New guidelines say vaginal birth OK after c-section

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Even if they aren’t staffed to handle emergency cesarean sections, hospitals should respect a woman’s informed choice to have a vaginal birth after cesarean (VBAC), new guidelines say.

VBAC is known to increase the risk that the scar left in the womb from a previous cesarean will tear during labor, leading to massive bleeding that can threaten the baby’s life. That has led to previous guidelines urging caution for women who have had cesarean sections.

But recent research shows so-called uterine rupture occurs in less than one percent of women who opt for vaginal birth, and that between 60 and 80 percent of VBACs are completed successfully.

While the new guidelines from the American College of Obstetricians and Gynecologists (ACOG) still say a full surgical team should be present in case an emergency cesarean is required, they now put a bigger emphasis on the woman’s decision.

“Respect for patient autonomy supports that patients should be allowed to accept increased levels of risk; however, patients should be clearly informed of such potential increase in risk and management alternatives,” they say.

“For most women with a previous cesarean delivery, a trial of labor is a safe and appropriate option,” said Dr. Jeffrey L. Ecker, referring to a planned VBAC attempt.

Ecker, who directs maternal-fetal medicine at Massachusetts General Hospital in Boston, co-wrote the new guidelines, published in the journal Obstetrics & Gynecology.

Even women who’ve had two prior cesareans might be good candidates for vaginal birth, he said.

He added that he hoped the new recommendations would help reduce the concerns about medical liability that many doctors have held out as a reason for not offering VBAC.

Today, about nine in 10 pregnant women in the U.S. end up with a repeat cesarean if they’ve already had one. By comparison about a third of all women who give birth have cesareans.

“I really think the cesarean rates are going up too fast,” said Dr. Peter Bernstein, of the Albert Einstein College of Medicine in the Bronx, New York. “There is no good evidence that newborns are better off now than they were 20 years ago.”

Bernstein, who is an ACOG fellow but did not work on the guidelines, said he was pleased with the new recommendations.

He said they updated information on what women would be good candidates for VBAC and were important in the discussion of delivery options that a woman should have with her doctor.

But he said it was hard to say if the guidelines would have any impact on the low VBAC rates.

Indeed, the guidelines note that health providers who feel uncomfortable with the delivery choice a woman has made may want to refer her to another provider.

SOURCE:  Obstetrics & Gynecology, online July 21, 2010.

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