Editorial poses new threats to Vaginal Birth After Cesarean. (Pregnancy & Birth).

Vaginal Birth After Cesarean (VBAC) has been controversial in medical circles for as long as it has existed. The latest comes following the recent publication of a study in the New England Journal of Medicine, entitled "Risk of Uterine Rupture During Labor Among Women With a Prior Cesarean Delivery," by Lyndon-Rochelle, Holt, Easterling and Martin (1) and the editorial by Michael F. Greene (2). The study, although flawed in its design, does not report any new or surprising results. The editorial based on the study, however, draws disturbing conclusions.

The good news about the study is that VBAC has been shown, once again, to be a safe procedure. The authors report that the risk of uterine rupture for women who chose a trial of labor (who planned a VBAC with spontaneous onset of labor is 5.2 per 1000 (0.5 percent) (3). This finding is not new. Dr. Bruce Flamm, a VBAC authority, published a report in 1994 that also showed the risk of uterine rupture to be "less than 1 percent" (4). The study simply shows again what VBAC pioneers have been saying for more than two decades: VBAC is safe.

What is interesting is that the authors of the current study reach a conclusion that natural birth advocates have been saying for years: induction of labor increases the risk of uterine rupture for women planning VBACS. The study reports that uterine ruptures occurred at a rate of 7.7 per 1000 (0.77 percent) in women whose labors were induced without prostaglandins. No description is given about induction methods in these cases. The rupture rate for prostagladin-induced labors climbs to 24.5 per 1000 (2.5 percent).

The authors conclude that "[a]t present, the data suggest that induction of labor increases the risk of uterine rupture among women with one prior cesarean delivery and that labor induced with the use of a prostaglandin confers a greater relative risk." They also note in the next sentence, interestingly, that "It]he overall effect of induction of labor with prostaglandins on uterine rupture is still unclear and may vary according to the preparation used, the regimen, and the degree of cervical readiness for induction" (5). The culprit here is according to their own study's conclusions, induction, not VBAC.

The study by Lyndon-Rochelle, et al. has been criticized for several reasons. The American College of Nurse Midwives (ACNM) released a critique of the report to its membership (6). ACNM notes that the authors of the new study relied upon diagnosis codes of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM codes) to determine if there were uterine ruptures. The researchers looked through old hospital discharge records and noted every time two specific codes, 665.0 or 665.1, appeared. If these codes were present, "uterine rupture was considered to have occurred" (7). The ACNM notes that other studies have cautioned against using ICD-9-CM codes to determine rates of uterine rupture because the codes make no distinction for degrees of rupture. A complete rupture may be coded exactly the same as a dehiscence.

ACNM also notes that the ICD-9-CM codes used by the current study can also be used for cases other than uterine rupture. In other words, although the codes 665.0 and 665.1 were in a patient's discharge records, there may not have been a uterine rupture. Also, another code that was not included in this study, 674.1, is sometimes used to indicate uterine rupture. The ACNM concludes that the "[b]ottom line is that reliance on ICD-9-CM codes alone, none of which are specific to UR [uterine rupture] associated with a previous C/S [cesarean section] scar, has the potential to over-report URs in some cases and to under-report them in others" (8).

Enter Dr. Michael Greene and his editorial. The conclusion that Dr. Greene draws is not consistent with that drawn by the authors of the study. Greene's editorial takes a dramatic turn at its end. "After a thorough discussion of the risks and benefits of attempting a vaginal delivery after cesarean section, a patient might ask, `But doctor [sic], what is the safest thing for my baby?' Given the findings of Lyndon-Rochelle et al., my unequivocal answer is: elective repeated [sic] cesarean section" (9). This logic implies that a woman is more likely to rupture when induced so she should just have an elective repeat cesarean section. Sadly, it is this statement of Dr. Greene that was picked up by the Associated Press service and that was broadcast on at least two of the three national network newscasts. When a well-respected, popular anchor says flatly that your baby is safer being born by a repeat cesarean section than by vaginal birth after cesarean it sounds very much like fact, even if it is not.

Dr. Greene further states that "It]he process of obtaining informed consent for medical care requires that physicians provide patients with the information that a reasonable person would want under the circumstances. Most reasonable women considering a trial of labor after a prior cesarean delivery would want to know that spontaneous labor is associated with a tripling of the risk of uterine rupture and that induction of labor with prostaglandins is associated with an increase in that risk by a factor of 15" (10).

I agree. However, I suggest that the same woman would want to know that the absolute risk of uterine rupture, when induction is avoided, is less than 1%. She would also want to know that elective repeat cesarean section carries an increased risk of death for her. Henci Goer reports on a study from Great Britain that demonstrated a 550 percent increase in the likelihood of death for women who had elective cesareans rather than a vaginal birth (11). The International Cesarean Awareness Network (ICAN) issued a press release following the publication of the Lyndon-Rochelle et al. study and the Greene editorial. In that document, ICAN reports a more conservative assessment of the risks of death from VBAC as compared to elective repeat cesarean section. They report what has been proven consistently in VBAC literature: a woman is twice as likely to die from an elective repeat cesarean section (12). The woman Dr. Greene describes might also be interested in knowing that elective repeat cesarean section increases the chances that organs adjacent to her uterus, her bladder and bowel, will be damaged, due to the buildup of scar tissue in the area (13).

In their press release reminding women of the safety of VBAC, ICAN reminds us that babies are not without risk from elective repeat cesarean section. They note that "[b]abies delivered by elective cesarean section are cut during surgery 2-6 percent of the time, have a 9 precent chance of being born prematurely, and risk a 0.4 percent chance of developing respiratory distress syndrome, a potentially fatal complication" (14). Women should also be made aware of these risks.

It might also behoove a reasonable woman to understand the politics of cesarean section. Doctors, anesthesiologists, and hospitals all stand to make more money from cesarean sections than from vaginal births. The time investment, and associated costs, required for nurses and doctors for an elective repeat cesarean section is much less than for labor and a vaginal birth. Elective repeat cesareans are performed during the day, when doctors and hospital staff are readily available and no one has to be gotten out of bed. Dr. Marsden Wagner, identify who he is ("of the World Health Organization" or "formerly of WHO"?) when he appeared on Good Morning America, said that he had some swamp land in Florida to sell to anyone who believes that doctors advocate cesareans to protect the rights of women (15).

It is a common assumption that a woman's obstetrician only wants what she wants for her birth. Women need to understand that doctors do their jobs the same way everyday, just like everyone else. A woman needs to be informed about her doctor's way of doing birth and she needs to be a sophisticated enough consumer to select a doctor whose way closely matches her expectations.

Many women would be interested to know that the backlash we are seeing against VBAC was predicted some seventeen years ago. Gayle Peterson and Dr. Lewis Mehl predicted that VBAC would come under attack in their book Cesarean Birth: Risk and Culture. They write that their chapter on VBAC "would not be complete without paying respect to the factor of self-selection prominent in much of the current VBAC population. As with homebirth in the early 1970's, women are self-selected who are highly motivated for birth. Whatever their personal reasons, at this time (1984) it is mostly the women believing they can have a vaginal birth who request or search for VBAC. Consequently, the success rate is very favorable, as with the early home birth population. As VBAC becomes more commonplace, the rate of successful vaginal delivery will no doubt decrease, and a rise (hopefully mild) in complications will be noted by the medical profession--hence suggesting a return to repeat cesareans, due to the statistically reported dangers which will no doubt occur in the future as this natural self-selection diminishes" (16).

Scare tactics are being employed to make news more sensational, to sell more newspapers and garner more television news viewers. But someone who is "on our side" was able to look ahead 17 years ago and see it coming.

Although rarely, if ever, reported in the press, on informed consent forms, or discussed in doctors' offices, cesarean sections also have other, less quantitative effects on women and their families. For many, women, the way they birth affects their mothering as well as their evaluations of themselves. Women whose babies are delivered surgically often feel as though they have not given birth. After all, they call cesareans "taking the baby." Some women who deliver by cesarean section, especially those who deliver under general anesthesia, have more difficulty bonding with their baby.

Women grieve, often in silence, often for years. They grieve for the loss of their dreams of a beautiful birth. They grieve for the loss of their opportunity to do the thing only they can do for their babies. They grieve for what they may perceive as their inability to perform the culmination of the reproductive cycle. I feel certain that our reasonable woman would want to know this, too.

References

(1.) Lyndon-Rochelle, M., PHD, V. L. Holt, PHD, T. R. Easterling, MD, D. P. Martin, PHD. "Risk of uterine rupture during labor among women with a prior cesarean delivery." New England Journal of Medicine, July 5, 2001; 345(1); 3-8.

(2.) Greene, M. F., MD. "Vaginal delivery after cesarean section--is the risk acceptable?" New England Journal of Medicine, July 5, 2001; 345(1); 54-55.

(3.) Lyndon-Rochelle, et al. Page 5.

(4.) Flamm, B.L., MD, J. R. Goings, CNM, Y. Liu, MS, G. Wolde-Tsadik, PHD. "Elective Repeat Cesarean Delivery Versus Trial of Labor: A Prospective Multicenter Study." Obstetrics and Gynecology, June, 1994; 83(6); 927-932.

(5.) Lyndon-Rochelle, et al. Page 7.

(6.) American College of Nurse Midwives statement, e-mailed to members, July 5, 2001.

(7.) Lyndon-Rochelle, et al. Page 4.

(8.) American College of Nurse Midwives statement, e-mailed to members, July 5, 2001.

(9.) Greene, Page 55.

(10.) Ibid., Page 55.

(11.) Goer, H. The Thinking Woman's Guide to a Better Birth. 1999. New York, New York: The Berkley Publishing Group. Page 26.

(12.) International Cesarean Awareness Network press release; International Cesarean Awareness Network Affirms Safety of Vaginal Birth After Cesarean; released July 6, 2001.

(13.) Flamm B., MD. Birth After Cesarean: The Medical Facts. 1990. New York: Prentice Hall Press. Page 147.

(14.) International Cesarean Awareness Network press release; International Cesarean Awareness Network Affirms Safety of Vaginal Birth After Cesarean; released July 6, 2001.

(15.) Good Morning America; June 20, 2000; Dianne Sawyer interview with Dr. W. Benson Harer and Dr. Marsden Wagner.

(16.) Peterson, G., MSW, L. Mehl, MD, PHD. Cesarean Birth: Risk and Culture. 1985. Berkeley, California: Mindbody Press. Page 389.

--Debbie Hull lives in Katy, TX, just outside of Houston. She is the mother of two, as well as a doula and certified childbirth educator (BirthWorks).