Show 6D Standard-Examine- Sunday June 5 1988 r ferrrmtCTntwi''n?nnii VBACs m a 7 m a m 9- - m a a a a v I gaining favor VBACs were still rare seldom done as recently as five years ago ‘You have to go slowly You have to find out what the limits are ’ Vaginal birth after Cesarean or VBAC may be the new buzz word in medical and consumer circles but the practice is still not commonplace in the working world of medicine say two Utah doctors Despite studies showing VBACs arc safe the concept has “not taken the country by storm” said Dr Dwight P Cruikshank vice chairman of obstetrics and gynecology at the University of Utah Medical Center And Dr Bruce Hunter an Ogden obstetrician said acceptance of the new procedure by both doctors and women is a — Dr Neil Kochenour 7 knew want to go into the hospital and get hooked up to all the machines and be treated like a key issue a Vaginal birth after Cesarean has been common for years in some European countries but the concept has only recently gained support in the United States including the endorsement of the American College of Obstetricians and Gynecologists in 1982 high-ris- k The physicians’ group estimates 50 percent to 80 percent of all Cesarean patients can deliver a subsequent baby vaginall- like was broken a a visit Spokesmen from both and St Benedict's said local doctors are generally supportive of VBACs “1 don’t know of any physician adamantly opposed to it” McKay-De- e continuously monitored and VBAC From ID said Dr Dwight P Cruikshank of the University of Utah Medical Center at a recent meeting of the Ogden Surgical Society If a woman has a recurring condition such as proven el a - I’ — Sheila Schultz one-thir- an patient I felt yd of the And because nation’s Cesareans are repeat surgeries VBACs are seen as a prime way to curtail the counrate try’s rising Yet in 1986 only 85 percent of American women with previous Caesareans had their next birth vaginally said Selma Taf-fstatistician at the National Center for Health Statistics in Hyattsville Md “The other 915 percent had a repeat Caesarean” she said VBAC rates around the country are spotty said Patricia Shiono a researcher for the National Institutes of Health in Maryland who did a study on the trend Some hospitals encourage all women with previous Cesareans to attempt vaginal births while others do not allow anyone a “trial of labor” In Utah statewide statistics on the VBAC rate are not available because the Utah Department of Health does not compile them yet said John Brockert director of the Bureau of Vital Records However department reports show 38 percent of all Cesareans performed in Utah in 1986 were repeats with several individual hospitals logging repeat rates near or above 50 percent Estimates vary on how common VBACs are locally Dr Steven Clark of Provo who does consultation work on high-ris- k cases in the C den area said the statewide VBAC rate is probably comparable to the national rate Marta Clark director of Women's Services for Intermountain Health Care — whose hospitals do 50 percent of all Utah deliveries — said VBACs are most likely occurring in Wasatch Front hospitals but not in rural areas Her own informal survey of 10 IHC hospitals showed some not offering VBACs at all while others had rates up to 20 percent But VBAC rates are higher than the national average at two local hospitals which have started monitoring the trend At St Benedict's Hospital spokesman Julie Muss said 25 percent of women with a previous Caesarean delivered vaginally in 1987 McKay-De- e Hospital started recording VBACs in January said Cathy Hcisen director of Women and Children’s Services During the first three months of this year 36 percent of women with previous Cesareans delivered vaginally she said At the University of Utah Cruikshank said he would guess the VBAC rate is about 30 percent and that is “not as good as I'd like to see it” A number of Ogden area doctors said they consider VBACs a safe option including Dr Stephen Wight who said he tries to bias the conversation in favor of VBACs from the first prenatal I didn't mm W disproportion or CPD — in which the baby is too large to fit through the pelvis — she would need a repeat Cesarean said the vice chairman of the university’s obstetrics and gynecology department However Cruikshank said studies show up to 65 percent of women diagnosed with CPD can deliver another baby vaginally That means he said that “a lot of what we call CPD is not truly CPD” Women who had Cesareans conditions infetal distress breech or cluding (the placenta placenta previa covers the woman’s cervix and would deliver first) have up to an 80 percent success rate for for non-repetiti- subsequent At his Ogden home Dr Bruce Hunter ponders the state of obstetrics Heisen said “Most will allow moms trial of labor Some encourage it” But old ideas about vaginal Vaginal deliveries per 100 mothers with previous Cesarean: birth after Cesarean die hard United States say both doctors and VBAC advocates Hunter said the repeat Cesarean philosophy is still deeply ingrained in many physicians’ minds Some doctors are aware of VBACs but are insecure about doing them because they haven’t tried them before or they have thought for years they are unsafe “They say ‘Yeah you can do (vaginal birth after Cesarean) but it’s dangerous and uteruscs rupture” and women die all the time’ he said With that kind average Source: American Journal of Public Health of information he said women naturally choose a repeat graphic Some doctors pay “lip service” to the VBAC issue said them about the risks associated willing and anxBetty Pankiewicz president of ious to allow patients a trial of with a repeat Cesarean which is the Ogden chapter of the Cesarelabor” major abdominal surgery an Prevention Movement While thte are exceptions Instead Pankiewicz said some “In early pregnancy they’re Clark said many women who doctors still use scare tactics to have experienced both vaginal very open and very willing (to steer Cesarean women away consider a VBAC) but when it and Cesarean birth “would far from vaginal birth As a childrather have another birth educator for Alternative gets to the end their tune starts to change” said Pankiewicz because is it less traumatic and Childbirth Education Pankiewwho recently worked with a exhausting icz said she has had women tell woman who changed doctors Or if a woman has only expeher about doctors relating stories seven times in her last month of rienced Cesarean birth — and of extreme incidents to frighten her surgery came after a long them or using outdated statistics pregnancy because of disagreement over a VBAC hard labor — she might very on the success rate of VBACs well choose another Cesarean Financial factors also enter inIn her own case Pankiewicz said Dr Robert C Newman of said her previous doctor told her to the VBAC issue Cruikshank said Insurance companies pay there was a 40 percent chance Ogden more for a repeat Cesarean than Clark S3id doctors could reshe might die if she tried a vagia VBAC he said even though fuse to do those Cesareans anynal birth after two Cesareans a the repeat may take one hour more but “at the present time statistic she said is not true and a doctor may spend eight to that’s not the standard of care" Consumer pressure will be the 16 hours wiih a woman having a If a woman wants a repeat she key to gaining acceptance for has that choice he said VBACs both doctors and womvaginal birth after Cesarean “Fear of the unknown” does “That doesn’t make sense” en said Cruikshank said “It always is consumer dekeep many Cesarean women A major stumbling block to from attempting vaginal birth mand that changes things” Pankiewicz of the Cesarean Prethe acceptance of VBACs comes Hunter said If women don’t ask from women said Steven Clark vention Movement said But about VBACs he said some director of the Utah Valley Redoctors should be educating doctors will remain “quite comwomen about the safety of fortable to go with the repeat gional Perinatal Center who adVBACs she said and telling ded that Utah physicians are That’s what they're used to" LVaginalbiitlfaftenCesarean: 1980-198- 5 Standard-Examine- “well-informe- d r vaginal births Cruikshank said The number of Cesareans a woman has had may also influence her likelihood of having a vaginal birth Some doctors and hospitals promote VBACs only for women who have had one or perhaps two Cesareans Both Cruikshank and Dr Robert Newman of Ogden said they do not recommend VBACs to women with more than two Cesareans In Brigham City Dr Thomas Matthews said only women with one previous Cesarean may attempt VBACs at Brigham City Community Hospital Women who have had two or more would be referred elsewhere he said But others say the number of Cesareans makes no difference Dr Steven Clark director of the Utah Valley Regional Perinatal Center in Provo said some studies show even women with three or four previous Cesareans can deliver vaginally Hunter who is hoping to go into practice in the East after 10 years in Ogden said several of his patients gave birth vaginally after one Cesarean and at least woman had a VBAC after four previous Pankiewicz — who went on to organize a local chapter of the Cesarean Prevention Movement after Scott’s birth — said she is concerned about how VBAC women are treated in labor Many doctors view vaginal birth after Cesarean as a high-ris- k situation she said and become “defensive” if women want a birth free from medical interventions such as fetal monitors While she admits doctors are restricted by guidelines set by insurance companies Pankiewicz said the general attitude is against women's choices When she was in labor with Scott at an Ogden hospital Pankiewicz said she had to have her doctor present to be allowed to walk the halls and avoid being hooked up to an IV “They wanted to put me in bed like a sick person” she said “I didn’t want to stay in bed I knew that would slow down labor and probably lead to another Sheila Schultz of Layton felt so strongly about medical interventions she decided to attempt her first vaginal birth after two Cesareans at home with a lay midwife “I knew I didn’t want to go into the hospital and get hooked up to all the machines and be treated like a high risk patient” said Schultz who gave birth to both her third and fourth children at her Layton home But Dr Neil Kochenour of the University of Utah Medical Center said even though the risks are low of something going wrong during a VBAC it is “perfectly legitimate” to require monitoring and other proce- dures for these women Changes don’t come overnight said Kochenour the chief of maternalfetal medicine VBACs were seldom done as recently as five years ago he said “You have to go slowly You have to find out what the limits are” However Hunter said that since he did his first VBAC 10 years ago with “trepidation” he has become very comfortable with the procedure and treats his VBAC patients no differently than other women in labor For women who have had a Cesarean and want to have more children VBACs mean they may no longer need to expect another surgical delivery Alyson Petersen had four normal births before Lucy was bom during an emergency Cesarean While the Ogden mother never doubted the necessity of the surgery she said when she became pregnant again she was “horror stricken” at the thought of having another Cesarean “I think I cried every night for five months” said Petersen who was able to deliver her next daughter Artimissia vaginally Sheila Schultz of Layton said she felt emotionally detached from her first two children's Cesarean births But when Jessica was born vaginally it was a much different experience “I love all my kids the same but I felt so close to her immediately" she said remembering how she held her newborn daughter right after birth and nursed her minutes later “That wonderful rush of motherhood instincts did come and I hadn’t had that before I hadn’t felt that at all with the Cesareans” said Schultz who had another VBAC last year In Ginger Law’s case a VBAC was the key to healing her anger and depression over the birth of her twins by Cesarean section After she gave birth to her son Morgan in a normal vaginal delivery the West Jordan mother said “I somehow let go of the |