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Woman fights old school over Caesarean section

Mary Joe Hertzog gave birth to her last baby without having her belly cut open, and she sees no reason why she can't do it this time, too. But doctors who deliver babies for Health Department patients in West Pasco won't let her try, because she had a Caesarean section two babies ago. With no money and no private insurance, Mrs. Hertzog can't argue.

What she has in mind is Vaginal Birth After Caesarean, or V-BAC. Trouble is, the doctors who deliver babies for Health Department patients at Riverside Hospital in New Port Richey are of the old school, the "once a Caesarean, always a Caesarean" mentality that has sent the C-section rate in the United States up to 25 percent. At Riverside Hospital, the rate is an amazing 36 percent, the 11th highest in the state.

"It's ridiculous to me," said Mrs. Hertzog, whose due date is June 30. "If it comes down to the child's safety or my safety, I could undergo a C-section, but otherwise I want to try" V-BAC.

Ten years ago, most obstetricians routinely scheduled C-sections in all pregnancies after women had their first one because of fears that the old uterine scar would rupture during labor.

But when surgeons switched from an up-and-down cut to a side-to-side cut at the bottom of the uterus, the danger of rupture fell drastically. Now most studies indicate the risk from V-BACs is no greater than from Caesareans.

In women who have the proper type of scar, "I think we can say a trial of labor . . . is rapidly becoming the standard of care," said Dr. Ronald Chez, obstetrics professor at the University of South Florida.

V-BACs are so standard in New York that some doctors are now requiring patients who don't want them to sign a form protecting the doctor from a suit for unnecessary surgery.

Somehow, the news hasn't filtered down to West Pasco.

The supervisor of the prenatal program at the Health Department, Cheryl Prentice, said she always schedules women for Caesareans if they have had one in the past because "the doctors have told us they will not do V-BACs."

Efforts to discuss the issue with the four doctors who treat Health Department patients were fruitless.

Riverside Administrator Wayne Deschambeau said last week that if Mrs. Hertzog persisted in wanting a vaginal birth, she would have to leave the county for care. He said she could go to Tampa General or Bayfront Medical Center in St. Petersburg.

"If you pay for (it), you can go to any doctor you want to," Deschambeau said. But if you want the state to take care of you, he said, you have to accept whatever doctor you get.

As it turns out, Mrs. Hertzog won't have to leave the county for her V-BAC. She has found help in East Pasco's Dade City, 45 minutes to an hour away. She opted for Dade City over St. Petersburg or Tampa, she said, because there's less traffic on State Road 52B than on U.S. 19. It takes about the same amount of time to reach all three.

"It's upsetting to me that I have to go way out of my way to deliver a child," said Mrs. Hertzog, who lives two blocks from Riverside Hospital.

If her husband is home with the car, he takes her to Dade City for her prenatal checks; if he's not, she goes by cab, with taxpayers footing the bill.

"I'm glad she found her way to us," said Ronald Melancon, head of East Pasco Health Center. "It's our policy to offer women the least invasive procedures," he said, provided there's no medical reason not to.

His federally funded program offers prenatal care through Dolly Hendley's Women's Health Resources, staffed by two obstetricians and two nurse-midwives. Women deliver next door at Humana-Pasco.

Mrs. Hertzog said the staff at the Hendley center regards her as a good candidate for vaginal delivery. She knows that could change at the last minute, but there's no reason to assume it will.

This will be her fourth baby. The first was born naturally, but the second was so big, almost 11 pounds, that the doctors at Riverside did a C-section. At the time of the third delivery, she was in Martin County, and the nurse-midwives there supported her in her desire for a trial of labor rather than a routine repeat C-section. It worked.

Now the family is back in Pasco. Gary Hertzog's job doesn't offer health insurance, and he can't afford to buy a family policy. So Mrs. Hertzog's delivery will be paid by Medicaid, after prenatal care provided through a public clinic.

Health Department Director Dr. Marc J. Yacht said he plans to hold meetings with the hospital administrator and the doctors who do deliveries in hopes of getting some flexibility.

But Yacht isn't in any position to make demands, since the doctors are receiving only $500 per delivery from Medicaid, far less than their usual fee. No law says they have to deliver these babies.

However, a law that takes effect Oct. 1 may nudge them to change their attitudes about V-BACs. Hospitals that deliver at least 30 babies a year at taxpayers' expense will have to set up guidelines as to when labor should be called off in favor of surgery. A review panel in the hospital will look at Medicaid C-section cases later to make sure they were necessary. Convenience is not a good enough reason.

Florida's Healthy Start program will help form maternal-child health coalitions that could do some nudging, as well. But Anne Richter, nursing consultant at the state Department of Health and Rehabilitative Services, understands how hard it is for some doctors, and some women, to accept V-BACs. "Change is just difficult," she said.

About four or five years ago in Tallahassee, a group of women got together and held a town meeting to inform women about their options in childbirth. Attitudes changed. Women began demanding a choice.

It's no longer acceptable medical practice to force a woman into surgery she doesn't need, whether it's a hysterectomy or a Caesarean. The times are changing, whether West Pasco is ready or not.