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.
"[Uterine ruptures] scar doctors as well as patients," Dr. Main said. "If the VBAC patient wants it, they'll be happy to do it, but they won't go out of their way to push a VBAC for patients. It's a shift of attitude that makes a significant difference in terms of the number of people who attempt a VBAC."
In fact, while nearly 80 percent of women with C-sections attempted a vaginal birth at the hospital during the '90s, now more than 80 percent automatically schedule another C-section surgery.
Many VBAC advocates and doctors say women are getting a biased view from many doctors about the potential risks of a VBAC vs. a repeat Caesarean.
"Women who do want VBAC are told they're being irresponsible and gambling with the lives of their babies," said Berna Diehl, spokeswoman for the International Caesarean Awareness Network (ICAN), a nonprofit that works to cut back unnecessary C-sections. "So they're shamed into a repeat Caesarean, which is too bad when you consider the overall safety [for a VBAC] is there. They're not always getting the full picture when they walk into a doctor's office to make a good, evidence-based decision."
In an unofficial telephone survey, ICAN counted 300 hospitals nationwide that had stopped doing VBACs as of 2005, influenced by the influx of malpractice cases and a change in the formal recommendations of the American College of Obstetrics and Gynecology in 1999 that required a surgical team be "immediately" available to perform emergency surgery for a woman attempting a VBAC.
The percentage of women with a prior C-section having a vaginal birth sunk from a high of 28 percent nationally in 1996 to 9 percent in 2004, according to the National Center for Health Statistics.
San Francisco had remained a haven for VBAC births at its five labor and delivery floors. And St. Luke's was a little-known gem: 85 percent of women with C-sections who tried labor were able to give birth vaginally in 2006, the highest rate in the city. Cynthia Banks, a certified nurse midwife at St. Luke's until this month, attributes the success to the midwifery model of care at the hospital, where midwives outnumber doctors on the labor and delivery roster.
"Whenever there's a strong midwifery presence and philosophy of labor as a natural process, that's when things are safe as can be [for VBAC births]. It takes the women believing in their bodies and it also takes the providers being supportive of that."
But St. Luke's foresaw a possible scenario on nights and weekends when less staff was on hand: The main operating room team could be occupied, the ob-gyn team always called in for a VBAC labor attempt could be busy, and a VBAC mother, should she need an emergency C-section, could be left without a surgical team. "It's absolutely a possibility," said Dr. Laura Norrell, the hospital's chair of obstetrics. "We've been lucky it hasn't happened, frankly. So while [stopping VBACs] is a painful decision for us to make, I think it's the right one because it's all about guaranteeing a patient's safety."
Some women whose first delivery ended in a C-section have become disillusioned with hospital births, feeling they were "going with the flow" in a culture that sees labor as a medical condition to be induced, monitored, and sped up with the woman often numbed and confined to bed, instead of a usually healthy process that develops at a different rate for each woman and can be helped along by methods as simple as changing positions.
A number of these women check in for their second birth better educated and accompanied by a birth coach to resist what they see as unnecessary interventions. Studies show that inducing or speeding labor and even the routine use of a continuous electronic fetal heart rate monitor can lead to more C-sections.
But a few expectant mothers, to the alarm of many doctors, opt to avoid the headache of challenging doctors and birth their next child at home. Kim Weiss, the CEO of a software company in Sausalito, recalls telling a doctor during prenatal care at CPMC that she wanted to have a VBAC epidural-free, to which he responded, "Trust me, honey, I've birthed thousands of babies, and you're gonna want that epidural." She saw a slippery slope before her from an epidural to another operation.
Weiss says she trusted CPMC to handle any complication and is a repeat customer for ob-gyn care, but "natural birth at CPMC is an oxymoron. I thought if I ended up at CPMC, I would not have a VBAC, and it would not be natural. It would be a Caesarean."
The marathon runner read 15 home-birthing books, delivered in a birthing tub in her bedroom with her husband and certified nurse midwife by her side, and was up walking minutes later.
But Dr. Main says a home VBAC is "absolutely crazy."
"You're rolling the dice. The problem with a [uterine rupture] is that it's sudden and catastrophic, it doesn't gradually develop and give you a chance to get to the hospital."
Still, mulling her options, Kilty Vahle considers a home birth her best chance to deliver vaginally. She had thought of going to Homestyle Midwifery in active labor since a hospital can't refuse a woman that far along, nor perform a C-section without consent, but now even that option is in jeopardy. Last week, St. Luke's informed the midwifery service that it will be kicked out of the hospital's Women's Center on Aug. 1 since it is considered beyond basic obstetric care, although the midwives are considering opening a private practice within the hospital, said Yeshi Neumann, the service's founder. Vahle's due date is Aug. 2.
Of course, she considers all of those sub-optimal choices.
"I have an activist side to me, so I'd love the thing to be reversed and be the first VBAC [at St. Luke's] after the cancellation of the ban."