Efforts to curb repeat cesareans
Most women who have had cesarean sections can safely give birth the normal way later, studies have shown, but in recent years hospitals, doctors and insurers have been refusing to let them even try, insisting on repeat cesareans instead.
The decisions have been based largely on fears of medical risks and lawsuits, medical and legal experts say. The hospital rules have infuriated many women, added to the nation’s ever-increasing cesarean rate and set off a bitter debate over who controls childbirth. Now, the American College of Obstetricians and Gynecologists is issuing a new set of medical guidelines meant to make it easier for women to find doctors and hospitals that will allow vaginal birth after cesarean, or VBAC (pronounced vee-back).
Women’s health advocates praised the new guidelines because they expand the pool of women considered eligible for vaginal births, but they expressed doubts about whether the recommendations go far enough to change a decade of entrenched behaviour by doctors, hospitals and insurers.
Policy matter
The new guidelines replace the obstetrician group’s earlier ones — which were exactly what led many hospitals to ban VBAC in the first place. But the group says it never intended to limit women’s access to vaginal birth, and it acknowledges that its policies may have helped fuel the trend toward too many cesareans.
“It will be better for women in the long run if we can lower the C-section rate,” said Dr Richard N Waldman, president of the obstetricians’ group and chairman of obstetrics at St Joseph’s Hospital in Syracuse, New York.
About 1.4 million women had cesareans — or about 32 per cent of all births — in 2007, the latest year with figures available, according to the National Centre for Health Statistics. Like earlier guidelines, the new ones say that vaginal birth is safe for most women who have had a cesarean, provided that the cut in the uterus was low and horizontal, the way nearly all cesareans are performed today. Sixty to 80 per cent of women who have what doctors call ‘a trial of labour’ — an attempt to deliver vaginally — after a cesarean succeed.
The new guidelines go beyond the earlier ones, however, stating that vaginal birth after cesarean is also reasonable for most women carrying twins and those who had two prior cesareans.
Even if a hospital does not offer trials of labour after cesareans, the group says, “such a policy cannot be used to force women to have cesarean delivery or to deny care to women in labour who decline to have a repeat cesarean delivery”.
The main worry is the risk of uterine rupture during labour, which can severely harm both the mother and the child and requires emergency surgery. But the guidelines state that for women with one previous cesarean, the risk of rupture during a trial of labour is quite low — from 0.7 to 0.9 per cent. If the same woman has a repeat cesarean instead, before labour starts, the risk of rupture is even lower — from 0.4 to 0.5 per cent.
But a cesarean increases the risk of placental problems in later pregnancies that can cause hemorrhage or lead to hysterectomy.
Compared with babies born after a repeat cesarean, those born vaginally after cesarean have increased risks of stillbirth (below 1 per cent), but decreased risks of breathing problems and jaundice.
Until the 1970s, the rule was “once a cesarean, always a cesarean”, largely because of worries about rupture. But medical opinion shifted, and an expert panel convened by the National Institutes of Health in 1980 found that vaginal birth after cesarean was safe for many women.
In 1985, 6.6 per cent of women with prior cesareans were giving birth normally. By 1996, the rate had risen to 28 per cent. But some uterine ruptures were reported, with lawsuits and enormous payments, and the rate began to drop.
