Vaginal birth after cesarean underused: panel
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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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By Frederik Joelving
NEW YORK (Reuters Health)
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