Both of Christine Simonds' children were delivered by Cesarean section and, as the arrival of her third approaches in April, she is determined to experience birth the old-fashioned way -- even if that means sneaking behind her doctor's back.
When Simonds became pregnant this time, the Enfield, Conn., woman began searching for a doctor who would assist her in a vaginal delivery.
But every place she went, the doors closed. Even the Birthplace at St. Mary's Hospital in Waterbury, Conn., one of the state's pioneers in natural child-bearing, turned her down, after initially agreeing to care for her.
Fewer obstetricians are willing to attempt vaginal deliveries for patients who have had Cesarean sections, even if hospitals will allow them.
Hospitals that allow such deliveries on their units require that patients attempting a vaginal birth after a previous Cesarean -- known as VBAC -- remain attached to a fetal heart monitor for the duration of their labor.
Simonds and women like her say they are victims of health care driven by insurance concerns, not sound medical practice. Doctors spooked by the threat of lawsuits and struggling to pay soaring malpractice insurance premiums are putting their financial interests ahead of the wishes of their patients, women and their advocates contend.
Some doctors concur, although they may see it a bit differently.
"The outcome you get is a patient not being able to get what you want," said Dr. Mark S. Defrancesco, chief medical officer of Women's Health Connecticut, a consortium of about 150 obstetrician/gynecologists.
Litigious environment
Doctors cite the risk of uterine rupture as the reason they are reluctant to perform vaginal deliveries after Cesarean, although they acknowledge that the risk is relatively small.
The chance of a previous C-section scar tearing during labor is less than 1 percent for women who are not given medication to speed up delivery, according to the American College of Obstetricians and Gynecologists. The risk rises to about 2.5 percent among women who are given the medication.
The professional organization of ob/gyns has not suggested banning VBACs but recommends that it be attempted only with continuous fetal monitoring and only in hospitals with anesthesiologists on the premises at all times in case a C-section becomes necessary.
That rules out natural birth centers, such as the one at St. Mary's, where patients are encouraged to walk around, do gentle exercise and soak in Jacuzzis to ease the discomfort of labor. Hooked to a monitor, patients cannot get out of bed.
Dr. Mark Albini, a Waterbury, Conn., obstetrician who delivered his own child in a bathtub six years ago and was the catalyst behind the St. Mary's birth center, said he decided recently to ban VBACs there.
He said he made the difficult decision to protect the hospital in a climate where patients are quick to sue if their babies are born damaged, even if that damage is an act of nature, not bad medical care.
Although the St. Mary's birth center is contiguous to the hospital, putting operating rooms and anesthesia just minutes away, he said the center's back-to-nature philosophy is not compatible with fetal monitoring.
Thus, patients such as Simonds may attempt a VBAC next door in the hospital's labor and delivery unit, but not at the birth center.
Waiting it out
That is not acceptable to Simonds, who is devastated.
Her first two children, a boy, 10, and a girl, 9, were delivered by C-section because her labor failed to progress. She feels certain now that her confinement to bed, lying flat on her back, contributed to her difficult labor.
She hoped that the relaxing power of water and the strong force of gravity might make it possible for her to deliver her third child naturally. She can't try those things if she's tethered to a monitor.
"I just feel like we've taken a huge step backwards," Simonds said. "We really wanted to use the water, and that's not going to happen."
The decline in the availability of vaginal birth after C-section comes at a time when more women are choosing to deliver by Cesarean simply for the sake of convenience. In the United States 23 percent of babies are delivered by Cesarean and that number is climbing.
While the increase in C-section rates is burdening some hospitals because women who have operations generally have longer recoveries, doctors welcome them in part because they can be scheduled ahead of time, they are quicker than labor, which can last 24 hours or more, and because doing a C-section might protect them in court.
"It's a fact of life: If a doctor does a C-section, in the jury's eyes he's done everything he could," said Kitty Ernst, a midwife and founder of the National Association of Childbearing Centers, which accredits natural birthing centers.
Obstetricians pay among the highest malpractice premiums of all doctors, and the squeamishness about VBAC coincides with struggles in many states for legislation that would limit damage awards to patients and thus theoretically lower those premiums.
Doctors predict that if jury awards are capped, potentially risky procedures such as VBAC might become more available.
"If there were (damage award) caps and other reforms, you could bring it back based purely on medical decisions, and you would see more people offer VBACS," Defrancesco predicted.
Christine Simonds cannot wait that long.
When her labor begins, Simonds plans to check in to a hotel near St. Mary's hospital with her husband and a doula, a woman trained to guide other women through labor. She says she will stay there, using the shower, massage, gentle exercise and other relaxation techniques until it is time to push her baby out. Only then, she says, will she go to the hospital and be attached to the fetal heart monitor.
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