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Doctors warn of risks from vaginal births
BY TARA PARKER-POPE
Wall Street Journal

After an angry backlash against Caesarean sections, most everyone for the past decade has taken it as a given: Vaginal childbirth is the best and safest way to have a baby.

But a number of high-profile doctors, concerned by an alarming incidence of serious birth injuries to women who’ve had vaginal deliveries, are beginning to challenge that conventional wisdom. They argue that more maternity patients should at least consider having elective C-sections. At the very least, they say obstetricians need to give their patients more information about the risks of vaginal delivery just as they would a C-section or any other medical procedure.

Surveys show that one-third of all women have suffered some type of birth injury, both temporary and permanent ? most commonly urinary or fecal incontinence, pelvic pain, sagging pelvic organs and sexual dysfunction. One in every nine women will require surgery as a result. A new medical subspecialty called urogynecology has evolved to repair the extensive damage childbirth can cause to a woman’s body. Yet few obstetricians warn patients of the possibilities of serious side effects.

“It’s like the silent epidemic of motherhood,” says Linda Brubaker, professor of obstetrics, gynecology and urology at Loyola University in Chicago. “We’re doing very well on infant health, but now we need to turn our attention to the mother’s health.”

Jeannette O’Neill, a 33-year-old mother of three, has undergone 19 procedures to correct the damage wrought by giving birth to three children. Vaginal delivery hurt the nerves that controlled her bladder, leaving her incontinent and without feeling in her bowel. The nerve damage also affected her leg, causing one foot to droop. An implant, similar to a pacemaker, now controls her bladder function.

“I was wearing diapers for 2? years,” says the Pembroke Pines, Fla., nurse. “It’s ironic that I don’t have a C-section scar, because I have scars down my spine and right side of my bottom and seven scars in front, all from trying to repair childbirth injuries.”

Debra Sandefur, a 45-year-old Naperville, Ill., mother of a 3-year-old son, had a partial hysterectomy and a “bladder sling” to repair birth injuries. In three weeks, she’ll undergo surgery for prolapse, which causes a woman’s pelvic organs to slip outside her body.

“It’s hard to lift my son because the body parts come out ? it’s like half of a ping pong ball coming out,” says Sandefer, who deals with the problem by pushing the organs back in place.

C-SECTION REDUCTION

One reason for the high incidence of birth injuries is the decade-long public health effort to reduce the nation’s C-section rate, which peaked at about 25 percent in the late 1980s, dropped to about 20 percent in the 1990s and is now at about 23 percent. Insurance companies, in particular, pressed for more vaginal deliveries, which cost far less. Today, the quality of obstetrical care given by doctors and hospitals often is measured by a low C-section rate.

Nobody believes every woman, or even most women, should have C-sections. Caesareans carry all the risks of major surgery, including infection, bleeding and blood clots. In addition, the abdominal incision can take weeks to heal and make it painful for mothers to carry their babies.

But an increasing number of physicians say their colleagues should be open to a “patient choice” C-section and provide women with enough information to make an informed decision.

Currently, “nobody is told the pros and cons of anything,” says G. Willy Davila, chairman of gynecology at Cleveland Clinic Florida. “Informing the patient is such a powerful tool.”

Still, it’s clear that even when advised of the risks, many women would opt for a vaginal birth.

Amanda Sherland, a 37-year-old mother of two in Deerfield Beach, Fla., had surgery in February to correct stress incontinence, which caused her to leak urine when she ran, coughed or sneezed. Al
though she wishes she’d been warned about the potential problems, she says she still would have chosen to deliver vaginally.

DETERMINING RISK

Gauging risk for birth injury is easier in a second pregnancy.

“If there’s a problem with the fetus getting through the first time, you probably have an increased risk of damage the second time through,” says Joseph Schaffer, director of urogynecology and reconstructive pelvic surgery at University of Texas Southwestern Medical Center in Dallas. “That’s a group of women that I think are at very high risk and should be considered for a Caesarean section.”

Other risk factors include having urinary incontinence during pregnancy or right after a previous birth; suffering a bad tear or laceration during a prior delivery and having existing prolapse of internal organs.

Having family members who have suffered prolapse or birth injury may also signal increased risk. A previous prolonged labor that involved a lot of pushing, the use of forceps and episiotomy also increases risk.

It’s known that women who’ve already had a C-section are at higher risk for bleeding during a vaginal birth. Even so, for years, they also have been pressed to have a vaginal birth after C-section, or VBAC, the second time around. But more recently, VBAC deliveries have begun to drop.

It’s also important that women become aware that incontinence and prolapse aren’t a normal part of aging, and that some, if not all, of the damage can be repaired.

“It’s kind of a private suffering,” says Sandefur. “Because the baby is healthy, nobody really cares about what happened to your body during delivery and how hard it is to fix things.”