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Trial Of Labor

By Elliot Berlin, DC

Up until the early 1900s, there was no good option for delivering high-risk births that would be safe for both the mother and baby. Joseph Lister’s use of carbolic acid as an antiseptic during surgery paved the way for surgical deliveries in which both the mother and baby were likely to survive.

Additional procedural innovations led to a rise in cesarean deliveries that in 1916 led Dr. Edwin Cragin, an obstetrician, to write a paper called “Conservatism in Obstetrics,” in which he termed the cesarean operation “radical obstetric surgery.” He urged his colleagues to practice sound obstetrics to avoid having to resort to cesareans. The famous “once a cesarean, always a cesarean” phrase came in the final paragraph of the article, and clearly was meant to emphasize that one of the risks of a primary cesarean is that repeat operations might be required. Interestingly, Cragin went on to point out that there were many exceptions to this rule, including one of his own patients who had delivered three babies vaginally after cesarean without difficulty.

There is no doubt that the advent of safe cesareans has and will continue to save countless high-risk mothers and babies during childbirth. However, the overuse of medical interventions, especially in low-risk cases, can only lead to more harm than good.

As a prenatal chiropractor of nearly a dozen years, I see countless women each day who want to avoid unwanted, unnecessary cesareans, or would like to try for a vaginal birth after cesarean (VBAC). Some of these women go on to have their dream births, while others are disappointed or worse. I’ve seen women devastated by their “inability” to birth naturally, saying that they feel like less of a woman because of it. It makes me extremely frustrated, because I know that many of these women’s cesareans were not medically necessary—and, of course, because in no way does a cesarean birth make someone less of a woman or mother.

One major contributing factor is the mismatch of providers with patients. In many countries, low-risk pregnancies are managed and cared for by midwives, with highly trained obstetricians only stepping in should a medical need or signs of greater risk become apparent. In the United States, the overwhelming majority of low-risk pregnancies are still managed by surgeons, who are not even present for most of the labor process. We do have low-risk pregnancy and labor specialists in this country; they are called midwives, and they practice both in and out of the hospital setting. Unfortunately, many women don’t know that having a midwife attend their birth is an option, and in many parts of the U.S., it’s not.

The World Health Organization recommends that the caesarean section rate should not be higher than 10 to 15 percent. In 2012, the U.S. cesarean rate was 32.8 percent. Why are we performing so many cesareans, including many that are not medically indicated?

According to Consumer Reports, at one Los Angeles hospital almost 55 percent of women anticipating low-risk deliveries end up birthing via cesarean. (A woman who hasn’t had a prior cesarean, is not delivering prematurely, and is carrying a single baby who is properly positioned is considered low-risk for labor.) Another Los Angeles hospital’s rate of cesarean delivery for low-risk labor was just 14 percent, while at another hospital 28 miles away, it was only 11 percent.

This disparity in cesarean rates between different nearby hospitals suggests that our high cesarean rate is not due to health-related factors alone, such as a low-lying placenta or rising blood pressure, but rather due to the policies of individual obstetricians and hospitals.

In 2010, the National Institutes of Health (NIH) held a conference on VBACs that should have turned the “VBAC ban”—a refusal of some hospitals or doctors to allow vaginal births for women who have previously had a caesarian—on its head. “Overall, the major benefit of trial of labor is the 74 percent likelihood of VBAC and avoidance of multiple cesarean deliveries,” their final statement read. “We are concerned about the barriers that women face in gaining access to clinicians and facilities that are able and willing to offer trial of labor.”

The American College of Obstetricians and Gynecologists (ACOG) responded to the NIH conference’s findings with a position paper that states “attempting a VBAC is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans.” This statement was a major reversal, as it was two statements from ACOG in the past that had resulted in the so-called “VBAC ban.”

Despite these position papers, there has been little practical change in terms of choice. There are still doctors, hospitals and entire states where it’s nearly impossible to get a trial of labor or a VBAC. This is not just an absence of choice—it is actively forcing women into surgery. That’s just not something we should be doing in the U.S.

A successful VBAC avoids major abdominal surgery, lowers a woman’s risk of hemorrhage and infection, and shortens postpartum recovery. The rate of complications in the mother or baby are similar in VBACs and repeat cesareans, although the risks are different.

Women who have had a cesarean are also considered to be at greater risk than women who haven’t; when they plan to have another child, they often find their birth options are limited further. There are also risks, such as placenta accreta, which go up dramatically with each subsequent cesarean.

Time and time again I’ve heard the same things from my patients—”The nurses laughed at my birth plan,” or “Nobody seemed to care what I wanted. I was pushed into the operating room crying and yelling, ‘No.'” I began to think about ways to get the word out about the truth about natural childbirth vs. caesarean. For years, I’ve been working on what I call the Informed Pregnancy Project, empowering new and expectant parents to make informed choices about their pregnancies, labors and deliveries and ensuring they feel supported in those choices.

A few years back I had four patients in my prenatal chiropractic practice who were due around the same time, each one planning a VBAC. I called the husband of a former patient, film director Robert Humphreys, and we immediately got out the cameras to follow the obstacles and victories along each woman’s individual path to labor. We didn’t have a game plan, but somehow we captured four compelling stories about four incredible women. We have now finished a documentary about the women’s journeys called Trial of Labor.

What is a trial of labor? It’s a planned attempt to labor by a woman who has previously undergone a cesarean delivery and desires a subsequent vaginal delivery. If she’s successful, it’s called a VBAC. If the trial does not succeed, a repeat cesarean will be performed.

Or, as one of the women in our documentary says, “Trial of labor, to me, means to be allowed the freedom to trust your body and experience what your body is doing.”

The women we followed came from all walks of life, but they shared some common experiences and feelings. All felt that they didn’t know enough about birth and their options before they went into their first labors, and some felt misinformed by their doctors. All were unhappy to end with a cesarean delivery or deliveries and felt determined to achieve a natural birth this next time around. Some of the women experienced a strong disconnect between the cesarean and their personal ideas of birth—so strong that nearly all the women used the word “surreal” to describe the experience. One said, “I couldn’t see it; I wasn’t a part of it. When he was born he flipped him over the curtain to where I could see ‘it’s a boy,’ and off he went; they took him away. I just got to see a glimpse of him, just for a moment. It was pretty sad.”

The women all felt some sense of shame about their cesarean births. One said, “I felt embarrassed, ashamed, I felt guilty for not having been there and aware of my son’s birth. It was really hard. I’m still dealing with that.”

Determined never to feel those feelings of shame, regret and anger again, each of the four women was intent on having a VBAC. They all planned to use minimal or no pain management and to choose the setting where they would feel most comfortable giving birth—in a hospital, a birthing center or at home.

Several of the women experienced difficulty finding doctors or midwives and hospitals and birth centers that would support their choice to attempt a trial of labor during their pregnancies. Some were told that no doctor or hospital would allow a trial of labor—especially the two women in the documentary who’d had two prior cesareans. Yet all the women were extremely proactive and were eventually able to find care providers willing to “allow” them a trial of labor.

One documentary participant felt sure she knew why doctors are so willing to go for repeat cesareans instead of allowing a trial of labor: “It’s simple for them to schedule you, and do a procedure that takes them 20 minutes. Lay you on a table, cut you open, deliver your baby, they’re done. [Otherwise they have] to wait for you to go through your process of labor and delivery. They want to put a time constraint on labor itself; they want to put a time constraint on pushing. Not all women have their babies within 20 minutes. Not all women push for two hours and have a child. It’s different for every woman.”

It’s true that there can be financial incentive for doctors to order more cesareans—they usually receive equal or greater pay for them compared to assisting in a natural birth, and a cesarean is generally a much faster and predictable process for a doctor than delivering a baby vaginally. As for the hospital, the bill can double or triple with a cesarean.

Even faced with the chance that all their efforts could still result in a repeat caesarean, the women still felt their journey toward a trial of labor was important in their healing process from previous caesarean births.

What astonished me was the lengths each woman was willing to go to in order to achieve her dream of a trial of labor—a dream that should be much more readily accessible and offered routinely to mothers who’ve had a previous cesarean. When these four mothers were told they had no choice but to deliver via a repeat cesarean, they didn’t flinch. Instead, they went off in search of information and resources that could help them have the birth experience they’d always wanted.

My hope for the future is that it won’t be so hard to find a provider who is willing to support a trial of labor. I’d like to see a future where VBACs will be discussed as a routine option in doctor’s offices, and pregnant women won’t have to look far and wide for care providers who will allow them the trial of labor they desire so greatly. All women are different—some happily opt for elective caesareans, after all—but by respecting each woman’s individual choice and allowing her to go with her gut instincts, I believe we’ll see happier, healthier mothers and babies.

Or as one of the documentary participants put it, “I just think there are so many good reasons to try.”