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VBAC, C-Section, and EFM: How Safe Are They? by Jennifer L. Griebenow

Practice Variation in Cesarean Rates: Not Due to Maternal Complications
This brief but well-referenced post analyzes cesarean rates relative to differences in maternal diagnoses or pregnancy complexity. On average, the likelihood of cesarean delivery for an individual woman varied between 19 and 48 percent across hospitals.”

Birth attendants often claim that their high cesarean rate is due to their clientele - that they provide care for a lot of high-risk clients.  This analysis shows that:

    Among lower risk women, likelihood of cesarean delivery varied between 8 and 32 percent across hospitals.
    Among higher risk women, likelihood of cesarean delivery varied between 56 and 92 percent across hospitals.
    Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics.

This shows that practice variation in cesarean rates is real, substantive, and not just a reflection of the mother’s risk level.

Tips for Choosing a Care Provider - great overview! from Henci Goer

VBAC (Vaginal Birth After Cesarean), C-Section, and EFM: How Safe Are They? 
Info compiled by Jennifer L. Griebenow 4/97

If you are pregnant for the first time, or are pregnant again after delivering by C-section last time, there are lots of things to think about. What is the best option for you and your baby? Is your doctor suggesting or telling you that you may or you do need a cesarean section?

What are the current rates of cesarean sections? They vary from hospital to hospital and doctor to doctor, but continue to remain around 20-25% on average in the US, although some individual doctors have rates significantly higher than that. Nurse-midwives tend to have lower rates of approximately 8-18%, especially when they practice within freestanding birth centers. And homebirth, lay, or empirical midwives usually have the lowest rates, varying from less than 1% up to 5 or 6%. As you can see, your birth outcome will vary a great deal depending on the health care provider you choose and is based a lot on their beliefs about what is safe in a birth. For specific information on the safety of birth in each of these situations, please see my info sheet entitled Home Birth and Out-of-Hospital Birth: How Safe is It?

What are the risks of the surgery? Cesarean sections carry a far greater risk of additional illness or death than most people realize. I think because they have become so routine in our society, everyone feels "It's no big deal." However, C-sections carry a 2 to 4 times greater risk of maternal death than do vaginal deliveries (Boston Women's Health Book Collective 341).

Several studies on the risk of death from the surgery alone (i.e. factoring out the conditions the surgery was done for) have shown varying, yet consistently depressing, results. Errard and Gold found with eleven years of statistics that the risk of death from cesarean section was 26 times greater than from vaginal birth (Cohen and Estner 26). Cohen and Estner also cite a study done in Georgia showing a maternal death rate of 59.3 per 100,000 women who had cesarean section versus 9.7/100.000 for women who delivered vaginally (26). A California study showed maternal death rate 2-3 times greater form C-section. Korte and Scaer state that obstetricians admit a rate of maternal death four to six times higher for C-section mothers (162) and state that many believe the rate is actually higher, giving a true death rate of 1 in 1,000 (163).

In certain cases, cesarean surgery can be a life-saving procedure for both mother and baby, for example, in cases of placental abruption, placenta previa, prolapsed cord, uncorrectable toxemia and other serious health problems, and when a baby is in an unbudgeable transverse position in the uterus. However, with the risks to your health and your baby's health as high as they are from the surgery, it is wise to consider very carefully if you really need an operation to have a baby.

Particularly in the 80's and 90's, many women have had primary cesarean sections after long labors because, so they were told, they were "just too small." Many doctors state (mine included) the reason for the increase in the section rate is that babies are bigger now than they used to be. Studies show, however, that the overall birth weight of babies has only increased by 2 ounces over the past 30 years. Also, outcomes with a large baby will vary a lot depending on your health care provider. Homebirth or lay midwives see cephalopelvic disproportion much more rarely than doctors do. They do not believe a 10 pound baby to be too difficult for a mother to deliver.

Banta and Thacker state that true CPD occurs in only 2% of first time labors (Korte and Scaer 144). [Note they do not believe it is necessarily a repeating problem.] This is in contrast to the outcomes obstetrics gives. Doctors would have us believe approximately 10% of all mothers are too small to birth their own children. This is given that 22-25% of all mothers will have C-sections, and 25-50% of them will be diagnosed with dystocia or CPD. It is interesting to note that Emanuel Friedman, author of the Friedman labor curve, the graph of average labor times which has become the all-governing "standard of care" in obstetrical wards, said, "There is no magic number of hours beyond which labor should not continue" (Korte and Scaer 144). Often in hospitals, a time limit is set upon each stage of labor, with no consideration of the individual motherís labor experience and no regard for the actual health status of the baby. For example, I experienced a C-section because I ! ! pushed more than two hours. I had gone outside the "normal" hospital parameters, and thus was forced to undergo surgery simply because I had a long pushing stage. My baby's heart tones, the guide to his well being, were within normal range at the time I was told I must have surgery. [Note: I did not know that at the time; I was told he was in imminent danger.]

For mothers who had sections because their first labors did not go perfectly or because they were told they were too small or their babies too big (dystocia); consider the following before automatically consenting to a cesarean for these delivery complications. Maternal mortality in labors complicated by dystocia is 41.9/100,000 for cesarean deliveries, versus 11.1/100,000 for vaginal deliveries (Cohen and Estner 19). Just because baby gets hung up is not a reason to agree to a section. Other things should be tried first, including walking, changing positions, and receiving loving support and affirmation from your labor attendants. Also, see Elizabeth Davis' Heart and Hands for midwifery techniques that can help. Familiarize yourself and your practitioner with these techniques before labor begins. You don't have time to look it up then! Or better yet, utilize the services of a midwife, who already is well-versed in using these techniques in her practice, for your baby's birth.

Dr. Diana Pettiti, gathering information from a large group of NYC birth certificates, draws this conclusion: "For term deliveries complicated by dystocia [a category which includes the ever popular diagnosis of CPD] or fetal distress, there were no significant differences in neonatal mortality between vaginally delivered and surgically delivered infants" (Cohen and Estner 12-13). In other words, cesarean section is not helping mothers or babies with this type of difficult delivery. Other options besides section are available to mothers with these problems, and it looks like surgery is killing more mothers than it helps. When several studies point to cephalopelvic disproportion as the main reason for sections in the 1980's, this is interesting news!

Cohen and Estner's classic VBAC study, Silent Knife, reviews the options for women who have had cesareans and are facing a second delivery. They have collected studies on the subject which cover 20 years. There has not been an article written since the 1930's that says VBAC is not a safe option (89). Please don't believe doctors who say that it is not safe; clearly, they have not read the available materials. More than five studies cited by Cohen and Estner show that VBAC is safer for mother and baby than elective repeat cesarean (77). Several studies also showed that elective repeat cesarean carried a greater risk of death to the baby, even with other complications factored out (36). From page 92 to page 96, Cohen and Estner review stats from every study done in each decade, that all support the safety of VBAC.

The main concern doctors mention with VBAC and what supposedly makes it high risk, is the possibility of uterine rupture. The risk of this happening is very low (less than 1%) and if it does occur, it almost never causes fetal or maternal death. The risk of other childbirth complications occurring (for example placenta previa, prolapsed cord) is much higher. Procedures medicine considers routine, like amniocentesis, carry a greater risk of fetal death (.05-1.5%), than there is probability your uterus will rupture.

Because of the standard interventions most VBAC women are forced to agree to in the hospital, interventions which greatly increase your chance of cesarean section and all its attendant ills, many childbirth educators and midwives encourage VBAC women to give birth at home. As one midwife stated, "Women who have had previous cesareans for non-repeating reasons place themselves at high risk for another section by going to the hospital. From that standpoint, I feel home is a safe place for them to give birth" (Cohen and Estner 308).

Cohen and Estner also quote a VBAC success rate for CPD moms of 85-90% (98). They believe from their work with VBAC moms that it is a non-repeating indication. Peel's study of CPD moms showed a 77% VBAC success rate (Cohen and Estner 98). Silfen and Wolf mention eleven VBACs in CPD women; all of the babies born were larger than their cesarean siblings (98). So, please don't assume that you are just "too small." You do not have to have a cesarean section just because you had one before. Don't be afraid of the pain of labor; you can handle that with the loving help of your family, friends, and confident birth attendants. The possible rewards are so great.

And now a few words about a particularly useless birth intervention you will find in your local hospital, which as a VBAC mother you will almost certainly be required to submit to, although this intervention is often required for first time mothers as well...

Most hospitals require you to have an IV and an external or internal fetal monitor. These inhibit mobility, and make you feel like there's something wrong just by their being there. Obstetricians believe that these monitors provide a more accurate record of the baby's heart rate, thus guaranteeing safer outcomes by providing the opportunity for quicker intervention. The monitors do provide very detailed information, but machines can and do malfunction, showing distress where there is none. A. Prentice and T. Lind surveyed monitoring trials and reported their conclusions in the journal Lancet in 1987. They found that "many mothers will have operative deliveries for "distressed" babies who show no such distress at birth" (Korte and Scaer 111). These researchers also noted that Van den Berg et al. reported that 71-95% of babies diagnosed as distressed during labor show no distress at birth. In other words, the monitor provides a "false positive" up to 95% of the time, and ! ! mothers undergo all the risks of surgery for nothing (111).

In a groundbreaking study done by Dr. Albert Haverkamp to assess the worth of external fetal monitoring, the results of a study group of 483 mothers showed that among those who had an external fetal monitor, the cesarean section rate was 2 1/2 times as high as it was in the group which had auscultation. However, there was no corresponding increase in the rate of problems for the monitored babies (Jones 15-16). These results surprised Haverkamp. Several other studies have verified this outcome. The EFM does not make your baby safer; it simply increases your risk of having surgery, which in turn, greatly increases your risk of injury or death, as described above. Another EFM study even found that the monitor did not improve neurological health outcomes for premature babies (Korte and Scaer 111), who certainly fit the definition of high risk, which is what the monitor was designed for originally!

In 1991, Warren Pearse, the director of the American College of Obstetricians and Gynecologists, stated that "ACOG's judgment is...that for low-risk situations [external fetal monitors] do not offer outcome advantages over auscultation via stethoscope" (Mitford 111). Even obstetricians are not "supposed" to be using them on patients! Despite this fact, most hospitals require their use and many obstetricians and other hospital staff members still think you and your baby are safer because of them. There must be some perceived benefits in their minds. You can ask for a fetoscope at the hospital, but be warned: many nurses don't know how to use them! On the other hand, midwives generally use them in standard practice.

Dr. Greg Troll, an obstetrician who practices using the midwifery model of care, believes that the cesarean section rate in the US has risen primarily because of the use of EFM (Mitford 147). Obstetricians have a tendency to practice with a "just in case" mentality, which I think the EFM has definitely added to. Doctors tend to feel if they have used all the available technology, they have "covered themselves" in case of a bad outcome, when the reality may be that they are causing many of the bad outcomes they hope to avoid.

It is also valid to ask what other reasons why doctors may have for resorting to a cesarean delivery besides fetal distress, prolonged labor, CPD, or fear of lawsuits. You may be interested to know that though C-section rates are up overall in the US, they vary depending on both the type of client involved and the type of insurance the client has. Several studies have pointed in this direction, including one by Roberta Haynes de Regt et al. done in 1986 (Korte and Scaer 133) This massive study included 65,647 deliveries which occurred in Brooklyn over a five year period, and compared clinic patients, who tended to be high risk, with private patients. Amazingly, the researchers discovered that despite low birth weights, the clinic patients' babies fared better than their private patients' counterparts. Not only that, the lower Apgar scores and more birth injuries experienced by private payers' babies were accompanied by a higher cesarean section rate. Does it make sense that mothers at higher risk have lower rates of C-sections and problems, and that those women with better insurance have both more C-sections and more problems?

Whether we like it or not, money does affect the outcomes of our babies' births. Doctors don't like to believe that they practice the way they do because they will get more money, but it does influence their thinking dramatically. An HMO in Kansas found a way to lower the C-section rate among its members. The rate dropped from 28.7% to 13.5% within one year. How was this accomplished? By providing the exact same monetary reimbursement to obstetricians, regardless of the method of delivery (Korte and Scaer 135).

When thinking about how and where you want to have your baby, there is a lot to consider, but looking at the risks, one thing is for certain: you don't want to have a cesarean section. The risks and the pain are only worth it when there is absolutely no other way to birth your baby safely. Look for a practitioner who believes in you and who believes that birth is a normal and natural process, not a disease that must be medically managed. Just doing that one thing can greatly decrease your chance of having surgery.

Wherever you decide to give birth is up to you; just remember that you can make the decisions that need to be made when you have true information. It is your body, your baby, your money, and your life on the line, not the doctor's or anyone else's. You have the right to accurate information and the right to decide what is best for your baby. Don't let anyone tell you otherwise. Also, when you ask for information, beware of health care providers who say they judge each case individually, so they can't really give you their statistics. It probably means either they don't know or they don't want you to know. You will have to live with the consequences of decisions made during your labor, for better or worse. For more information or support, call me at 606/625-0185 or email me at griebenow@iclub.org

The author disclaims any liability for any actions arising from information on this sheet, and urges you to use your own mind.

References



This Web page is referenced from another page containing related information about ICAN/VBAC/Cesarean

 




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