FACTS &
ARGUMENTS
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Monday, March 28, 1994
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FIFTH
COLUMN
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MEDICINE
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"Once a cesarean section
always a cesarean section" no
longer true, Gabor Maté says

Neither Cindy Ausma, nor I as her family doctor,
expected that she would have a vaginal birth with her fourth child.
Mrs.Ausma,33,came to me for the first time in November,1992,in the fifth
month of pregnancy,having undergone cesarean sections three times in the
past.She characterized the attitude of her previous physicians as "You do
it my way,on my schedule,no ifs or buts."

I referred her to Keith Williams,a perinatologist at Grace Hospital
(since renamed British Columbia's Women's Hospital)for an obstetrical
opinion.I was nearly as surprised as she was when the consultant wrote
back that Mrs. Ausma could be offered a trail of vaginal labour. I had
been used to attending vaginal births following one or even two
previous cesareans but had never seen one after three.

"I was not advocating that this patient have a vaginal birth" says Dr.Williams,
"but I felt it was safe enough for her to try if she wished."

Mrs.Ausma recalls: "It was exciting for me that for once I had a choice in the matter
the other times I had been told "absolutely not" by every doctor I phoned.

"Once a section,always a section"was the received wisdom in medical circles
for many years.That is, if a woman had been delivered by cesarean once,
all subsequent deliveries had to be by the same route.It was believed
that if a woman failed to deliver vaginally in the first place,she would
not be able to do so in the future.Further,the risk of the operative scar
tearing under the impact of labour contractions was thought to be too great.

The cesarean-section rate in Canada is notoriously high.The chance of a Canadian woman
having a C-section in 1970 was little over 5 percent;20 years later it had quadrupled to
about 20 percent. "Not only does repeat cesarean section contribute to the large
increases in the rate of total cesarean sections," an Ontario study found,"but it
is also the most common single indication.by 1990,40 percent of all cesarean
sections involved women who had previously undergone the procedure."

Many of those repeat sections were not necessary.In 1986,a national
panel recommended that most women who had undergone a cesarean
should be given the opportunity of a vaginal birth in future pregnancies.
The chief exceptions were women who had had the old-fashioned vertical
incision,which did present a significant risk of rupturing during labour.
For the vast majority,vaginal birth after cesarean section (VBAC)reduced the
risk of complications,not to mention health costs and the length of hospital stay.
The incidence of uterine rupture was found to be only about two or three per thousand.

VBAC is also safe for infants,causing no greater risk of perinatal mortality
than repeat sections.Some vigilance is necessary:Dr.Williams recommends
intermittent monitoring of the fetal heart.This gives the earliest
warning of a rupturing scar,which may threaten fetal health.

About three-quarters of women allowed to try VBAC succeed at having
a vaginal birth,many of them without any significant medical interventions.

"A lower VBAC success rate would actually indicate better medical care"
says Michael Klein,professor of family medicine at the University of British Columbia.
In other words,if women who tried VBAC failed more often,it would mean that the
reasons for the original C-sections were more valid."That so many can deliver
vaginally,having been told the first time that they couldn't,shows that in too
many cases the indications for the original operation must have been
shaky,"Dr. Klein points out.

Despite the physical and psychological benefits of VBAC,and contrary
to the 1986 recommendations,the acceptance of the practice across
Canada has been relatively slow and sporadic.Some hospitals have been
less reluctant to permit it,much less to encourage it.A study reviewing births at
Toronto General Hospital in 1986 found that most of the women who underwent
repeat C-sections would have been eligible for a trial of VBAC,but only
a minority of them had been offered the opportunity.

Cindy Ausma was admitted to Grace Hospital on March 16,1993.In five hours,
her cervix was fully dilated;one hour later she pushed out a healthy baby girl.
"I still find it amazing,"she says.

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