Amy Mead and her doctor both care about the health of the baby she will deliver in three months, but a recent medical policy shift for Juneau has them disagreeing on how to deliver the child.
The question is whether she should have her second Caesarean section or a natural vaginal birth. As it turns out, Mead won't have the option of staying in Juneau for a natural birth.
No woman who has had a previous C-section has that option anymore.
Mead's doctor at Valley Medical Care told her and other women who have had C-sections that the physicians will no longer help them have a vaginal birth. They either have to go to other cities to have a vaginal delivery or have another C-section here in Juneau.
"I don't think it is fair for me not to have a choice," said Mead, a 37-year-old attorney. "I need to know why having a C-section is better for me and my baby. After doing a lot of research, I am not convinced having a major abdominal surgery is a better choice."
Physicians at Valley Medical Care said they don't have a choice, either.
"Our liability insurance company said VBAC (vaginal birth after Caesarean) has become indefensible in court when we cannot provide immediate C-section," said Priscilla Valentine, a family physician who practices obstetrics at Valley Medical Care. "That means having a surgical crew in house 24 hours a day, doing nothing else except for C-sections. Big hospitals can afford to do that. We don't have that in Juneau."
Physicians at Valley Medical Care deliver their patients' babies at Bartlett Regional Hospital, where there are two operational crews in house on weekday workings and one crew after hours and on weekends. If there is an emergency C-section, a surgical crew has to be called in.
Since 1999, the American College of Obstetricians and Gynecologists has recommended a surgeon be "immediately available throughout active labor" for women who have a previous C-section and want a vaginal birth.
Juneau is not the only community where pregnant women face the dilemma.
More than 250 hospitals across the nation now ban vaginal birth after Caesarean, according to International Cesarean Awareness Network, Inc., a nonprofit that promotes vaginal birth after Caesarean.
"A lot of communities like Juneau don't have staff immediately available for a C-sections," said Bruce Flamm, a clinical professor of obstetrics and gynecology of University of California at Irvin. He has studied vaginal birth after Caesarean for almost 20 years. "Many cities have shut down their VBAC programs."
Flamm said the risk of vaginal birth after Caesarean is low: Only 1 out of 100 women has uterine rupture, but if a rupture happens, a delayed C-section can cause the baby to die or suffer permanent brain damage.
"Although there is no specific time limit, some people use 17 minutes as a general guideline of how soon a C-section should be performed after a rupture," Flamm said.
Valentine said the physicians at Valley Medical Care stopped offering vaginal birth after Caesarean, keeping their patients' and their babies' best interests in mind.
"The risk is low but the result can be catastrophic," Valentine said. "The fastest we can do a C-section is 20 minutes. The longest was four hours. We have people on call at home. But they are not standing outside the labor room."
But Laura Maples, who started the Alaska chapter of the International Cesarean Awareness Network, said women are forced to have unnecessary surgeries and that the risk for uterine rupture is exaggerated.
"Women should have a right to choose for themselves," said Maples, who found a doctor Soldotna to help her have a vaginal birth.
Publications from the Coalition for Improving Maternity Services said a repeat C-section can increase the risk of maternal death and preterm birth, prolong postpartum recovery and affect the woman's reproductive ability.
Mead said she hasn't ruled out the possibility to have a C-section in Juneau or flying to Seattle to give birth vaginally. She said either will be difficult for her and her family.
"Although my son is good on the plane, traveling with a 2-year-old is emotionally and physically exhausting," Mead said. "I want someone to tell me what is the best for my son and my baby."
I-Chun Che can be reached at firstname.lastname@example.org.