Born again

One cesarean doesn’t always have to lead to another, new guidelines indicate

Photo by Kat Kerlin

Brandee Shipman had smooth, uneventful labors and vaginal births with her first two children. So it came as a surprise when, nearing 10 centimeters dilation, she needed an emergency cesarean with her third child when his heart began to decelerate.

“They said this is what I had to do or my baby would die,” says Shipman. “[The doctor] even went so far as to tell me I would ruin his retirement because I could sue him for all these things.”

She didn’t want a c-section.

While c-section is considered a safe procedure and can save the lives of mothers and babies, it is major surgery. Certain risks are higher after c-section than after vaginal delivery, according to the National Institutes of Health. These include increased risk of infection, injury to the baby and can cause problems with future pregnancies and deliveries.

“But have you tried to argue with the doctor while you’re in bed and in labor?” says Shipman.

She looked at her doula at the time, Sherry Asp, who is now a midwife.

“I can still remember the look on her face, and she nodded, yes, this is what I had to do,” says Shipman. “If I were having the baby at home, I would have been transported. But to this day, I feel like I was ready to push him out.”

In addition to the negative feelings she associates with that labor, Shipman says recovery from the c-section was harder than it was from her vaginal births.

“By the time I wanted the fourth baby, there wasn’t any way I was going to have another cesarean,” she says.

She wanted a VBAC, or Vaginal Birth After Cesarean. But this was in 2007, and there weren’t many obstetricians in Reno supportive of VBACs. One physician told her he would do a VBAC with her, but he couldn’t guarantee he’d be at the birth, and therefore couldn’t guarantee the doctor on call would be as receptive to her wishes.

“That just wasn’t good enough,” she says.

She decided to go to midwife Diane Schaub, under whom Asp apprenticed. The fact that Shipman had two vaginal births with no complications made her a good candidate for a VBAC. Her fourth baby was born vaginally at home.

“I felt more comfortable having that fourth baby VBAC than my whole other three at the hospital,” says Shipman.

Midwife Sherry Asp has attended several successful vaginal births after cesareans.

photo by Kat Kerlin

Organized labor

Since 1970, the cesarean rate in the United States increased from 5 percent to more than 31 percent in 2007—a figure similar to rates in Washoe County hospitals. And over that time, once a woman had a cesarean, she was expected to have one for every subsequent birth. Meanwhile, the rate of VBACs fell from 28 percent in 1996 to 8.5 percent in 2006, partly due to restrictions hospitals and physicians placed on what’s termed “trial of labor after cesarean” (TOLAC), as well as patients who decided the risks involved with a VBAC outweighed the potential benefits.

“If you have a successful VBAC, there’s less blood loss, less infection for mom, less chance for going to the NICU [Neonatal intensive care unit], a quicker recovery for mom, less potential for respiratory problems for the babies,” says Dr. Vickie Tippett, one of seven providers in rotation on the labor and delivery floor 24 hours a day at Renown Health. It’s part of a year-old program with Renown Medical Group-Women’s Health that accommodates women who want a VBAC.

But there is a 0.5 to 1 percent risk of uterine rupture with a VBAC, which can pose great health risks to the mother and child.

“We have all seen as physicians the ugly side of VBACing—the rupture, the bleeding,” says Tippett. “Not everyone is a good candidate.”

New, relaxed guidelines from the American Congress of Obstetricians and Gynecologists (ACOG) have opened the field as to who should consider a VBAC. These include women who’ve gone past their due dates, who have an unknown uterine scar type from a previous cesarean (some scar types are riskier than others), who are pregnant with twins or who’ve had two previous cesareans.

However, the guidelines are not rules, and physicians don’t have to abide by them.

“My job is to make sure the baby is healthy and the mother is healthy,” says Tippett. “Whether ACOG agrees, you need to make sure your patient has the best care possible.” So while ACOG says women who’ve had two c-sections, unknown scars and are having twins make appropriate VBAC candidates, Renown Medical Group-Women’s Health wants only one previous cesarean, a documented scar incision, and they aren’t willing to do a VBAC with women having twins.

Yet, the program at Renown is largely in response to past and current ACOG guidelines that say “Because of the risks associated with TOLAC [Trial of Labor After Cesarean] and that uterine rupture and other complications may be unpredictable, the College recommends that TOLAC be undertaken in facilities with staff immediately available to provide emergency care.” Many hospitals took that to mean the obstetrician should be on site throughout the entire birth.

“If you rupture, you need to have the baby as soon as possible,” says Tippett. She says an emergency c-section may need to be underway within eight to 10 minutes of a uterine rupture. “You can’t be in your office and have that happen.”

However, that recommendation in recent years has caused somewhat of a de facto ban on VBACs in Reno hospitals, especially given that many obstetricians attend births at both Renown and Saint Mary’s Regional Medical Center, and may have their offices elsewhere.

“If their office is down the street, they can’t be there and at the hospital for the birth, too,” says Asp. C-sections are often completed in under an hour, whereas labor tends to last anywhere from six to 24 hours.

“VBAC has never been forbidden at either Saint Mary’s or Washoe Medical [Renown],” says Dr. Bruce Farringer, who’s done several VBACs. “The reason there hasn’t been nearly as many VBACs at the hospitals or in the U.S. in general in the last 15 years is not because hospitals forbid it but because doctors encourage against it.”

Then there’s the liability issue.

“Both labor and deliveries in Reno have always had 24-hour, in-house anesthesia for women in labor,” says Farringer. “I think the two biggest reasons for the decline in VBACs for the last 15 years is physicians are more afraid of getting sued in general because of bad things that have happened with VBAC than they are of getting sued for c-section problems.”

While Farringer is one of the few VBAC-friendly local physicians, he says he hasn’t seen much demand for them. “There’s been a fair amount of media coverage over the past couple of decades that make women fearful of that,” he says. “The vast majority of my patients who’ve had a c-section aren’t interested in VBAC. Obviously, we all want to avoid complications. A successful VBAC has a lower risk of serious complications for mom and baby than a repeat c-section. But an unsuccessful VBAC, there’s actually a higher risk of major complications than if the woman had had a scheduled repeat c-section.

“So you want to offer a VBAC to the women who are most likely to be successful. Those are women with only one prior cesarean or women who’ve had a prior vaginal delivery before their c-section, and women who’ve had spontaneous labor, as opposed to induced labor, and women whose previous c-section was not because they were in labor and got stuck—they have a very low chance of successful VBAC.”

According to ACOG, the success rate for VBAC attempts is 60-80 percent.

“People read the new guidelines and think, ‘Oh, I can have a VBAC,’” says Tippett. “That’s not necessarily true. They need to talk to their provider and make an informed decision. Not everyone is a good candidate.”

Dr. Vickie Tippett is with Renown Medical Group-Women’s Health, which helps accommodate mothers who want to avoid a repeat c-section.

photo by kat kerlin

Get talking

Asp has worked with several good candidates. She attends about six homebirth VBACs per year, none of them yet resulting in uterine rupture.

“I’ve just been to so many wonderful births, and I love it when a mom with one or two cesareans—they have the mentality that they’re broken—and then they do it and are so happy, and they get that confidence back in their body,” says Asp. “With births, mom wants that healthy baby at the end and the vaginal birth. But if she doesn’t get that second piece, she’s ecstatic about that healthy baby but loses confidence in her body’s ability.”

Ultimately, how a woman gives birth is up to her. It may not always seem that way while in labor, but doctors can’t force a woman to have a cesarean or deny care to a woman in labor who declines to have a repeat cesarean delivery, explains ACOG. However, if conflicts arise as labor is underway, health risks to the mother and baby could increase. That’s why it’s important for a woman and her provider to have a clear, informative discussion about her options and desires for labor long before the contractions begin.

“We wouldn’t have to worry about VBACs if they didn’t do so many cesareans in the first place,” says Shipman. “When people hear I had a baby at home after a cesarean, they say, ‘They let you do that?’ Who is ‘they’? We can decide, and until we decide to do things another way as mothers giving birth, it’s not going to change. Some mothers do have to have cesareans because they do save lives, and that’s why it was created. But when you’re looking at cesarean rates upwards of 30 percent, there’s no way! That’s taking it a little bit too far. … I’m not saying everybody should say, ‘I’m going to do this hell or high water.’ I’m just saying if we think we have other options in our lives, things can change.”