No Hail Caesarean

Expectant mothers are losing an option to birth babies naturally and activists are charging it is more about money than safety

Kilty Vahle planned to deliver her first baby as Mother Nature intended. No painkiller. No cutting. But as labor stretched on while her cervix did not, she surrendered to first painkiller, then labor-speeding hormones and an epidural, and finally a Caesarean section while the baby's heartbeat was still strong. She walked out of the hospital with a healthy baby, but vowed kid No. 2 would be pushed out in a rush of endorphins, not cut out in the fog of anesthesia.

So, pregnant again last fall, Vahle scheduled her delivery at Homestyle Midwifery at St. Luke's Hospital in the Mission. There, a certified nurse midwife would guide her through labor with natural techniques, and the staff assured her she could push for a vaginal birth. But only as long as it was safe. That's because her prior C-section poses a small but horrible risk during labor: a .5 to 1 percent chance of tearing the uterine seam from the previous surgery, causing heavy hemorrhaging and requiring an emergency C-section to save the mother's uterus, her baby, and herself.

Vahle changed her insurance to a more expensive HMO that would cover the midwifery service.

But in mid-March and five months pregnant, she got an e-mail: St. Luke's, having merged with California Pacific Medical Center (CPMC) on Jan. 1, had stopped scheduling patients who wanted a vaginal birth after a C-section (known as a VBAC). She could schedule a C-section with St. Luke's or find somewhere else.

"When I finally had a moment to breathe, I burst into tears," the 39-year-old Lower Haight resident said. "I might not find the advocates I know I had at Homestyle" for a vaginal birth. "They may cut me off sooner and say we recommend a Caesarean now."

Joining a national trend, the CPMC-St. Luke's campus, known for its low-intervention midwifery approach to labor even outside the Homestyle Midwifery service, is now the first labor and delivery site in the city to stop scheduling vaginal births after C-sections.

Hospital officials say more expertise and staff are available to handle the higher-risk VBAC delivery at the main CPMC campus. It's the city's biggest labor and delivery floor with nearly 6,000 deliveries a year that practices a more medically managed method of delivery, with higher intervention rates and only four midwives practicing among the 50-some obstetricians who deliver babies.

But VBAC advocates argue the decision was more about money than safety, since St. Luke's has been successfully delivering post-Caesarean vaginal births for years. Advocates say the move limits a soon-to-be mother's control in one of the most important events of her life — forcing women to choose between a natural birth at home that lacks the safety net of an operating room steps away, or hospitals that may be more likely to urge women to have a repeat C-section, a surgery with more risk of complications and a longer recovery than a vaginal delivery.

"How can you take away the right to birth with whom you want and how you want?" asks Charity Pitcher-Cooper, a birth educator who is heading up a May protest march in support of VBACs. The march will end at St. Luke's door. "If you go to a place that does a lot of C-sections, you get nudged in that direction, just because they do a lot of them and see them as normal."

St. Luke's has now presented to some 20 pregnant women the options of transferring to the main CPMC campus or other area hospitals. Aside from a few who scheduled C-sections at St. Luke's, patients are now scrambling before the contractions begin to find a birthing option that fits their wishes and that their insurance will cover.

With the national C-section rate ballooning from 5 percent of births in 1970 to 29 percent in 2004 — San Francisco hovering at 24 percent — more and more women who have a second baby will have to make a similar choice: advocate a vaginal birth that carries a tiny risk of catastrophic consequences, or schedule one C-section after another with the risks of complications increasing each time.

For years, the saying was "once a Caesarean, always a Caesarean." But in the 1980s, with research showing the risk of uterine rupture was less than previously thought, VBACs came into vogue nationally. Government health officials advocated VBACs to curb the climbing C-section rate.

California Pacific Medical Center joined the trend, said Dr. Elliot Main, chairman of obstetrics and gynecology. Throughout the '90s, doctors suggested that all women with a prior C-section try to have a vaginal birth. They often induced labor or used synthetic hormones that make contractions harder and faster, both practices that later studies showed increase the risk of a rupture.

Consequently, the hospital had one to three ruptures a year, resulting in the "loss of uteruses, loss of babies," and the increase of malpractice cases, said Dr. Main. After four uterine ruptures in 1999 alone, CPMC changed its policy for VBAC patients. It stopped inducing labor, cut down on artificially speeding along labor, and screened candidates for those at low risk for a rupture.

Doctors became "gun-shy" in advocating that women with prior C-sections attempt labor.

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