there's more chance of things going wrong with a cesarean section."

VBAC rates in Australia are very low. Some hospitals flat out refuse to "do" VBACs. Others openly discourage them.

But some obstetricians believe that new evidence supports allowing some women the option of trying for a vaginal birth.

... Saddleback supported Wales' desire for a vaginal birth. Nine days after her due date and after 30 hours of labor, she gave birth -- the way she wanted -- to an 8-pound, 11-ounce boy.

"I was so glad nothing happened at the last minute to have an emergency C-section because I'd gone through all this work," said Wales, resting in her hospital bed with baby Carson in her arms. "I'm so relieved that I don't have to deal with a [cesarean] recovery because I have a 2 1/2-year-old at home who is very active."

It can be very hard to achieve a VBAC in hospital. It's far easier to have a VBAC at home. Hospital policies typically work against natural labour, and interventions such as continuous fetal monitoring and vaginal examinations every 2 or 4 hours will most likely see you labouring on your back in bed. This doesn't allow you to work with your body to see you through a natural labour.

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