The born dilemma

Mothers find themselves sparring with hospital over natural childbirth following C-sections

09/02/2008 12:00 AM

08/31/2008 5:27 PM

Angela Hathaway wanted natural childbirth for her third baby.

But she had trouble finding a doctor who would agree to it.

That's because Hathaway's first two children were delivered by Caesarean section. And most obstetricians believe women who have had more than one C-section are at high risk for uterine rupture if they try vaginal delivery again.

But Hathaway, 33, of south Charlotte, researched the subject and concluded that having another C-section was riskier than having a VBAC – vaginal birth after Caesarean.

After interviewing more than 20 doctors across Charlotte, she found one, Dr. Mark Peacock, who would agree to try a vaginal delivery at Presbyterian Hospital Huntersville.

But before her baby was born in July, she and other advocates of natural childbirth grew alarmed when they thought Presbyterian officials were about to ban VBACs, as 300 other U.S. hospitals have.

So they formed a Charlotte chapter of the International Cesarean Awareness Network to support women seeking VBACs.

“I was not going to have the hospital tell me that I was not allowed to birth my own baby,” Hathaway said. “No woman should be forced to have major surgery for no medical reason.”

Hospitals officials deny they ever intended to ban vaginal deliveries for women who have had Caesareans.

“I'm not sure where that came from,” said Dr. Thomas Zweng, chief medical officer for Presbyterian. “It was never a consideration to eliminate VBACs.”

A change of plans

Hathaway said she was more than seven months pregnant, in May, when she learned from Peacock and his office's certified nurse midwife, Marcia Chiluck, that they had been told to stop performing vaginal delivers for women who had undergone more than one C-section.

Hathaway said Chiluck, who has performed VBACs at Presbyterian's Huntersville hospital in the past, was also told to stop performing VBACs without a physician present.

These changes angered her enough to ask for a meeting with hospital officials. As a result, she said she was allowed to go ahead with her vaginal birth plan. But she still worries that Presbyterian wants to limit a woman's choice of a VBAC.

Presbyterian's Zweng declined to talk about specific patients or situations.

He said the hospital has no formal policy on VBACs. But in recent months, a committee of doctors and administrators had been looking at safety issues because some obstetricians have concerns about the risks involved in performing vaginal deliveries for women who have had more than one C-section.

The committee chose not to write a policy. For now, as before, Zweng said the decision to do a VBAC is between the patient and her doctor. “There's no policy in place, and there's no plan to put a policy in place,” he said.

Generally, the hospital follows guidelines from the American College of Obstetricians and Gynecologists. The group says women who have had one Caesareran delivery can be candidates for VBAC. If a woman has had two Caesareans, it says, only those who have had a prior vaginal delivery should be considered for VBAC. The recommendations say an obstetrician should be available to perform an emergency C-section.

Uterine rupture during labor after a previous Caesarean delivery “is a life threatening complication that has been directly attributed to attempted VBAC,” the college's policy says. “A previous vaginal birth significantly reduces the risk of uterine rupture.”

A ruptured uterus usually requires emergency intervention, such as blood transfusions or hysterectomy for the mother, said Dr. Sarah Yavorski, an obstetrician-gynecologist with Presbyterian Healthcare. The baby might also suffer, from brain injury or death.

Officials at Carolinas HealthCare System, Charlotte's other, larger hospital system, said VBACs are permitted at its hospitals if a mother wants to try and her physician agrees. They proceed knowing that a C-section could be required if complications develop.

Debated for decades

The VBAC debate dates back more than 30 years.

Between 1970 and 1988, the Caesarean delivery rate in the United States increased dramatically, from 5 percent to nearly 25 percent of births. During that time, the adage “once a Caesarean, always a Caesarean,” which dominated obstetrics for nearly 70 years, began changing with improvements in medical care.

In the mid-1990s, VBACs had increased and Caesareans decreased to 21 percent. But as VBACs rose, so did the incidence of uterine rupture and other complications. The C-section rate increased again, to a high of 26 percent in 2002.

Meanwhile, mothers interested in natural childbirth, even after Caesarean, are reasserting themselves.

After fighting for her right to a vaginal birth, Hathaway ended up delivering her son, Daniel, by C-section anyway.

He was born July 24, almost two weeks past his due date. Because of that delay and the risk of complications, Hathaway agreed it would be “safer to go ahead and get him out.”

“I was disappointed,” she said. “But it was safest for Daniel. And it was my choice. Not the hospital's choice.”

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