REBIRTH OF A CONTROVERSY CAESAREAN SECTION RATE RISES AGAIN AS DOCTORS DEBATE THE SAFETY OF VBAC.

Byline: Mariko Thompson Staff Writer

WHEN KAREN GIBBS gave birth to her second child, she did what fewer and fewer women are doing. Even though her first child was born via Caesarean section, Gibbs opted for vaginal birth.

The decision wasn't easy. Every month, the Moorpark resident would read an article or book about the dangers of VBAC - vaginal birth after Caesarean. And every month, her Tarzana obstetrician, Dr. Taaly Silberstein, had to reassure her that she was still a strong candidate for vaginal birth.

``My doctor said the decision was up to me,'' said Gibbs, who gave birth to a 6-pound, 14-ounce boy named Kendal in April. ``Based on her confidence level, I felt comfortable trying VBAC.''

A recent report from the Centers for Disease Control and Prevention shows most doctors and expectant mothers are unwilling to attempt VBAC. After reaching its peak in 1996, the VBAC rate has tumbled 72 percent and is seen as the primary reason for the upswing in Caesarean-section births.

In 2001, nearly one in four births was a Caesarean section. At 24.4 percent, the Caesarean rate has returned to the 1987 level, before a decade of efforts to reduce unnecessary Caesareans. From 2000 to 2001 alone, the Caesarean rate jumped 7 percent. VBACs fell 20 percent, while the number of first-time Caesareans rose 5 percent in the same time period.

``This result did not surprise me at all,'' said Dr. Bruce Flamm, an obstetrician and gynecologist at Kaiser Permanente in Riverside and a pioneer of VBAC studies. ``For the first half of the 20th century, the rule was once a C-section, always a C-section. The swing is going back toward that rule.''

Experts list a number of reasons for the rising Caesarean rate, including fear of malpractice suits and the reluctance by doctors to use forceps or vacuum extraction if vaginal delivery fails.

Flamm says the most influential factor was the revised VBAC guidelines issued under then-president Dr. Benson Harer of the American College of Obstetricians and Gynecologists in 1999. Before, ACOG guidelines had called for doctors, operating crew and anesthesiologists to be readily available to perform emergency C-sections on VBAC patients. Under Harer, the wording changed from ``readily'' to ``immediately.'' Many hospitals determined they couldn't meet the new standard and stopped doing VBACs, said Flamm, also an ACOG spokesman.

``A lot of doctors felt complacent,'' said Harer of the change. ``They'd do 50 consecutive VBACs with no problems. But when the disaster comes, they can be really big.''

Harer, chief of staff at Riverside County Regional Medical Center in Moreno Valley, argues the managed-care push for VBAC in the '90s took away a woman's right to make an informed choice. Those managed-care organizations, spurred by the lower cost of vaginal birth compared to Caesarean section, paid the price when complications led to lawsuits, he said.

Groups such as Redondo Beach-based International Cesarean Awareness Network scoff at the notion the rising Caesarean rate reflects informed choice on the part of mothers. Several studies have shown that hospitals staffed with certified nurse midwives, who approach birth as a natural process, have lower rates of Caesarean section. By contrast, doctors historically have treated pregnancy and childbirth as a medical problem, said Kathryn Berkowitz, ICAN spokeswoman.

``If a doctor says your baby could die, no woman wants to live with that,'' she said. ``It's really a lot of propaganda.''

Risk factors

There are always risks in childbirth. Doctors may recommend Caesarean section to an expectant mother based on a number of medical indicators, including breech position, pregnancy-induced hypertension and projected birth weight of the baby. While Caesarean section can be a life-saving procedure, it carries the risks of any other major surgery, including bleeding, infection and damage to other abdominal organs.

When considering VBAC, doctors look at such factors as the reason for the previous Caesarean, whether the abdominal cut was made vertically or horizontally, and whether the mother plans to have more children. More than two Caesareans creates a significantly higher risk for complications. VBAC, too, has risks, the most severe of which is uterine rupture.

``My philosophy is still pretty positive toward VBAC,'' said Dr. Carol Kurz, an obstetrician and gynecologist at Kaiser Permanente in Woodland Hills. ``To require elective surgery, with all of its inherent risks, when there's a more natural way doesn't make sense.''

Other complications

The natural way doesn't make the most sense to all doctors, which is why the debate over Caesarean sections doesn't begin and end with VBAC. Over the past few years, elective Caesarean section has become an increasingly divisive issue.

Dr. Jennifer Berman, urologist and co-founder of UCLA's Female Sexual Medicine Center, is a proponent of elective Caesarean section. Two years ago, Berman, who has a small build, vaginally delivered a 9-pound, 8-ounce boy. Looking back, she says she should have had a Caesarean.

``I had a complicated birth and I'm incontinent at times now due to that,'' Berman said. ``Yes, there are a lot of benefits to vaginal birth. But there are times when it's risky.''

Also feeding the movement toward elective Caesarean section is new concern over pelvic floor damage. Childbirth - particularly prolonged or traumatic labor - is one factor that might damage the pelvic floor, leading to such problems as incontinence later in life, Berman said. Harer concurred.

``Most of the damage will occur with the first delivery and then it's cumulative,'' Harer says.

But Flamm says such talk is premature and unnecessarily scares women away from vaginal birth. He's waiting to see more definitive research.

``There are women who have never had a baby and suffer from urinary incontinence,'' he said. ``There's not a lot of data showing these things are related to birth itself.''

Viable options

For Gibbs, the Moorpark resident who recently chose VBAC, her decision came down to recovery time. With 18-month-old Keegan to care for in addition to a newborn, she wanted to be on her feet as soon as possible.

``Two weeks spent recovering was not really an option,'' Gibbs said.

When she was in labor the first time with Keegan, Gibbs stopped dilating, which led to the Caesarean section. For the second pregnancy, Gibbs discussed VBAC with her obstetrician, Silberstein. Based on the reasons for the first Caesarean, and lacking any other medical indicators, Silberstein determined Gibbs could try VBAC.

The vaginal birth went smoothly. Gibbs said she was able to get out of bed two hours after the delivery, compared to 24 hours when she underwent a C-section.

``It was a wonderful experience compared to the first one, just in terms of recovery,'' Gibbs said.

Doctors stress that pregnant women should be given the information they need to make a decision and also feel confident that their obstetrician supports their choice. Regardless of how doctors feel about VBAC, experts say one thing is certain: They expect the overall Caesarean rate soon will hit an all-time high, if not this year then next.

CAPTION(S):

6 photos, graph

Photo:

(1 -- 4 -- color) 1 in 4 births is by Caesarean section

Why the number is rising

(5) no caption (baby smiling)

David Sprague/Staff Photographer

(6) Karen and Kenny Gibbs of Moorpark enjoy a day with their two sons. Although Keegan, far right, was born via Caesarean section, Karen was able to give birth to Kendal vaginally 18 months later.

Andy Holzman/Staff Photographer

Graph:

C-SECTION ON THE RISE

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