Written By: Bette Marston, (with some of my birth stories in it)!
June 2, 2010
All Lori Shourds wanted for her fourth and most recent pregnancy was to experience a natural vaginal birth. But after three cesarean sections, her chances were poor. While most of 27-year-old’s prenatal care for her fourth pregnancy was under the watch of a certified professional midwife who supported her desire for a vaginal birth after three cesarean sections, the work-at-home mom who runs two Web sites struggled to find a hospital near her Ocean View, Delaware, home that would perform the delivery.
“The plan was just to show up in labor and refuse to have a cesarean, because we know that research shows the chances of [uterine] rupture are only increased by a very small percentage with multiple cesareans,” Shourds said.
Shourds was willing to risk her uterus potentially rupturing along one of her old cesarean scars to have a vaginal birth. Still, no doctor wanted to face the potential complications that come after three cesarean sections.
“I have four children, and I have never been the first person to hold my baby, ever,” Shourds said. “I want to be able to birth my baby, because I have seen all these mothers who have a vaginal birth, and get to put their babies right on their stomach.”
Shourds’ experience introduces one of the biggest debates in obstetrics today: vaginal birth versus cesarean section. According to the National Center of Health Statistics, a division of the Centers for Disease Control and Prevention (CDC), deliveries by cesarean have reached an all-time high in the United States. The number of cesarean sections performed has increased from a low 21 percent in 1996 to 32 percent of all births in 2007, which is the latest year of full statistical compilation. Doctors performed more than 1.4 million births by cesarean section in 2007, almost one in every three births, making the cesarean section the no. 1 surgery performed in the United States.
A myriad of reasons contribute to this rise in cesarean sections, including changes in obstetrical practice, such as the reduced number of vaginal births after a cesarean, the recommendation of breech position deliveries by cesarean section, and increased labor interventions; older and more obese mothers; and increased popularity of infertility treatments.
Shourds’ experience does not exemplify this controversy as a whole. Some doctors still perform vaginal birth after cesareans after one or two pregnancies, unlike Shourds’ doctors, and some patients accept their cesarean section. Women have even begun to approach their OB/GYNs during pregnancy about scheduling a cesarean section without a known medical reason, a phenomenon that has become known as cesarean section on demand.
Why is the rate of cesarean sections increasing? Is it because of the patients’ desire for a cesarean, or the doctors’ need to perform one? Is the doctor or patient in charge of this decision? Why is the popularity of VBACs decreasing? And should something be done to decrease the rate?
The History of the C-section
Shourds and her doctor planned for her second delivery to be a vaginal birth, despite the risk of uterine rupture. Unfortunately, when Shourds arrived at the hospital in labor, the doctor on call refused to let her labor for a vaginal delivery because of her previous cesarean section, even though Shourds signed a waiver acknowledging the risks.
“I was not educated, and at that time, I was unaware of informed refusal of cesarean,” Shourds said. “I just thought you go into the hospital and have a baby the way you want!”
If Shourds had her fourth child back in the 1990s, she may have encountered a doctor who would attempt a vaginal birth after three cesarean sections. Before 1990, doctors strongly believed in the mantra “once a cesarean, always a cesarean,” meaning that once a patient has a cesarean delivery, she cannot ever have a vaginal birth for any future deliveries. However, in the early ‘90s, doctors evaluated the cesarean situation, and determined that the rate at the time, 21 percent of births by cesarean, was too high. The American College of Obstetrics and Gynecology (ACOG) updated their guidelines to recommend a vaginal birth after a cesarean, a previously discouraged procedure, for the right patient in the right facilities – a place where an immediate emergency c-section can be done, that has a blood bank available, and where a doctor is readily available.
However, not long after the ACOG changed its guidelines, the trend shifted again when a handful of studies published in 1996 found that women having a vaginal birth after a cesarean were at a higher risk than previously thought for uterine rupture. The risk is still less than one percent chance, but doctors and patients alike do not want to take a chance on harming the baby and causing a potential law suit.
Some doctors were skeptical of the movement away from vaginal births, because of the problems posed by a cesarean section. A cesarean calls for a longer recovery period and more severe pain as the scar heals. Also, the mother faces an increased risk of normal surgical problems, such as hemorrhage, blood clots, and injury to other organs.
“I’ve done so many c-sections, but it doesn’t matter, it’s still surgery,” said Dr. Marc Feldstein, an attending physician at Northwestern Memorial Hospital and associate professor of clinical obstetrics and gynecology at Northwestern University’s Feinberg School of Medicine. “You can injure a bowel, bladder, have bleeding, or even need a hysterectomy. It’s a fact. When you’re pregnant, your blood flow is four to five times greater than normal to the uterus, and when you cut it open, that thing bleeds like stink.”
What’s the big deal with VBACs?
The vaginal birth after a cesarean section is one of the most highly debated procedures in the world of obstetrics, as seen by the decreasing number of doctors who will agree to perform it. The ACOG changed its guidelines when law suits increased in the mid-’90s to say if a doctor is going to do a vaginal birth after a cesarean, he or she must be available in the immediate labor and delivery area throughout the patient’s entire labor, carefully monitoring her, and cannot have any other responsibilities during that time. The doctor must be able to perform a c-section within 30 minutes on a patient attempting to have a VBAC.
In general, a doctor will only allow a patient a trial of labor after having a cesarean section if they are in a teaching hospital or a university hospital, which can provide the constant attention required by the ACOG, and have a wider umbrella of malpractice insurance in case something goes wrong.
Several risks, most notably uterine rupture along the scar and placenta accrecia, where the placenta grows along the uterine scar, can cause severe brain damage to the baby and severe damage or potential death to the mom. Uterine rupture occurs in one of about every 400 births and severely harms the baby in about one of every 1,000 births – these percentages are very small, but doctors with limited insurance coverage do not want to jeopardize themselves.
“I offer it if I have a candidate who is good for it, but I certainly don’t push it,” said Feldstein. If a patient is going for a VBAC and her labor at all falls off the curve, fetal problem or anything, then it’s over and the patient has a c-section.”
However, three out of every four patients who goes through a trial of labor after having a cesarean section successfully delivers a baby vaginally. Take Elizabeth Weber for example. She had two c-sections, one urgent and one not-so urgent, and wanted a vaginal birth for her third pregnancy to experience the natural birth process; she just had to look a little harder to find a doctor who would support her in having a vaginal birth after her cesareans. “After going to three different doctors in the Kansas City area, I found a doctor who would support it, which is practically impossible to do after 3 sections,” Weber said.
Increase in law suits by definition increases cesarean sections
Dr. Robert Yelverton, the Medical Director of Women’s Care of Florida, said the risk of law suits stopped the whole VBAC movement in its tracks.
“The doctors could no longer guarantee that they can drop everything they could do and be available in the labor and delivery area,” said Yelverton. “And even then, if there is a catastrophic problem, there will be a law suit. So quite frankly, a lot of private practitioners who were an advocate of VBACs said to hell with it.”
The increase of malpractice law suits is one of the biggest reasons why doctors are performing more cesarean sections. The relentless trial lawyers have doctors constantly watching their backs, and if the slightest thing were to go wrong in a delivery, causing any damage to the baby, the patient would have leverage to sue the doctor and the hospital. OB/GYNs are now more likely to defensively perform a cesarean in a questionable situation to reduce their fault in case something goes wrong.
“Risk of liability is huge,” said Dr. Kathleen Brown, a practicing OB/GYN with Partners in OB/GYN, a part of Women’s Care Florida, in Tampa, Fla. “Even the slightest abnormality on the tracing or not a perfect labor curve, a lot of people are jumping to c-sections. It’s quick, easy, done and you know that the baby is safe, which is the most important thing. You don’t hear of people getting sued for doing a c-section.”
In the past decade, the doctor/patient relationship has changed significantly, according to Feldstein, who has been practicing obstetrics in the Chicago area for 16 years. He claims the doctor/patient relationship has shifted to a more business-like relationship, especially with the increased use of the internet, where the doctors work as providers and the patients are more like clients. Patients come into the office with their ideal birthing plan in mind, and expect the doctor to comply with it.
“Patients think that because they’ve gone online and done their research, they know they can have a c-section at 39 weeks when it is convenient for them – they can schedule their surgery, go in and have the baby, and get out of the hospital like that,” Feldstein says. “Patients take us for granted, and we have lost that good doctor/patient relationship from the earlier years.”
A patient requesting a certain type of delivery can create a tricky ethical situation for an OB/GYN. However, the ACOG says that if a woman demands one method of birth and understands her risks, the doctor should use his or her own judgment; there is no ethical issue in not doing it for her. However, normally the method of birth is not for the patient to choose. It is widely agreed upon that a vaginal birth is best for the mother, so doctors should encourage all normal pregnancies should attempt a trial of labor. But if the baby has a problem in labor, the doctor ultimately decides how to act in the situation no matter what the patient says.
“I don’t agree with granting a patient a c-section, because for most people the recovery from a vaginal birth is better, and you’re not having the risks of surgery,” said Brown. “If the mother has never delivered before, she needs to at least do a trial of labor. It’s a pretty rare circumstance for a woman to walk in and we give it to her.”
When her patient requests a certain delivery method, Dr. Julie Ericson of the Women’s Group of Northwestern tries to get to the bottom of her patient’s thought process. “I try and talk to the patient and figure out what she is thinking and why in order to make a reasonable recommendation for her. I hear her concerns and educate her on things that she may not understand. Sometimes, a 45-year-old patient comes in and says she does not want to do an [amniocentesis], but I have to do it on her.”
Just another trend?
The potential law suit over a vaginal birth is not the only thing encouraging doctors to perform a cesarean section. Doctors and patients think differently than they did 20 years ago, technology has advanced, and the characteristics and interests of mothers are changing. For example, “Mothers used to smoke and drink during pregnancies, so the babies were four and five pounds,” said Dr. Stanley Friedell, a clinical assistant professor at Northwestern University and president of Northwestern Women’s Health Associates practice. “However, patients are more educated now, so babies are eight, nine, ten pounds.”
Dr. Mike Jaeger, also a practicing OB/GYN with Partners in OB/GYN, a part of Women’s Care Florida, in Tampa, Fla, said that he thinks that obesity is the single biggest factor in the increase of c-sections, “because the fat moms who are out of shape have big babies, and they just can’t get the babies out. […] They’re obese and really they just can’t push – they even say that they can’t go through labor.”
Obesity in the United States is rising with every French fry eaten – 68 percent of adult Americans are overweight and 34 percent are obese – and with obesity comes problems such as diabetes and hypertension, which can increase the risk in pregnancy and lead to a cesarean section. Doctors try to get a baby out as soon as possible to avoid complications from these morbid conditions. Jaeger’s partner Brown agrees with him. “Some women that we go to deliver are so big, and their legs get in the way. You can’t easily get to the vagina in these women.”
Women in their late 30s and early 40s are becoming pregnant as well, which was unheard of a few decades ago, and according to Yelverton, they expect their babies to be perfect. Unfortunately, as a woman gets older, she is more likely to develop problems which can lead to labor complications. Also, women over the age of 40 do not labor as well, meaning they have less spontaneous and effective labor, and often fail to progress, resulting in a cesarean section.
“These women have waited 40 years to have their baby, many have developed a career, now they want to have their 1.2 babies, on average, and they want it to be perfect,” said Yelverton.
On the flip side of things, changes in obstetrical practices are causing an increase in cesarean sections. In vitro fertilization, the process in which eggs are fertilized outside of the womb, then implanted in the uterine lining, is a new obstetrical advancement becoming more popular among infertile women. These pregnancies are often high risk, because in-vitro often results in multiple babies, and the babies are in a more fragile state.
Also, breech deliveries, meaning the baby is positioned in the uterus buttocks first as opposed to head first, which happens in five percent of pregnancies, are no longer delivered vaginally. Adding to that, doctors are reducing the amount that they use operative vaginal delivery techniques, such as forceps and vacuums, and doing a cesarean section in those situations instead. Finally, the increased number of labor interventions, such as induced labor and continuous fetal monitoring, allows doctors to see more potential problems and lead them to do a cesarean section more readily than they would in the past.
Scared of a c-section?
Many women have horror stories about their birthing experiences with a cesarean section, saying their doctor did not honor their wants and needs. With the increasing rates of cesareans, these stories cause women to fear having a cesarean, sometimes causing conflict between the patient and the doctor. However, the doctor’s main goal is to get the baby out safely with no harm done to the mother, which is sometimes best done through a cesarean.
Lara Wheatley, mother of one child birthed by c-section in Lewisport, Ky, describes her pregnancy and c-section as one of the worst experiences of her life. Throughout her pregnancy she was plagued by depression, and she hoped that the vaginal delivery would help her snap out of it. Unfortunately, her failure to progress during her 25-hour labor led to a cesarean section.
“A mega-boost of meds was shot into my epidural line and everything went fuzzy after that,” said Wheatley. “I was so terrified of feeling something painful that I couldn’t focus on the beauty and wonder of something so perfect about to enter the world. It’s just not natural. Being sliced open while awake is not something I want to experience ever again.”
However, some women feel their cesarean was the best thing for them in their situation. Brown, a mother of three herself, had a cesarean delivery after a complicated labor process for her first child, but he doctor delivered her vaginally for her second child, despite her prior cesarean.
“Looking back, they should have just repeated my section, because [my second child] Caroline was this little baby, and I ended up with an un-ideal vaginal delivery with forceps,” said Brown. “I thought it was a lot worse than the c-section, and a lot harder to recover. With my last baby, it was kind of a no-brainer – I absolutely wanted a c-section.”
Women who are adamantly opposed to cesarean sections take it upon themselves to speak out and try to do something about the increasing rates. But most women are like Brown, who just accept their cesarean without question.
In most cases, if the doctor comes in and says ‘You’ve been in labor for 14 hours, I think you’d be better off with a c-section,’ most patients raise their hand and say I’m ready,” said Yelverton.
The Future of Cesareans
All doctors are in agreement over one thing – cesarean rates are going to continue to increase, at least for the next couple of years. “People aren’t getting in better shape, people aren’t getting smaller, and lawyers are not going away. Right now, nothing looks like it’s going to be changed,” said Jaeger.
“Fewer VBACs, fewer forceps, fewer vacuums are all resultant of insidious influence of trial lawyers,” said Feldstein. “Defensive medicine is the elephant in the room – everyone knows it’s there but no one wants to talk about it.”
While insurance companies are keeping their mouths shut about this issue, Dr. Pamela Spry in an interview for MedScape said she heard a speaker suggest a potential solution that providers should be reimbursed the most for a labor and delivery, and reimbursed the least for a scheduled, elective cesarean section. Right now, the difference in payment for a vaginal birth and a cesarean section is minimal, so this approach could encourage doctors to do a vaginal birth.
One of the surgery technicians that Jaeger works with summed the situation up well. One night, he said, “You know what Jaeger, give it another 100 years of evolution, and the vagina is going to be up here, and there will be a sign down there where the c-section goes.”
Crass? Yes. The truth? Also yes.
Northwestern University 2011
Medill School of Journalism
Cesarean Hurts! WATCH & READ THIS FOR MY STORY: