March 11, 2010

Vaginal Birth After Cesarean Still An Option

Pregnant women who have had a cesarean section before most likely end up having one again, according to one in three hospitals that say a repeat cesarean is the only option.

Experts say that 9 out of 10 women end up getting a cesarean if they've had one before, a fact that worried those in attendance at a national conference this week on vaginal birth after cesarean, or VBAC.

There is no agreement about how often VBAC should be attempted, but experts agree that the current rate of cesarean births is too high, especially where VBAC doesn't require invasive surgery and mother and baby can spend more time together and leave the hospital sooner than after a cesarean.

After reviewing earlier studies, an expert panel found that VBAC was as nearly safe as first-time vaginal childbirth. They agreed that women should be able to choose which method they prefer, and recommended that health-care professionals and policy makers work together to lift barriers to VBAC. They also feel guidelines that limit the availability of the procedure need to be eliminated.

"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 led 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.

"There is quite a presence of young women who are not willing to be told what to do," Debra Bingham, president-elect of Lamaze International, 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."

VBAC has been the subject of heated debate for decades. The rule of thumb always was "once a cesarean, always a cesarean." Doctors were concerned that the scar left in the womb from a previous cesarean could tear during labor, which could lead to internal bleeding and be deadly.

But at an NIH conference held in 1980, a panel suggested that the chance of damage was small in most women and that VBAC was as safe as other delivery methods. Maternity wards began accepting VBAC as a means to cut high cesarean rates.

As more and more VBACs were used, however, reports of uterine ruptures increased, and the method began to slump in the mid 90s. By 2004, VBACs dropped to less than 10 percent, despite high overall success rates of 60 to 80 percent of the procedure.

According to a new study, uterine ruptures occur in less than one percent of VBAC procedures, and fewer than 4 in 100,000 women die. And while uterine rupture is more rare in repeat cesarean, the risk of maternal death is almost three time higher. Women who undergo several cesareans also 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."

Despite expert's appeals that VBAC is safe, surveys show that one in three US hospitals and half of all physicians will not perform the procedure. Part of the unwillingness comes from fear of lawsuits.

"We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL," -- "trial of labor" procedures -- the consensus panel concluded in a statement.

Current guidelines, updated in 2004, recommend that a full surgical team be present during VBAC should an emergency cesarean become necessary. But many hospitals are not staffed for this, they say, and usually discourage VBAC.

Sandra Moore , a nurse at Jones Memorial Hospital in southwestern New York State told Reuters Health that their rural hospital, which performs 370 deliveries per year, stopped offering VBAC after the guidelines changed in 1999. Moore, who had never seen a uterine rupture, said "it was a shame that we took that stance, but it was all because of insurance and liability."


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