Richmond Parents Monthly | Richmond magazine for families

You can hear the wistfulness in Janice DeLong’s voice when she talks about the birth of her third child.

“I guess at the point I had the Cesarean it was necessary,” she said, and paused. “Mostly I still blame myself. At any point I could have stopped the doctor, like many women have done.”

DeLong said she had a healthy pregnancy with no indication that a C-section would be needed. She chose an obstetrician she trusted, but says, “since I was over 35, I was given ‘a look’ as soon as I walked into the office.”

“I kept saying to myself, ‘I’m going to have a vaginal birth,’” the Richmond mother recalled.

“I guess I thought that since my doctor was a woman, I would be protected, but the whole time I was being scared.” After allowing the OB to induce labor two weeks early and give her epidural anesthesia, the baby’s heart rate dropped. DeLong delivered her daughter by Cesarean section.

Under the Surgical Knife

The rate of birth by C-section—incisions in a mother’s abdomen and uterus—is rising in the United States. In 1995, about 21 percent of births were Cesarean; in 2006, 31 percent were. In the Richmond area that year, the figure was about 33 percent. Despite risks such as infections and greater blood loss, doctors deem Cesarean deliveries necessary for several reasons. Women carrying twins and women over 35 are flagged for C-sections by many doctors, since these are regarded as higher-risk births. As a pregnancy progresses, doctors can become worried that a baby will be too big or a woman’s pelvis too small to deliver safely. An infant that is not positioned head down or is turned awkwardly inspires concern and will likely be delivered by Cesarean. If labor has started but is not progressing—if a woman’s cervix does not dilate, or open, quickly enough or as expected—doctors may recommend a C-section. If the infant’s heart rate drops or there are other signs of distress, a C-section is required out of concern for the baby’s health or life. And, increasingly, it seems that having had a C-section once is regarded as a reason to have one again.

Percentage of VBACs Falling

Despite assurances by the American College of Obstetricians and Gynecologists that vaginal birth after Cesarean, or VBAC (pronounced “v-back”), is a safe and successful option for most women, the VBAC rate is dropping—from 27.5 percent in 1995 to just over 9 percent in 2004 (the most recent government figures available). VBAC rates are calculated by dividing the number of VBAC deliveries by the sum of VBAC and repeat Cesarean deliveries. Dr. Stephen Bendheim is a partner with the Virginia Physicians for Women who said he’s always glad to do VBACs after talking to mothers about the risks and benefits. But when asked about the drop-ping VBAC rate nationally, he quickly replied, “A lot is due to the medical and legal climate.” “Doctors have difficulty getting insurance after one lawsuit,” he said, and without insurance, they can’t work in hospitals. He explained that insurance companies consider VBACs riskier than repeat Cesareans because the catastrophic risk is greater. For example, if a woman having a VBAC does need to have a C-section, the surgery is more likely to be performed under emergency conditions. At a scheduled repeat Cesarean, “everything is in place,” said Bendheim.

Preventing Cesareans

The International Cesarean Awareness Network educates families about birthing choices in order to prevent first-time and repeat Cesareans. ICAN has more than 100 chapters all over the world, including one in Richmond started by Mary Callendar and Sara Fariss Krivanec in 2002.

Krivanec’s first child was born by C-section after an induced labor. “I knew I wanted a vaginal birth after my Cesarean because the recovery was so long and hard, breastfeeding was a struggle, and the care I received during the labor and birth was really bad,” she wrote in an e-mail.

She began researching the risks and benefits of repeat Cesarean and VBAC deliveries, as well as women’s options for VBACs in the Richmond area. In the process, a passion was born. As an ICAN leader, Krivanec is dedicated to spreading the word about the safety of VBAC deliveries based on studies and statistics.

For example, the risk of uterine rupture is under one percent for VBAC deliveries. A uterine rupture occurs when the previous incision opens, anywhere from a little bit—which Bendheim described as “mild”—to a complete, “catastrophic” split.

Bendheim noted that the use of medications such as Pitocin to augment, or strengthen, labor can increase the risk of uterine rupture in a VBAC delivery. Later, when explaining falling VBAC rates, he said, “[Doctors] realized in the last 10 years that the risk of uterine rupture is greater than we thought.”

According to Krivanec, doctors “distort” the evidence on VBAC safety. “Women that come to [ICAN-Richmond] meetings are made to feel [by their doctors] that the risk of uterine rupture is almost 50 percent!” she wrote. “Uterine rupture is discussed at every visit while the risks of Cesareans are glossed over if even discussed at all.”

“Doctors don’t always discuss choices with women, and most women assume the doctor is always right, they don’t question what the doctor says,” Krivanec lamented in a phone interview.

Deferring to the Degree

The difficulty of questioning a doctor is an experience shared by nearly all the women who contacted Richmond Parents Monthly for this article. Jessica Caldwell, of Fort Lee, delivered twins by Cesarean. She had made it clear to her doctor all along that she wanted to deliver vaginally since both babies were perfectly positioned. “He said that if I carried them to 35 weeks, we could discuss it,” she wrote in an e-mail.

Caldwell went into labor at 34 weeks. The doc-tor “came into the room and said that a Cesarean would be best for them since he didn’t want to put them through any unnecessary stress. I consented, thinking my babies were in danger.” Some mothers also met resistance when they chose to pursue a VBAC. “I am no pushover, but it took every ounce of guts I had” to insist on having a VBAC, wrote Christina Kearney Saba of Henrico County. “I can’t imagine how a younger, more impressionable mom would deal with all the resistance flowing her way in the traditional OB practices.”

“In Richmond, you have to do your homework to have a VBAC,” asserted Jennifer Kyzer, a mother of two who co-leads the Richmond chapter of Birth Matters. (See sidebars.) “Doctors say, ‘Yes, we can do that if everything is perfect,’ but around 36, 37 weeks they start finding things wrong.” Kyzer was straightforward: “You have to be an advocate for yourself.”

Questioning the Necessity

Each woman who told about her experience for this article has come to believe that her first C-section was either entirely unnecessary or could have been prevented by better care during labor and by education, both of herself and of her doctors.

“I could have had my first [child] vaginally… had I been permitted to move during labor, thereby allowing the baby to get into a position to come out,” wrote Saba.

Caldwell feels that her operation was needless. “I was 4 cm dilated and in full-blown labor when they wheeled me back for the surgery.” When she became pregnant nine months after her twins’ birth, she actively educated herself about VBACs, but “I didn’t sense that [my doctor] had much confidence in my decision.” She switched to a midwife for greater support, and had a successful VBAC. Ultrasounds revealed Jennifer Klee’s first baby to be over 10 pounds, perhaps closer to 11 pounds. Her doctor was worried about the risk of the baby’s shoulder getting lodged inside her pelvis during delivery.

Klee’s brother had gotten “stuck,” and “I felt sure my baby would get stuck too. At the urging of my OB, I consented to a planned cesarean with no trial of labor. I was confident I had made the right decision,” the Henrico mother wrote in an e-mail. “I just knew I could not have delivered him naturally, normal babies aren’t 10 pounds. I know better now!” She has gone on to deliver three children vaginally. The last two were over 10 pounds, and were delivered at home by a midwife.

A Different Paradigm

The presence of a midwife is a recurring characteristic of VBAC stories. Many mothers said they believe midwives are trained to be supportive of a woman’s natural ability to give birth vaginally under a much broader range of circumstances, whereas doctors are trained to see birth as a medical “problem.”

Krivanec notes that nationally, midwife-assisted deliveries have a higher VBAC rate than obstetrician-assisted deliveries.

“Midwives understand that women’s bodies are made to do this,” she said in a phone conversation. She makes a distinction between a doctor’s “active management” of a birth—which tends to result in interventions such as induced labor and epidural use, which in turn can lengthen labor, lead to fetal distress and increase the necessity of a C-section—and a midwife’s “expectant management” which emphasizes a mother’s role.

Prenatal care with a midwife typically involves long, informative visits. Richmond mother Elaine Peterson’s experience with using a midwife for her second and third children, both VBACs, was in stark contrast to her first child’s birth, when she was “just too drugged to push the baby out,” she wrote in an e-mail. With a midwife, “I could be more in control because I was more educated about the birthing experience.”

“Truly the education and sincerity gained from two-hour visits to a midwife as opposed to 15 minutes with an OB is the most invaluable thing to have happened in my life,” said Abbie Radcliffe in an e-mail.

Radcliffe, a mother of three from Richmond, gave birth to her first child when she was 18. “I went to the hospital…about 12 hours too soon!” she said. “They gave me something to ‘let me rest,’ I positioned myself on my right side and basically didn’t move for 36 hours. At about the 28-hour mark, Devon was ‘stuck’ (of course, he was)… and they called for a C-section.”

A Personal Achievement

DeLong, whose fourth child is due this fall, said she overhears pregnant women talking about their doctors’ plans for interventions such as induced labor or scheduled C-sections. “I see something in their faces that [indicates] they’ve lost control … some deep spirituality that’s been taken away.”

She’s hoping to have a VBAC, although her primary wish is to regain control over her birthing experience. “When I say, ‘That’s not going to hap-pen again,’ it wasn’t necessarily the Cesarean, it was the way it happened,” she mused, “the way the doc-tor was saying I had choices but really I had none.”

DeLong is still working on building up her confidence. If all goes well, in several months she’ll be able to say, in the words of Jessica Caldwell, “I DID IT, I DID IT, I DID IT!”

Confidence in Numbers

The following organizations pro-vide a forum for expectant and new parents to support each other by sharing research and personal stories.

ICAN of Richmond Monthly meetings at YES Chiropractic 8600 Quioccasin Rd., Suite 210 http://www.freewebs.com/icanofrichmond/

BirthMatters www.birthmattersva.com/richmond www.birthmattersva.com/charlottesville

Motherwise Birth Resources (804) 502-0900 www.motherwisebirth.org

Birth Matters is a statewide organization with a mission to “improve the culture of birth in Virginia.” Its annual awards gathering and fundraising dinner will be held on Sunday, August 10, 1 p.m., at The Renaissance Center in Richmond. Cara Muhlhahn, the mid-wife featured in the 2007 documentary, “The Business of Being Born,” is the guest speaker. For more information or to purchase tickets ($25-35), visit www.birthmattersva.com/richmond or www.birthmattersva.com/charlottesville.

Angela Lehman-Rios is a freelance writer and editor of Fifty Plus magazine.