Nursing Birth

On Thursday February 19, 2009, TIME.com published a remarkable article entitled The Trouble With Repeat Cesareans which takes a hard look at the rising cesarean rate in the United States, making C-sections the most common women’s surgery in the country.  If you haven’t yet read the article I highly suggest you do!

There are many things about this article that I like.  First off, to find an article tackling the lesser-known side of a debate, like the “VBAC-lash” as author Pamela Paul so aptly describes it, is uncommon in popular, highly circulated news magazines (“VBAC” for those that are not familiar with the term, stands for “Vaginal Birth After Cesarean”).  Typically media outlets like these go for what I like to call the “rare & scare” stories like such nonsense as, “The 100 ways your baby could die at birth!” and “Midwives Going Postal!”  The major and life-threatening consequences related to our country’s rising cesarean rate and the rapidly declining opportunities that women have to plan for a VBAC are serious public health and women’s health issues that need and deserve national attention!

The second thing I really like about this article is the title; “The Trouble With Repeat Cesareans” couldn’t be more appropriate.  Kudos to the editors of TIME magazine for nailing it with this one, considering that currently 9 out of 10 births following a cesarean are also a cesarean.  Clearly there are too many obstetricians and even many women not taking the risks of multiple major abdominal surgeries seriously! 

Thirdly, I think author Pamela Paul does a great job emphasizing the risks related to repeat cesarean sections when she writes,

“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 thirty fold in the past 30 years.”

Much too often articles related to this subject only report on the risks of VBAC and not the risks and complications of repeat C-sections which is both misleading and dangerous!  I would like to take this opportunity to elaborate on Paul’s list by citing some other serious risks related to repeat cesareans, as outlined in the book The Thinking Woman’s Guide to a Better Birth by Henci Goer (pg 168):

1.      Increased risk of injury to other organs, including bladder & bowels,

2.      Anesthesia complications including spinal headache, low blood pressure, backache, infection, nerve damage (including paralysis, loss of bladder and bowel function, loss of sexual function), allergic reactions, seizures, cardiac arrest and death (see: Redding Anesthesia),

3.      Scar tissue formation (called adhesions) resulting from every abdominal surgery leading to a more complicated surgery with each additional cesarean which increases a mother’s chance of chronic pain and bowel problems,

4.      Increased risks for baby including poor condition at birth, breathing difficulties, bruising, and jaundice,

5.      Increased risk of placental abnormalities including placenta accreta (described above) and placenta previa (where the placenta grows over the cervix) putting mother at risk for a life threatening hemorrhage during the pregnancy & delivery, which could result in hysterectomy in serious cases, and

6.      Increased risk of ectopic pregnancy (a surgical emergency where a fertilized egg implants somewhere besides the uterus (e.g. in a fallopian tube)).

The Bottom Line: All of these complications increase a mother’s risk of prolonged hospitalization, hysterectomy, and maternal death. 

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Although I feel the article made some great points, I feel that some very important facts were either missed or not stressed enough in the article and at this time I would like to share some additional information that I feel will provide you with a more comprehensive picture of the VBAC/Repeat Cesarean debate.  Here we go!

(1)   FACT: The high-profile cases of uterine rupture during a VBAC in the 1990s were directly related to the use of the drug Cytotec (generic name misoprostol) for labor induction on women with a history of a prior C-section. 

Marsden Wagner writes in his book Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First that between the years of 1994 and 1999 approximately 25,000 women in the United States who had previously undergone a prior C-section were given Cytotec for labor induction and out of those women, 1,000 of them suffered ruptured uteruses, a rate that is a twenty-eight fold increase in the rate of rupture over having a VBAC without Cytotec induction.  He also writes that despite years of mounting evidence and research studies reporting the risks of using Cytotec for labor induction on women with uterine scars, OBGYNs continued to use the drug (which was neither approved by the FDA for labor induction nor clinically trialed in a research study for a safe and effective dose) for this very purpose proving once again the pervasive anti-precautionary obstetrical culture of “assumed safe until proven otherwise.”

(2)   FACT: Women can safely have a VBAC in a hospital, an out-of-hospital birth center, and even at home!  (And they have too!)  VBAC becomes more and more risky when you start to obstetrically intervene, like in the case of labor induction and augmentation.

Wagner writes,

    “The phenomenon [with the increase in uterine ruptures during VBAC in the 1990s] was almost certainly related to the fact that the percentage of births in which powerful drugs, such as Cytotec, were used to induce labor had doubled, given that studies show there is an increased risk of uterine rupture with pharmacological induction.  But instead of acknowledging and addressing this connection by recommending that obstetricians not use Cytotec for induction, the organization recommended that a women not be permitted to attempt a [VBAC] unless she was in a hospital where an  anesthesiologist was [immediately available].  In other words, instead of preventing uterine rupture, ACOG said that we should surround the woman with experts to deal with the rupture when it happens.  This is like trying to solve the problem of children drowning at summer camp by not teaching the children to swim, but rather by putting a couple of life preservers in the lake.”

(3)   FACT: A cesarean section performed after an attempted VBAC is NOT necessarily an emergency cesarean section! 

In the TIME article, author Pamela Paul writes:

“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 without needing an emergency cesarean.”

In other words, the 27% of women that Paul describes needing a C-section after an attempted VBAC did not necessarily have an emergency cesarean, contrary to what Paul writes.  The high-risk urban hospital where I am currently employed as a labor & delivery nurse (which happens to have anesthesia and an attending physician in house 24/7) classifies the urgency of cesarean sections into 4 categories:

            ● Category I (STAT): Immediate threat to life of woman or fetus (e.g. prolapsed umbilical cord, uterine rupture, anaphylactoid syndrome, prolonged fetal heart rate deceleration with no return to baseline).  Luckily, these are the most rare type of all cesarean sections; however, the risk of needing a STAT cesarean increases with more obstetrical interventions.

            ● Category II (URGENT): Maternal or fetal compromise, not immediately life threatening (e.g. non reassuring fetal heart rate pattern, like prolonged and repetitive variable decelerations or repetitive late decelerations caused by cord compression or utero-placental insufficiency).  Indications for these types of cesareans allow for the physician and anesthesia to get to the hospital (quickly of course) and for nursing to prepare the patient.  Don’t get me wrong, these cesareans are considered an emergency, but they allow for decision making and (rapid) preparation, unlike category I cesareans, which always require immediate transfer to the operating room and general anesthesia.

            ● Category III (ASAP): Needing early delivery but no maternal or fetal compromise (e.g. “failure to progress,” “dysfunctional labor,” and “cephalopelvic disproportion.”)  This category of cesareans is what the majority of women who have attempted a VBAC but ended up needing surgery will encounter.  They require a timely delivery but these women often “sit” for hours if needed, like if the operating room is currently working on a more urgent case.  These are NOT emergency cesareans.

            ● Category IV (INTRAPARTUM SCHEDULED): At a time to suit the mother and maternity team (e.g. scheduled primary or repeat cesarean sections for indications such as breech baby, stable placenta previa, and elective repeat cesarean). 

As you can see, if you are one of the 27% of women who ends up with a C-section after an attempted VBAC it will not necessarily be an emergency, but unfortunately, that is what the public has been mislead into believing.  Regrettably, fear clouds good judgment.

(4)   FACT: The current medicalized culture of childbirth in the United States, as well as the territorial nature of obstetricians have resulted in the development and use of the so-called “informed consent” form for VBAC, but no such form is routinely given to patients who agree to scheduled repeat cesareans. 

In The Thinking Woman’s Guide to a Better Birth, author Henci Goer writes:

            “[The informed consent for VBAC form] details all the horrible things that could potentially happen should the scar give way during a VBAC.  But this form is not really about informed consent because it says nothing about all the equally horrible things that could potentially result from an elective cesarean.  In fact, the obstetrician editor of OBG Management, who devised its prototype and promotes use of such forms, openly admits that the motivation behind them is forestalling lawsuits and that using them will ‘send your C/S rates soaring.’”

Why are we teaching our women to fear birth but blindly accept risky obstetrical interventions and major abdominal surgery as no bid deal?  We’ve got it backwards!  When the operative consent for a repeat cesarean is reviewed with patients at my hospital, the residency staff is taught the following spiel, and I quote, “This is a consent for your doctor to perform a cesarean section for you today.  The risks of the procedure include injury to your bowels or bladder, infection, and bleeding, all of which are very rare and can also occur in a vaginal delivery.  Sign on the X please.”  Talk about spinning the facts and lying by omission! 

The obstetrical community spends a lot of energy arguing that it should be a woman’s right to choose whether they undergo the “risks” of VBAC or choose the more “controlled” and “predictable” option of the repeat cesarean section.  While I agree with basic idea behind this (i.e. that a woman deserves the right to make choices about her own body), OBGYN providers in this country are NOT providing patients with true informed consent.  In addition, these obstetricians are especially not letting women on to a very important and real phenomenon that is a direct result of the cesarean epidemic: The first cesarean is very easy but the second, third, forth, and fifth cesareans are exponentially more complicated and dangerous. 

Which leads me to my next point…

(5)   FACT: Women are notoriously bad at predicting how many children they will have at the time of their first delivery.

A 2008 research study published by physicians in the Division of Maternal-Fetal Medicine at the University of Michigan, Ann Arbor in the journal Obstetrics and Gynecology found that at the time of a woman’s first pregnancy, “many women underestimate their final parity,” meaning at the time of their first baby, almost 40% of women thought that they were eventually going to have fewer children than they actually ended up having.  This research finding is very important to the VBAC debate because many women figure that if they are only planning to have one more baby, then it is “no big deal” to have a repeat cesarean.  

…Until of course they separate from their partner or go through a divorce, meet someone new and want to have baby with their new partner.  Or what about those women who never expected that “oops” pregnancy after what was supposed to be their last baby. Or the couples who decided that they really do want to try for that baby boy/girl they don’t have after all!  Not only do these scenarios happen but they are common in today’s society.  So what are we left with?  A bunch of women who thought they were going to have just one more cesarean, that now are going for their third or forth, resulting in even less providers who will attend their VBAC and even more risk for complications if they even try.

Bottom line, we need to change our whole mindset when it comes to VBAC.  When a woman undergoes her first C-section, everyone should just assume that if she gets pregnant again she will plan for a VBAC, NOT the other way around!  North American obstetricians should not have to be dragged into doing VBACs.  If there is a good reason why a woman can’t VBAC, like prior classical uterine scar/extensive uterine surgery or placenta previa, its then and only then that our providers recommend a repeat cesarean.  OBGYNs tend to forget that the only way one can know that a VBAC will or will not be successful is to allow the woman to labor!  In her book The Thinking Woman’s Guide to a Better Birth, Goer reports that several studies published in leading obstetric journals have found that when physicians “genuinely encouraged women to have VBACs, most of them did, and when they said nothing or acted neutral, most women didn’t.”   

(6)    FACT: Physician convenience should not enter into the VBAC debate at all!  With the safety of our mothers and babies at stake, the “make it home in time for dinner” phenomenon among obstetricians is unsafe, selfish, and irrelevant.

In the TIME article, Paul writes,

“Among obstetricians, many solo practitioners are unable to stay for what could end up being a 24-hour delivery; others calculate the loss of unseen patients during that time and instead opt to do hour-long cesareans, which are now the most commonly performed surgeries on women in the U.S.”

I feel Paul has correctly captured the attitude of too many obstetricians in this country (and how outrageous it is!).  First of all, putting “time limits” on how long a woman should be “allowed” to labor is preposterous and irresponsible and often leads to the unnecessary “cascade of interventions” too often seen during labor in a hospital setting.  Newsflash! Labor takes time.  This fact of life should not be an indication for cesarean section.  This is why physicians and midwives form group practices, so one can be “on-call” while the others can be in the office seeing patients or have the day off.  Perhaps “solo practitioners” need to rethink their business strategy instead of “opting” to perform unnecessary major abdominal surgery on the unsuspecting women of our country. 

And lastly…

(7)   FACT: BIRTH IS SAFE, INTERVENTIONS ARE RISKY!

I wish I could scream this from the rooftop of every labor and delivery ward in this country.   In Paul’s article she reports, “Some doctors, however, argue that any facility ill equipped for VBACs shouldn’t do labor and delivery at all.”  I hate to break it to these physicians but 24/7 in house anethesia is not necessary for a woman to have a VBAC.  It seems like it is just impossible for many obstetricians to open their eyes and realize that the research and statistics of 26 other countries with better maternal and fetal mortality rates than our own have shown, time and time again, that birth can safely happen OUTSIDE of the hospital.  You heard me right!  For women with normal, low-risk, uncomplicated pregnancies, labor and delivery can safely and does safely occur in homes and out-of-hospital birth centers around this country (and the WORLD) every single day. 

Look, if it was true that prominent national figures in power were never wrong, then John McCain wouldn’t have told the American people that “the fundamentals of our economy are sound” two days before our country began its slide down into the biggest economic crisis since the Great Depression!

So what does it all mean?  In conclusion, whether you are a pregnant mom, partner, labor companion, concerned citizen, healthcare professional, or birth advocate, I just hope that when it comes to the “VBAC debate”, you will make a truly informed decision based on sound research and evidenced-based recommendations rather than become subject to the dangers of defensive medicine and poor or untrue information that currently plagues our existing maternity system in the United States.