Vaginal birth after cesarean underused: panel

NEW YORK Wed Mar 10, 2010 6:09pm EST

A pregnant woman in a file photo. REUTERS/File

A pregnant woman in a file photo.

Credit: Reuters/File

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NEW YORK (Reuters Health) - If you're pregnant and have had a cesarean section before, chances are you'll have one again. In at least one-third of US hospitals, a repeat cesarean is the only option, and nine in 10 women end up getting one -- a fact that had experts worried at a national conference this week on vaginal birth after cesarean, or VBAC.

Because VBAC doesn't require surgery, mother and baby can spend more time together and leave the hospital sooner than after a cesarean.

There is no agreement about how often VBAC should be attempted, but experts agree that the current overall cesarean rate -- one-third of US births -- is too high.

"The pendulum has swung too far," said Debra Bingham, president-elect of Lamaze International, a non-profit advocacy group that promotes non-medical childbirth techniques.

According to Bingham, participants at the three-day meeting in Bethesda, Maryland, agreed.

After reviewing earlier studies, the expert panel found that VBAC was about as safe as first-time vaginal childbirth. The panel emphasized that women should have access to the delivery method they prefer, and recommended that health-care providers and policymakers collaborate to eliminate current barriers to VBAC, including guidelines that limit availability of the procedure.

"The data indicate that hospitals are not able or willing to provide" VBAC, said Dr. F. Gary Cunningham, of the University of Texas Southwestern Medical Center at Dallas, who chaired the panel.

"We are just hoping that putting these data out there after this exhaustive review will prompt some people to look at the problem," he told journalists after the conference.

Bingham said Lamaze was pleased with the result, which was also welcomed by others at the meeting.

"There is quite a presence of young women who are not willing to be told what to do," she told Reuters Health from the conference, which was organized by the National Institutes of Health. "They don't want their reproductive decisions made by others."

CHANGING RECOMMENDATIONS

VBAC has long been the subject of heated debate. For decades, the mantra was "once a cesarean, always a cesarean." Doctors were concerned that the scar left in the womb from a previous cesarean would tear during labor, leading to life-threatening bleeding.

But in 1980, an NIH conference panel suggested that the chance of uterine rupture was small in most women and that VBAC was as safe as other vaginal births. Maternity wards soon began embracing VBAC as a means to slash high cesarean rates.

As more and more women gave birth vaginally, however, reports of uterine ruptures increased, and VBAC rates began to slump in the mid-1990s.

By 2004, they had dropped to less than 10 percent, despite high overall success rates between 60 and 80 percent for the procedures.

According to the new panel, uterine rupture occurs in less than one percent of the women who attempt VBAC, and fewer than 4 in 100,000 women die.

While uterine rupture is more rare in repeat cesarean, the risk of maternal death is about three times higher. Women who undergo several cesareans also seem to have a higher risk of having their womb removed.

"It is concerning that the rate of VBAC is falling," obstetrician Dr. Alison G. Cahill of Washington University in St. Louis told Reuters Health.

"The big picture is that vaginal birth after cesarean remains an important delivery option," said Cahill, who was not at the conference in Bethesda.

She added that several factors -- including the type of cut made during the previous cesarean, the mother's health status, and the size of the child -- were important when deciding whether a woman should attempt VBAC.

MANY BARRIERS

Despite the enthusiasm surrounding VBAC, surveys have shown that as many as one-third of US hospitals and half of all physicians will not perform it.

"We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL," the consensus panel concluded in their statement, referring to the so-called "trial of labor," a planned VBAC attempt.

Part of the reluctance is fear of lawsuits, the panel said.

The current guidelines from the American Congress of Obstetricians and Gynecologists, updated in 2004, recommend that a full surgical team be present during VBAC should an emergency cesarean prove necessary.

But many hospitals are not staffed for this, they say, and so discourage VBAC.

"We are very rural here," nurse Sandra Moore of Jones Memorial Hospital in southwestern New York State told Reuters Health. The hospital, which performs 370 deliveries per year, stopped offering VBAC after the guidelines changed to their current form in 1999.

"My personal opinion is that it was a shame that we took that stance, but it was all because of insurance and liability," said Moore, who has never seen a uterine rupture and was not at the conference.

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Comments (5)
Wintersnow wrote:
Idiots.

Insurance companies insist that we do vaginal birth before they approve c-section. They made me suffer 28 hours of labor and 6 hours of pushing for a C-section. We were lucky the baby didn’t have brain damage.

They did the SAME thing to my younger sister 15 years later! It wasn’t till I intervened that the Doctor did the C-Section.

What is so great about vaginal birth? Who would do that instead of a C-section?
Only an idiot.

Mar 11, 2010 10:54am EST  --  Report as abuse
RebeccaQ wrote:
Wintersnow,

Just like years ago, when your insurance company “forced” you into a trial of labor before your c/s, TODAY INSURANCE and fear of litigation are forcing many women into a surgical births without the option of a Trial of Labor and/or vaginal birth.
You may not think a VB is all that great; however there are women who do.

Just as you should be respected and honored in YOUR RIGHT TO CHOSE the method of your child’s birth so should all other women without being called names or disrespected for their choice.

Mar 11, 2010 11:46am EST  --  Report as abuse
chudia86 wrote:
After two prior C-sections I had a successful VBAC with my third son. After a very scary and traumatic emergency c-section with my second son due to a high epidural (in which both my son and I almost died)I opted for a natural VBAC. I am a nurse and I knew about VBAC’s and researched it all that I could during my pregnancy. I hired a doula to help in my birthing experience and went completely natural (except for the pitocin). I was advised not to walk during my labor (but I shut the door and walked around the room with my contractions). There are risks involved with hemorrhaging along the scar line but there are risks for c-sections as well. My OB-GYN called my baby a miracle, however I did not feel that was the case since during my labor he was never in distress. Overall, my VBAC experience and the birth of my third son was by far the better experience.

Mar 11, 2010 12:13pm EST  --  Report as abuse
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