movement to discourage mothers who have had C-sections from
going back to vaginal birth alarms many women and childbirth
Jennifer Leidig, at eight months pregnant, was told her
doctors practice no longer supported allowing women
to have vaginal births after cesarean sections because they
question the safety of Saratoga Hospital for VBAC,
she felt betrayed: How could they take such an important
decision away from me and how could they not act in my best
interest? she wondered.
awaiting the birth of her second child, due late in June
or early July, Leidig felt a sense of elation until she
received the telephone call, informing her of the news,
two weeks ago. Now, she is faced with either scheduling
another cesarean to give birth to her child or with trying
to find a new medical provider and hospital that offers
the VBAC option.
I known then that opting for a C-section might prohibit
me from ever having a vaginal birth in the future, I am
not quite sure I would have made the same decision,
says Leidig. I believe that doctors who previously
advised their patients that a vaginal birth after C-section
was possible have a moral and medical responsibility to
carry through with their promises.
working on her doctoral dissertation at the University of
Albany in humanities, with specialties in philosophy and
womens studies, Leidig took classes in the history
of womens medicine, an enlightening experience for
womens studies class, Leidig learned that men have
made medical decisions for women through the years, not
always in womens best interests. Although women have
fought hard to gain control over their bodies and to do
what is best for them and their families, for the most part,
women have been without a voice when it comes to their reproductive
all too easy to allow insurance companies, doctors and hospitals
to make womens health decisions, says Leidig.
The unwavering bottom line is they do not have the
right to make these decisions for us.
community hospitals no longer provide VBAC services, although
eight months ago, most still did.
has been a significant media frenzy in response to recent
VBAC studies that claim the procedure threatens womens
reproductive health. However, critics question both the
methodology of the studies and the interpretation of the
results by the media. Most controversial is an article about
a nine-year-long University of Washington study, completed
by Dr. Mona Lydon-Rochelle, a senior research fellow in
the Department of Family and Child Nursing at the university,
and her colleagues. The article appeared in the prestigious
New England Journal of Medicine on July 5, 2001, under the
title Risk of the Uterine Rupture During Labor Among
Women With a Prior Cesarean Delivery. The article
was accompanied by a scathing anti-VBAC
editorial by Dr. Michael F. Greene, an obstetrician and
director of maternal/fetal medicine at Massachusetts General
Hospital in Boston.
who has been a resident of Saratoga Springs for 14 years,
gave birth to her daughter, Katya, at Saratoga Hospital
by cesarean section four years ago because the baby was
in a breech position. Had she realized then that she might
be giving up the choice to have a vaginal birth with her
next baby, she would have at least considered an alternate
procedure that might have turned her baby around. However,
she was advised by her doctors that having a cesarean would
not have any bearing on her future births.
cant promise for sure I would have made the same decision
about not having the procedure to turn my baby around four
years ago, but I do feel that because I made the decision
on the advice of my doctors, they owe me a VBAC, says
Liedig. They have a certain responsibility to patients
they formerly advise.
to Henci Goer, an award-winning medical writer and a former
childbirth educator from San Jose, Calif., The main
fear with labor during a VBAC is that the C-section scar
will open enough to cause bleeding, or that the umbilical
cord or the baby will pass through the opening. In 30 studies,
totaling 56,300 VBACs, the rate of this kind of scar separation
was 4 per 1,000 VBAC births. The few instances when this
did occur and resulted in harm to a baby is the real issue.
However, the perinatal mortality rate [stillbirths and newborn
deaths combined] was 3 per 10,000not much different
than the perinatal mortality rate of 2 per 10,000 in 29,900
a handful of months after the Lydon-Rochelle article and
editorial was published in the New England Journal of Medicine,
many doctors and community hospitals across the United States,
including Glens Falls Hospital in Glens Falls, stopped supporting
any vaginal births after cesareans. Saratoga Hospital in
Saratoga Springs is in the process of evaluating its fiscal
and medical capability to continue to provide VBAC services,
according to Tisha Graham, the hospitals childbirth
educator. Meanwhile, both local obstetric practices affiliated
with the hospital are no longer offering VBACs.
few hospitals which have banned VBACs view labor after a
prior cesarean as a risky elective procedure,
says Nicette Jukelevics, childbirth educator and presenter
at the International Childbirth Education Association and
at Lamaze International conferences. They have determined
that its in their patients best interest to
schedule a repeat [cesarean] operation. Some hospitals say
they are not equipped to provide an emergency cesarean quickly
enough to comply with the current VBAC safety guidelines
recommended by the American College and Obstetricians and
interesting to note that the ACOG recommendations were issued
in July 1999; almost three years passed before community
hospitals and doctors stopped supporting women who wanted
a vaginal birth after cesarean. However, within months after
the article and editorial regarding the Lydon-Rochelle study
was published in July 2001, many community hospitals and
doctors began discontinuing VBAC support. And more continue
Keefe, a cofounder of BirthNet, a Capital Region organization
that informs the community about maternity care in order
to improve it, is concerned that ACOG is not getting input
from other maternity specialists in the medical community.
ACOG recommendations came out regarding VBACs without
any apparent consultations with the family practitioners,
osteopaths, anesthesiologists, nurses, hospital administrators
and medical insurance companies, says Keefe. It
seems that in many cases, obstetricians are making all the
decisions for consumers about VBACs and leaving consumers
with few choices. Nor are they consulting other participants
in the maternity system, most notable, midwives, who are
the specialists in normal births.
book Guide to Effective Care in Pregnancy and Childbirth,
by Murray Enkin and others, the authors question the notion
that a C-section scar bursting during a VBAC is any more
difficult to deal with than other, more common childbirth
emergencies: Treatment of rupture of a lower segment
scar does not require extraordinary facilities. Hospitals
whose capabilities are so limited that they cannot deal
promptly with problems associated with a planned vaginal
birth after cesarean are also incapable of dealing appropriately
with other obstetrical emergencies. Any obstetrical department
that is prepared to look after women with much more frequently
encountered conditions, such as placenta praevia, abruptio
placentae, prolapsed cord, and acute fetal distress, should
be able to manage a planned vaginal birth safely after a
previous lower segment cesarean section.
says, One wonders if hospitals are able to handle
any childbirth emergency, and if not, why are we using them
for childbirth? The whole point of going to a hospital is
in case of an emergency. If the capabilities of hospitals
arent there, why are we going to hospitals?
author of The Thinking Womans Guide to a Better Birth
and Obstetric Myths Versus Research Realities, has a similar
concern: The general hospital population has about
the same potential for a labor emergency as the potential
for the scar giving way, she says. If the hospital
isnt safe for a VBAC labor, then it isnt safe
for any woman in labor.
in the maternity field have also responded strongly to the
New England Journal of Medicine article and the editorial
about the Lydon-Rochelle study.
Bruce L. Flamm, research chairman for the Department of
Obstetrics and Gynecology at Kaiser Permanente Medical Center
in Riverside, Calif., in a December 2001 editorial in the
medical journal Birth, titled Vaginal Birth After
Cesarean and the New England Journal of Medicine: A Strange
Controversy, wrote that the amazing thing about
the uproar surrounding this studys publication is
that it was ignited, not by the study itself, but by a strongly
worded editorial that accompanied it. Strangely, the profound
conclusions espoused in the editorial had little if anything
to do with the results of the study. Flamm is also
a clinical professor in the Department of Obstetrics and
Gynecology at the University of California, Irvine Medical
School, Orange, Calif.
this studys serious methodological flaws and almost
total lack of any new findings, it is indeed paradoxical
that the NEJM, a journal that rarely accepts even the most
outstanding papers in the field of obstetrics and gynecology,
found this particular study suitable for publication,
writes Flamm. Moreover, he says, the study by Lydon-Rochelle
was not only accepted but was given the additional honor
of appearing as the journals lead article
and the fact that Dr. Michael Greene, author of the
scathing editorial commentary that accompanied the study,
is also an associate editor of the NEJM may be related to
this paradox or may be completely coincidental.
Midwives Alliance of North America wrote in a press release,
titled Questionable Medical Study Could Undo Two Decades
Worth of Reform in Childbirth, that The Lydon-Rochelle
et al. study published in the NEJM does not confirm many
former studies on the subject which suggests that a woman
delivering vaginally after cesarean carries a decreased
Anne Daviss, chairwoman of the Midwives Alliance of North
Americas statistics and research committee, says,
The unqualified way in which the study [Lydon-Rochelle]
is being interpreted is an unjustified threat to one of
the major reforms in childbirth that women have accomplished
since the early 1980s: vaginal birth after cesarean.
accompanying editorial misinterpreted the conclusions of
the study, states Jukelevics, and strongly recommended
elective, repeat cesareans as a preferred alternative to
the risks associated with VBACs.
to Goer, a cesarean is anything but a preferred alternative
to the risks associated with VBACs. Cesarean section
results in more pain, debility, and a longer recovery period.
It substantially increases the risk of infection, injury
to other organs, hemorrhage, and blood clots. These
complications, in turn, increase the likelihood of prolonged
hospitalization, hysterectomy, readmission to the hospital,
and maternal death, says Goer. Babies who were
healthy before delivery are more likely to be born in poor
conditions or have breathing difficulties. In the long term,
cesareans can lead to chronic pain or bowel problems, and
they increase the risk of infertility, miscarriage, placental
abruption, [placenta detaching before the birth], and placental
previa [placenta overlaying the cervix].
Leidig gave birth to her daughter Katya at Saratoga Hospital,
she felt that attending physician, Dr. Martha Dexter, and
the nursing staff were exceptional. However, she said that
the C-section itself was horrible.
was overmedicated by the attending anesthesiologist because
he was unprepared for a particular procedure I was also
scheduled for [stem-cell preservation], she says.
The meds knocked me nearly unconscious, only allowing
me to briefly hallucinate and vomit. At first I did not
believe the baby they were showing me was mine, and it took
a while before I could really grasp the fact that she was
mine. Emotionally, there was something missing. Physically,
I could not even lift my baby to breastfeed for the first
two days. The nurses had to come in and help with every
little thing. It took a good two weeks before I was able
to get the last of the drugs out of my system.
is not the only woman to complain that cesarean birth is
a difficultoften hellishexperience. Women who
have been through it say it is difficult, painful, emotionally
draining, depressing and debilitating. And not all women
who have had cesareans feel that it was the right choice
for themthat in fact, they may have been pushed into
it by a health-care provider. Take Victoria Greenwood of
Delmar, for example.
and her husband arrived at St. Clares Hospital in
Schenectady, eager to give birth to their first child, almost
13 years ago. Upon arriving at the hospital, Victoria was
given pitocin to stimulate her contractions. She remembers
a doctor yelling at her husband because she refused pain
medication, and the doctor on the next shift, although kinder
and gentler, suggested that the baby was too big and that
she might want a cesarean. Not yet, Victoria
kept saying, but finally, exhausted from not eating for
two days, she agreed. Despite what the doctor had told her
about her babys size, her daughter Kate weighed only
5 pounds, 12 ounces.
until a few years later that she and her husband found out
that there were other options that would have had less of
a horrific impact on her delivery.
remembers that she was given medicine to make her stop shaking
(a common symptom after giving birth). The anesthesiologist
neglected to mention one particular side effect of the drug:
amnesia. I saw my daughter shortly after she came
out, when my husband held her next to me, but I dont
remember anything else until I woke up in the recovery room,
says Greenwood. Later, I learned I was actually conscious
the whole time. By then, the baby had gone to the nursery,
and I had to wait to be brought upstairs to see herI
remember my husband and I in the elevator on the way up,
and he said, Were never going to do this again
in a hospital! I was shockedhes a physician!
But thats the way I felt, too.
and Fred Conroy of Albany had a similar experience. They
planned to have their first baby, now 5 years old, in the
birthing center connected to their hospital. That didnt
happen. Because Dianas membranes ruptured before her
labor started, she was immediately hooked to IVs for induction,
a continuous blood-pressure cuff, and tethered to a 4-foot
wire. She ended up with a cesarean and a baby weighing 9
pounds, 12 ounces.
passed before Conroy was fully recovered from the cesarean,
before she could even carry or push her son in a stroller.
Emotionally it took longer. I cried often, she
says. In simplest terms, I felt at that time, by having
a surgical birth, I was no longer an active participant
in a situation where my participation is supposed to be
crucial. I had lost all power, control and identity. . .
. I felt guilty about the medications I intentionally exposed
my baby to during my labor.
there are women who have experienced cesareans who do not
have a nightmarish tale to tell. Mary Ellsworth of Greenfield
Center said she had a positive experience during the birth
of her son, born July 4, 1996, even though it was a cesarean
was OK because no one was pressuring my husband and me,
says Ellsworth. The midwife and the anesthesiologist
were instrumental in allowing me to make decisions about
my birth and making it positive. The nurse was going to
take Clarence away from me right after the birth, before
I had a chance to breastfeed him. The midwife told her to
leave the baby with his mother and that she would take responsibility
maternity advocates feel that the rise in cesarean births
in the United States (according to the National Center for
Health Statistics, C-sections now comprise 22.9 percent
of all births in the United Statesone of the highest
rates in the worldand New York states rate is
even higher, at 24.7 percent) and conversely, the lowering
of the VBAC rate has much to do with liability insurance
and the threat of malpractice and little to do with whats
best for mother and baby.
think liability is the root for doctors not supporting VBAC,
declares Goer. I think it is a chain of things. The
root of it is that they are trained to think about surgery,
the surgical aspects. Obstetricians have openly admitted
that one reason for the turnaround is reducing liability
stemming from the scar giving way during labor, a concern
that arose from some successful malpractice suits involving
VBACs. This self-confessed incentive provides a powerful
motive for bias, conscious or unconscious, against VBAC
and a cause for skepticism of statements and policies favoring
adds, Hospitals say they are not equipped to provide
emergency cesareans quickly enough to comply with the current
VBAC safety guidelines recommended by ACOG. Their major
concern is a fear of malpractice suits in the event of complications
following a uterine rupture. . . . Some facilities have
decided that the number of VBACs they have per year does
not justify the cost of complying with the new guidelines.
May 6 ACOG news release, doctors were warned about liability
threats in obstetrics and gynecology: You have to
love what you do with a passion, because the liability threat
will always be there, no matter how outstanding the care
you provide, said ACOG President-Elect Dr. Charles
to the release, obstetrics-gynecology is considered a high
risk specialty by insurers. It is always one of the
hardest-hit professions in times of liability-insurance
problems. The number of lawsuits against all physicians
has been rising over the past 30 years in an increasingly
litigious climate, and OB-GYNs remain at the top of the
list of doctors affected by this trend.
I have no proof, my suspicion is that the policy to ban
VBACs is motivated by the insurance companies, Leidig
states. Even though the chances of anything going
wrong during a VBAC are considerably low, I believe the
payments of the corresponding lawsuits with the few patients
concerned have been exceptionally high. I believe the insurance
companies are pressuring the medical communities across
America to change their policies and stop performing VBACs.
exacerbating the situation, wrote Dr. Flamm in his article
Vaginal Birth after Cesarean and the New England Journal
of Medicine: a Strange Controversy, is that newspaper
reporters somehow believe that studies published in the
NEJM are of special significance and media coverage of the
journals articles is typicalno matter whether
the studies were good or bad. In the case of the Lydon-Rochelle
study, Flamm says, the results were not accurate because
of the method used to measure the uterine ruptures. No hospital
charts or medical records were actually reviewed in this
a New York Times story titled A Risk Is Found in Natural
Birth After Cesarean declared that the Lydon-Rochelle
study found that VBAC was riskier to both mother and
baby than a second cesarean, although not a single
maternal death was reported in the study. Before offering
alternative viewpoints, reporters quoted Dr. Greenes
response to a woman asking about the safest method of birth
for her next baby. He responded, My unequivocal answer
is elective, repeated caesarean section.
more and more groups are forming to educate and support
the public about choices and options available during pregnancy
of BirthNet says that her organization is always willing
to engage in a battle worth fighting, educating people that
maternity care should be supportive and respectful, and
that each womans fears and concerns should be addressed.
BirthNet offers educational programs for the public throughout
the Capital Region, including an upcoming VBAC program scheduled
for June 17 at Saratoga Springs Public Library, which will
examine issues around the controversy and the inconsistencies
it has exposed in maternity care, along with ways to ensure
that all women have access to their full range of birth
local organization, the Cesarean Group, offers a place for
women to discuss their cesarean experiences with people
who have had similar problems. Greenwood, who leads the
group, says that no one can better relate to the stories
of the women who were unable to see and hold their babies
after the surgery, had difficulty nursing with the painful
incisions and dealt with insensitive remarks about the cesarean
procedure, than other women who have been through the experience.
The group discusses ways to avoid some of the traps
of the medical establishment and ways women can empower
themselves in the face of limited childbirth options. Greenwood
is a licensed registered nurse who moved away from traditional
medicine some years ago.
another woman who has been restrained during a cesarean
can fully appreciate the horror and humor of the crucifixion
position, Greenwood says. You are on your back
with your arms secured straight out from your sides, your
ankles secured together to the stretcher.
. . . And we dont need to be reminded again and again
that the health of our baby needs to come first. We know
that. We want that, of coursebut its particularly
helpful to remind people that the babys and the moms
health should come before the doctors, nurses,
hospitals needs, preferences, rules, regulations.
. . . The main focus should be whats best for mom
her first cesearean, Greenwood was pregnant again. She and
her husband kept their word to each other: They never had
a birth in the hospital again. The idea for a home
birth started right on that elevator, when I was 20 minutes
post-cesarean, Greenwood says. Both my husband
and I felt betrayed by the doctors at St. Clares,
particularly my husband, who had to deal with an irate obstetrician
who berated him because I refused the pain medication. I
wasnt being a martyrthe pain was not that bad.
hired a midwife, and instead of using pitocin to get her
labor into full swing, she walked, took a shower, and got
into various funny positions to stimulate the
process. It worked a lot better than lying in bed!
Greenwood says. Caroline came out a healthy baby girl, two
pounds bigger than Kate. The midwife made room for
my husband so he could catch the baby as she came out. It
was hard work and painful, but it was also wonderfulright
there in my bedroom, no nurses to argue with just to see
my baby, no nasty remarks from doctors, no janitors buffing
the floors at 2 AM, no one telling me I was not competent
to take care of my baby, she says. The icing
on the cake was when my 2-year-old daughter came into the
room to see her new baby sister, who was only minutes old,
followed by my mom and my sister.
Greenwood, Conroy was determined to avoid a second cesarean
when she became pregnant again. While pregnant with
our second child, I did a ton of research, she says.
I read everything I could get my eyes on about the
benefits and risks of having a vaginal birth after a cesarean.
One of my greatest concerns was that my uterus would not
be able to grow and support a baby because it had been cut
had another long labor, but this time with the encouragement
and physical support of her birth team in her own surroundings.
When Conroy reached 8 centimeters, she took off for St.
Peters Hospital with her husband and her birth assistants
to meet her midwife. Some hours later, with no episiotomy
(a surgical incision made to enlarge the vaginal opening)
and no tearing, Conroy gave birth to her daughter, 9 pounds,
years after her first cesarean, Ellsworth gave birth to
Madeline at home. She said it was a long labor, but throughout
the 48 hours, the midwives and she discussed a lot of things,
of the biggest things was being able to eat. I was happy
to have the option, and I did eat cream of wheat and scrambled
eggsI was never denied food, Ellsworth says.
I think if I was at a hospital, I would have been
forced into another C-section because I was in labor for
feel extremely happy that I had a lot of choices. That played
a major role in the decisions involved in each birth, but
that was because I talked to lots and lots of people before
each one and wouldnt let myself be intimidated by
the nurses in the hospital for my first birth.
women have taken what they have learned through support
organizations, childbirth classes and the maternity and
birth Web sites, and through their own birth experiences,
to fight back. Leidig wrote a two-page letter to David Anderson,
the president and CEO of Saratoga Hospital, to ask him to
reinstate the VBAC services at the hospital as soon as possible,
since she has only a few weeks left before she gives birth.
told Anderson in her letter that her obstetrical practice
has been forced to refuse her and other women the VBAC option
until the hospital meets specific necessary conditions for
the safety of VBAC patients. Unfortunately, she wrote, she
is at the end of her pregnancy and finds herself in a position
where she may have to leave her doctor of 10 years to find
a new onenot something she is looking forward toand
leaving the warmth and support of her community behind.
Leidig says she does not want to have another major abdominal
surgery that isnt in her best interest, but she still
wants to have her baby with her doctor, at her hospital.
have only a .8-percent chance of a rupture occurring during
a VBAC, she says. My odds of having something
go wrong during a C-section are higher, and the odds of
me having long-term medical problems due to multiple C-sections
are much higher.
has already done the hard work: She has opened the CEOs
door, and now she is waiting for his response.
completed her hard work too: educating herself about her
options. The result is one she will not forget.
the end, I felt I could have moved the very earth itself
with the pure elation, power and emotional strength I was
riding on, Conroy says. What a difference a
vaginal birth made for me. I didnt have the stress
and pain of an abdominal incision.
. . . I believe it was because this time I played a very
educated and active role. I remember telling everyone that
if I could do this, then I can do anything.