Natural childbirth OK after Caesarean sections, health groups say

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Updated: March 24, 2011 9:32AM

Women who’ve delivered a baby via cesarean section can consider vaginal birth for subsequent children, according to two leading health organizations.

The groups examined the safety of vaginal deliveries after a prior cesarean birth. Both indicated a trial of labor is reasonable for most women.

This summer, the American College of Obstetricians and Gynecologists (ACOG) issued a statement that said attempting a vaginal birth after a cesarean (VBAC) is a safe and appropriate choice for most women who have had two prior cesarean deliveries. This includes women who are delivering twins and those with an unknown type of uterine scar.

In March, the National Institutes of Health concluded that, because a VBAC and elective repeat cesarean both have important risks and benefits, a trial of labor is a reasonable option for many women with one prior low-transverse incision.

Fears remain

Despite these statements, some still fear the chance the uterus may rupture at the site of the previous incision.

Furthermore, an emergency hysterectomy performed under these conditions is riskier because of pregnancy’s prominent blood vessels, said Dr. Shamim Y. Patel, board certified gynecologist and obstetrician at Adventist Bolingbrook Hospital.

Women with multiple cesarean sections may also develop excess scar tissue and adhesions and bowel injury. They have a higher possibility of developing placenta previa or placenta accrete in future pregnancies.

However, women can and do safely undergo multiple cesareans, more than the three that used to be considered standard, although ACOG warned these women have higher risks for blood transfusions and infections.

Patel recently performed a patient’s sixth cesarean section. “The patient did great,” Patel said.

Nevertheless, many consider the country’s cesarean rate as too high, 32 percent in 2007.

‘Horrifying’ rate

Some people, such as New Lenox doula Colleen Curry, call it an epidemic. “It’s pretty horrifying to think that 32 percent of women can’t birth on their own without surgical help,” Curry said. “If that was true, our species would not have survived.”

Others, such as, Patel, feel those numbers must be tempered with other data. Fetal distress, cord prolapse and failure of labor to progress are considered legitimate reasons for a cesarean. Many breech and twin pregnancies are also performed by cesarean.

Obese women are more likely to experience a cesarean, as are mothers with uncontrolled hypertension and diabetes. Since more women are delaying their first pregnancies until their 30s and 40s, there is a higher likelihood that some of these women will have pre-existing health conditions that may necessitate a cesarean.

Still, for patients who meet certain criteria, including a low transverse incision (a vertical incision carries a slightly higher risk for rupture), no induction with prostaglandins and continuous fetal monitoring, Patel offers a trial of labor, along with a full explanation of its risks and benefits. She maintains that any woman undertaking a VBAC should do so at a hospital equipped with 24/7 anesthesiology services and access to emergency care, should a rupture occur.

However, when a patient prefers a repeat cesarean, Patel will not attempt to change her mind, especially if Patel feels that woman is not a good candidate for that trial. “A rupture usually happens once the patient is in active labor, so you cannot predict in advance who will rupture,” Patel said. “It can just suddenly happen.”

Catherine Craig, a certified nurse midwife affiliated with Silver Cross Hospital in Joliet, takes a more lenient approach to VBACs.

She believes that many of the current guidelines health care providers have adopted toward trial of labor are based on fear of litigation. These fears may be communicated to the patient, which then influence her decision and access to care.

This may be especially true in solo practices or rural communities where it is impractical to cancel patients for an entire day because a woman with a previous cesarean is in labor.

Many doctors, Patel added, prefer to be at the hospital when a woman with a previous cesarean is in labor.

“Few people go into medicine to get rich, so it’s devastating when people sue,” Craig said. “Yet a healthy woman doesn’t need someone constantly sitting at her bedside when she is in labor.”

Craig said there is an assumption within the medical community that, even if the outcome is less than desirable, when doctors perform cesareans, they have done everything possible for the patient.

Nevertheless, although Craig believes VBACs are inherently safe, both trial of labor and repeat elective cesarean have risks. “It just depends which risk the patient is willing to take,” Craig said. “You cannot prevent all bad things from happening.”

Colleen Curry, who has provided doula support for some of Craig’s patients, said much of the success for a trial of labor depends on building up a woman’s confidence that her body can successfully birth a baby, the way nature intended.

“Uteruses just don’t rupture,” Curry said. “Certainly after a cesarean it is weakened, like a knee becomes weakened after knee surgery. But just because you have repair done, that doesn’t mean you can no longer use the knee, that the ligaments are going to tear and fall off.”

Erin Mincks, 30, of Somonauk, changed doctors five times before finding Craig and having her first VBAC in 2006 at Silver Cross Hospital. Before her cesarean in 1998, Mincks said her doctor thought she would never birth naturally. “My husband’s 6 foot 2 inches and I’m 4 foot 9 inches, so he said I was too small,” Mincks said.

She blames her cesarean more on the medication she received in labor rather than a small pelvis. At first she was grateful that her doctor had “saved” her and the baby, but when she began studying natural and holistic health, Mincks knew she wanted a trial of labor with her next baby.

Ironically, the second was 2 ounces heavier than her first. Mincks’ third child was born in 2009, also by VBAC.

Mincks appreciates working with a health care specialist who works with her as an individual and respects her wishes. For instance, Mincks received intermittent, as opposed to constant, fetal monitoring, and felt her outcome was just as good.

“Basically, I feel it should be a woman’s right to decide how she wants to give birth,” Mincks said. “I am outraged that I had so switch doctors so much in order to have a VBAC because no one wanted to do it.

“The high C-section rate is ridiculous. I feel some women are being strong-armed into having one.”

Caroline Egdorf, 29, of Joliet knew her doctor had a no VBAC policy, but that was fine with her. Two years ago, Egdorf had a cesarean because her son was breech, so she assumed her second child, then due November 2009, would also be breech, so she did not push the trial of labor issue.

At 26 weeks, after an ultrasound revealed the baby’s head was down, Egdorf wondered if she couldn’t possible have a vaginal birth after all. So she researched her options and switched doctors at 32 weeks. She is glad she did.

“I don’t hold any grudges against the doctor who did the cesarean section, but I had a much better experience this time,” Egdorf said.

“You’re in pain, but it is a different kind of pain. You can move around. You can take care of the baby. With my first son, I was so sick for 13 hours that I couldn’t really hold him for more than 30 seconds because I was throwing up.

“If I had a C-section, I’m not sure what I would have done. My husband works nights so I had no one to help me take care of my 2-year-old.”

Not everyone feels as strongly about a trial of labor. Lynn Smith, 40, of Plainfield, had two previous cesarean sections in 2000 and 2006 and plans to deliver her third baby, due in December, by a scheduled, repeat cesarean section.

“I had my first C-section because had been in labor without any drugs for 26 hours and I had pushed for a long time,” Smith said. “You could see her hair and she wasn’t in distress or anything, but she just wasn’t coming out. We tried lots of things, repositioning, relaxation techniques, but it wasn’t happening for me.”

For Smith’s second pregnancy, her doctor felt she was a good candidate for a vaginal birth but during labor, she experienced similar difficulties. Instead of feeling bitter, Smith is thankful for modern medicine, for surgical interventions and for birthing choices.

“If it happened 100 years ago, I might not have survived the first time,” Smith said. “Both times when I had the C-sections, I was exhausted from labor. I don’t want to be physically worn out if it’s going to happen again anyway. I want to enjoy the baby and not fretting so much about recovering from surgery.”