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You have to subscribe (free) to read the article, but here is a link to the Times website <a href="http://www.nytimes.com" target="_blank">http://www.nytimes.com</a>. The article is titled <span style="text-decoration:underline;">Repeat Caesareans Becoming Harder to Avoid</span> and is probably now located in the Health Section (about half way down and click on Health).<br><br>
The essence of the article is basically what we all know -- VBACs are getting harder to come by. It gives a general overview of the problem but, of course, fails to discuss why the rate of rupture may be up (single layer sutures combined with induction/augmentation). In any event, I thought it was interesting and that I'd share. If anyone wants more info., please feel free to pm me. I can log on to the NY Times and email the article to you if you'd like.
 

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I had this article emailed to me through the ICAN list so I thought I would post it here:<br><br>
Trying to Avoid 2nd Caesarean, Many Find Choice Isn't Theirs<br>
By DENISE GRADY<br><br>
The notice, posted in her obstetrician's office in Lancaster, Calif.,came as a shock to Danell Freeman: the local hospital would no longer allow doctors to deliver babies vaginally for women who, like her, had previously had a Caesarean section. Unless she changed doctors and hospitals, Ms. Freeman would have to have another Caesarean - something she had hoped to avoid.<br><br>
Ms. Freeman is 29, pregnant with her fifth child. The first three were born normally, the fourth by Caesarean. "I don't like the idea of being cut open again," she said.<br><br>
Women around the country are finding that more and more hospitals that once allowed vaginal birth after Caesarean, or VBAC (commonly pronounced VEE-back), are now banning it and insisting on repeat Caesareans. About 300,000 women a year have repeat Caesareans. The rate of vaginal births in women who have had Caesareans has fallen by more than half, from 28.3 percent in 1996 to 10.6 percent in 2003.<br><br>
Major medical centers still perform such deliveries, but many smaller ones have banned the practice, saying that it is riskier than once thought and that they do not have the staff to handle emergencies that may arise. Obstetricians estimate that there is a 1 percent chance that the old Caesarean scar will cause the uterus to rupture during a subsequent labor, which can cause dangerous blood loss in the mother and brain damage or death in the baby. A decade ago, the risk of rupture was thought to be 0.5 percent or less. The percentage of<br>
babies injured after a rupture is not known but is thought to be low.<br><br>
Many women are willing to take the risk, and the hospitals' stance has become a charged issue, part of a larger battle over who controls childbirth. Some women say their freedom of choice is being steamrolled by obstetricians who find Caesareans more lucrative and convenient than waiting out the normal course of labor. Doctors say their position is based on concern for patients' safety.<br><br>
On a practical level, many women prefer vaginal birth because they recover more quickly and with less pain than they do from a Caesarean. In addition, each Caesarean increases the risk of complications in the next pregnancy, so women who want more than two or three children often hope to avoid the operation.<br><br>
Some doctors and hospitals freely acknowledge that fear of being sued has driven their decisions. Hospitals say they cannot comply with guidelines issued in 1999 by the American College of Obstetricians and Gynecologists, which call for a doctor to be available "immediately" throughout active labor during such a birth, to perform an emergency Caesarean if needed. Previous guidelines had called for them to be "readily" available.<br><br>
Half the hospitals in New Hampshire and Vermont have stopped allowing women who have had Caesareans to try normal deliveries, according to Dr. Peter Cherouny, an associate professor of obstetrics and gynecology at the University of Vermont. A telephone survey by an advocacy group, the International Cesarean Awareness Network, found<br>
300 hospitals around the country that had quit offering the deliveries.<br><br>
"My intuitive feeling is, it's going to be harder and harder to find<br>
places that offer it, because of the known risk and the medical legal climate we live in," said Dr. Gerrit Schipper, chief of obstetrics at Frederick Memorial Hospital in Frederick, Md., which banned the procedure recently. The decision provoked a protest outside the hospital on Nov. 9 by about 50 mothers with their children.<br><br>
Some doctors worry that banning the procedure may lead women who have had Caesareans to try giving birth at home or in birthing centers that are not equipped to perform an emergency Caesarean if it becomes necessary. Doctors also say some women, determined to avoid a repeat Caesarean, have endangered themselves and their babies by staying at<br>
home in labor - or even staying in the hospital parking lot - until<br>
the last minute.<br><br>
"There are very irate people in various parts of the country," said<br>
Dr. Bruce Flamm, an obstetrician with Kaiser Permanente and a clinical professor at the University of California, Irvine, who has written a book and many articles about vaginal births after Caesarean sections.<br>
A recent study by Dr. Flamm, published this month, concluded that such deliveries should be handled in hospitals, not birthing centers, because of the increased risk of complications.<br><br>
"The real issue going across American right now is, what do we do?" Dr. Flamm said. "Hundreds of thousands of women a year now are coming to hospitals with a previous Caesarean, some in communities where every hospital has shut down its VBAC program. That's the issue. Some will go to a lay midwife and have a VBAC in their bedroom. A good number will do fine, but some will have horrendous outcomes."<br><br>
As a solution, he suggested, hospitals that do not allow normal birth after a Caesarean should refer women to hospitals that do. Or, he said, "you don't have a whole crew in 24/7, but how about just a few nights a year when you have a VBAC patient in labor, you say, 'We will sleep in the hospital or sit in the lounge'?"<br><br>
Having a Caesarean or not, Dr. Flamm said, "should be the woman's choice."<br><br>
Some women see a Caesarean as having an operation instead of giving birth, and feel it means missing out on life's most joyful rite of passage.<br><br>
"I'm an earthy person," said Barbara Stratton of Baltimore, who had her first baby by Caesarean in 1999. "This is a womanly thing to me. I wanted to birth my baby. You have that taken away if you're lying in a room full of strangers and they cut your baby out of your abdomen.<br><br>
"For some of us who really care about birth, it can completely crush you."<br><br>
Ms. Stratton said that she hoped to have another child, and that if she does, "I'm going to VBAC and I'm doing it at home."<br><br>
But some doctors report that women themselves seem to have lost interest in trying labor after a Caesarean.<br><br>
"I'm a huge advocate," said Dr. Laura Riley, an obstetrician and<br>
maternal-fetal medicine specialist at Massachusetts General Hospital in Boston. "But our rates have dropped. Patients aren't interested. When there's any risk, they don't want to hear about it. A lot of people are into total convenience. If I tell them we can schedule a Caesarean on X day at X time, they go for it."<br><br>
A study published in an obstetrical journal in 1997 found that when women with a previous Caesarean were offered a natural delivery, 30 to 50 percent wanted it.<br><br>
In the past, the medical rule was "once a Caesarean, always a<br>
Caesarean." The thinking changed in the 1980's, when studies at big medical centers suggested that 60 to 80 percent of women could safely go through labor and a normal delivery after a Caesarean. The risk of rupture appeared to be about 1 in 200.<br><br>
A burst of enthusiasm followed. The proportion of mothers who had had a Caesarean and then a normal birth rose from 19.9 percent in 1990 to 28.3 percent in 1996. In Europe, the rate was about 50 percent in 1997.<br><br>
Government health experts in the United States endorsed the procedure as a way to help control climbing Caesarean rates, since repeat Caesareans account for a third of the one million done each year. A government health report published in 2000 said one of the nation's goals for the year 2010 should be a VBAC rate of 37 percent. Instead, the trend reversed.<br><br>
In 2002, more and more women with a previous Caesarean began calling the International Cesarean Awareness Network, saying they could not find a nearby hospital that would allow a normal delivery, said the group's director, Tonya Jamois. Now, she said, she receives such calls every day.<br><br>
"Women are not being allowed to have a choice even if they have had several VBAC's before," Ms. Jamois said.<br><br>
Dr. Charles Lockwood, chairman of the department of obstetrics,<br>
gynecology and reproductive sciences at Yale and an author of VBAC guidelines issued by the American College of Obstetrics and<br>
Gynecology, said alarms began to sound in the late 1990's.<br><br>
"What precipitated this were reports in the literature and reports<br>
that came to the college itself about women who had ruptured their uterus, particularly in rural settings, with no doctor and no<br>
anesthesiologist around," Dr. Lockwood said. "Babies died, and women lost the uterus in some cases."<br><br>
That prompted the obstetrics college to change its formal<br>
recommendations for vaginal births after Caesareans in 1999, saying a doctor should be immediately available during labor to perform an emergency Caesarean.<br><br>
"That had a chilling effect," Dr. Lockwood said, particularly on<br>
hospitals in rural areas that did not have anesthesiologists available around the clock, and on doctors in solo practices who could not stay with a patient throughout her labor.<br><br>
"I think the real death knell to VBAC's was the malpractice crisis," Dr. Lockwood said.<br><br>
About 2,000 babies a year are born at Frederick Memorial Hospital, including about 60 last year delivered vaginally after a previous Caesarean. Dr. Schipper said he had been a proponent of VBAC, but felt differently after three women at Frederick had major complications within the past three years. Two had severe blood loss, and one needed a hysterectomy. The hospital banned the procedure.<br><br>
As for his own patients, Dr. Schipper said: "I can't think of any who had major issues. By and large, the feeling was, 'Great, I don't have to make a decision, go ahead and do the C-section, I was agonizing about it anyway and who am I as a lay person to go against what you think?' "<br><br>
If a woman still wants a vaginal birth, he added, he will refer her to a larger hospital in Baltimore, 50 or 60 miles away.<br><br>
Dr. George F. Lee, a former obstetrician who is an administrator at California Pacific Medical Center and a spokesman for the American Hospital Association, said that while VBAC had proved safe in carefully controlled studies, the risks were higher in the real world of everyday medical practice.<br><br>
"We went from seeing a ruptured uterus once every several years to seeing half a dozen a year at our medical center," Dr. Lee said.<br><br>
Dr. Cherouny of the University of Vermont said that not all women who had had Caesareans faced the same amount of risk from trying to deliver vaginally. Women who have had more than one Caesarean, for instance, have a considerably higher risk of rupture and other complications, and many doctors say they should not try a vaginal birth. Women whose first labors were very sluggish are also unlikely to succeed, as are those who pass their due date and do not go into labor spontaneously. Drugs commonly used to induce labor also markedly increase the risk of rupture, studies have found.<br><br>
Dr. Cherouny said some women were so determined to avoid a Caesarean that they delayed coming into the hospital until they were in advanced labor, leaving doctors little choice but to deliver the baby.<br><br>
"I'm not going to chain them down and do a C-section," he said, adding that courts rarely force women to have Caesareans.<br><br>
For that reason, he said, he and his colleagues tell hospitals: "You must be ready. Even if you don't want to do VBAC's, you will. The patients will make you."
 

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<div style="margin:20px;margin-top:5px;">
<div class="smallfont" style="margin-bottom:2px;">Quote:</div>
<table border="0" cellpadding="6" cellspacing="0" width="99%"><tr><td class="alt2" style="border:1px inset;">Women whose first labors were very sluggish are also unlikely to succeed, as are those who pass their due date and do not go into labor spontaneously.</td>
</tr></table></div>
Well by these definitions then I guess I shouldn't have had a successful VBAC 2 weeks ago. My first labour (induced at 42 weeks and 2 days) ended in c-section due to failure to progress past 4 cm. My second baby was born at exactly 41 weeks in a completely unmedicated vbac with no complications. I think doctors are setting up so many roadblocks to vbacs that they are responsible in large part for the "failures" out there!<br><br>
Steph
 

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The things the docs said were laughable, except for<br><br><div style="margin:20px;margin-top:5px;">
<div class="smallfont" style="margin-bottom:2px;">Quote:</div>
<table border="0" cellpadding="6" cellspacing="0" width="99%"><tr><td class="alt2" style="border:1px inset;">As for his own patients, Dr. Schipper said: "I can't think of any who had major issues. By and large, the feeling was, 'Great, I don't have to make a decision, go ahead and do the C-section, I was agonizing about it anyway and who am I as a lay person to go against what you think?' "</td>
</tr></table></div>
scary that women are like that, that they will just follow whatever the doctor says <img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/bow.gif" style="border:0px solid;" title="bow"> without question and sickening, because that doc showed exactly what he thinks of himself.
 

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I agree, it makes me sick that some women just do blindly whatever their doctor tells them. How about having some confidence in their body? A woman is not a "lay person" when it comes to birth! She is the expert, and the doctor needs to be looking to her for advice! XX$$#%$YBJ!!!!<br><br>
Another ICAN member also had issues (as do I) about the comments made about HBAC's:<br><br><i>"The real issue going across American right now is, what do we do?" Dr. Flamm said. "Hundreds of thousands of women a year now are coming to hospitals with a previous Caesarean, some in communities where every hospital has shut down its VBAC program. That's the issue. Some will go to a lay midwife and have a VBAC in their bedroom. A good number will do fine, but some will have horrendous outcomes."</i><br><br>
A "lay" midwife is a very knowledge, credible, well-trained professional! I was monitored intermittenly by dopplar throughout my labor, and studies have proven that this is as safe as continuous electonic fetal monitoring. You could say the same for those who do repeat c/s-a good number will do fine, but some will have horrendous outcomes. There is no such thing as a risk free birth, but I feel it becomes much riskier when you have a doctor just eager to use whatever interventions possible to make birth as unnatural as possible. I have to respectfully say, I think men really need to get out of the birthing business, and leave it to the experts, us women!<br><br>
Ok, rant over, back to my corner!<br><img alt="" class="inlineimg" src="/img/vbsmilies/smilies/eyesroll.gif" style="border:0px solid;" title="roll">
 

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I thank God everyday that I live in Canada...I have not heard of any hospitals here banning VBAC (although some may have) and the ONLY hospital in my town is fine with VBAC, and in fact a VERY good progressive hospital. After my c-sec (dd was presenting brow, partially transverse and obviously NOT dropping!) I mentioned to my midwife that I was going to wait awhile longer for #2 cause I want a VBAC and she said "HELL yeah!!" very emphatically I might add. <img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/orngbiggrin.gif" style="border:0px solid;" title="orange big grin"><br><br>
What it comes down to is that it is the WOMANS choice, and this is not one that should be forced on her! a c-sec is more risky that a VBAC anyway, and besides, who are doctors to decide what EVERY woman should do??!! <img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/irked.gif" style="border:0px solid;" title="irked">: My cousin had a totally UNneccesary c-sec with her first and then a repeat with her second, because the doc told her to! <img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/irked.gif" style="border:0px solid;" title="irked">: She is not very strong though, and a surprisingly good patient, which I am NOT!<br><br>
Anyway, to sum it up, the whole situation sickens me. <img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/angry.gif" style="border:0px solid;" title="angry">
 

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Interesting article--thanks so much for posting it!<br><br>
I do want to comment on this:<br><div style="margin:20px;margin-top:5px;">
<div class="smallfont" style="margin-bottom:2px;">Quote:</div>
<table border="0" cellpadding="6" cellspacing="0" width="99%"><tr><td class="alt2" style="border:1px inset;">
<div>Originally Posted by <strong>ilovebeingamom</strong></div>
<div style="font-style:italic;">I was monitored intermittenly by dopplar throughout my labor, and studies have proven that this is as safe as continuous electonic fetal monitoring.</div>
</td>
</tr></table></div>
This is not true, at least not for VBAC. There is no study showing that either one is as safe or better than the other. Maybe it is true for non-VBAC, low risk births.<br><br>
The comments in the article about HBAC irritated me, also. They don't want these women VBACing at home, but they won't allow them in their hospitals where they feel it is safer! Makes no sense!<br><br>
And why aren't more women in communities with no VBAC putting up a fuss about it? They are all just agreeing to sections? If certain communities wanted to take away a woman's right to choose the fate of her own body in whether or not to continue a pregnancy, for example, dontcha think there would be all kinds of women's organizations protesting in the streets?
 

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This just makes me so angry and sad. <img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/shake.gif" style="border:0px solid;" title="shake"><br><br>
Like slightly crunchy pointed out, if it's "not safe" to VBAC at home, and we're not "allowed" to VBAC in a hospital, where does that leave us?<br><br>
And to think, I was getting excited about starting to TTC #2. Now I feel anxious and afraid about what my birthing options may be. As if anxiety and fear aren't already my biggest challenges when it comes to a VBAC. <img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/mecry.gif" style="border:0px solid;" title="crying">
 
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