PDA

View Full Version : New guidelines aim to reduce repeated C-sections



lmh2402
07-21-2010, 06:45 PM
http://www.google.com/hostednews/ap/article/ALeqM5h_mnSBPCqGUBnvQFfUb9T4toeAZwD9H3M1100

New guidelines aim to reduce repeated C-sections

By LAURAN NEERGAARD (AP) 1 hour ago

WASHINGTON Most women who've had a C-section, and many who've had two, should be allowed to try labor with their next baby, say new guidelines a step toward reversing the "once a cesarean, always a cesarean" policies taking root in many hospitals.

Wednesday's announcement by the American College of Obstetricians and Gynecologists eases restrictions on who might avoid a repeat C-section, rewriting an old policy that critics have said is partly to blame for many pregnant women being denied the chance.

Fifteen years ago, nearly 3 in 10 women who'd had a prior C-section gave birth vaginally the next time. Today, fewer than 1 in 10 do.

Last spring, a National Institutes of Health panel strongly urged steps to reverse that trend, saying a third of hospitals and half of doctors ban women from attempting what's called VBAC, for "vaginal birth after cesarean."

The new guidelines declare VBAC a safe and appropriate option for most women now including those carrying twins or who've had two C-sections and urge that they be given an unbiased look at the pros and cons so they can decide whether to try.

Women's choice is "what we want to come through loud and clear," said Dr. William Grobman of Northwestern University, co-author of the guidelines. "There are few times where there is an absolute wrong or an absolute right, but there is the importance of shared decision-making."

Overall, nearly a third of U.S. births are by cesarean, an all-time high. Cesareans can be lifesaving but they come with certain risks and the more C-sections a woman has, the greater the risk in a next pregnancy of problems, some of them life-threatening, like placenta abnormalities or hemorrhage.

The main debate with VBAC: That the rigors of labor could cause the scar from the earlier surgery to rupture. There's less than a 1 percent chance of that happening, the ACOG guidelines say. Also, with most recently performed C-sections, that scar is located on a lower part of the uterus that's less stressed by contractions.

Of those who attempt VBAC, between 60 percent and 80 percent will deliver vaginally, the guidelines note. The rest will need a C-section after all, because of stalled labor or other factors. Success if more likely in women who go into labor naturally although induction doesn't rule out an attempt and less likely in women who are obese or are carrying large babies, they say.

Thus the balancing act that women and their doctors weigh: A successful VBAC is safer than a planned repeat C-section, especially for women who want additional children but an emergency C-section can be riskier than a planned one.

Because of those rare uterine ruptures, the obstetricians' group has long recommended that only hospitals equipped for immediate emergency C-sections attempt VBACs. Many smaller or rural hospitals can't do that, and that recommendation plus high-dollar lawsuits have been blamed for some hospital VBAC bans.

"Restricting access was not the intention," the new guidelines say. They say hospitals ill-equipped for immediate surgery should help women find care elsewhere, have a plan to manage uterine ruptures anyway, and not coerce a woman into a repeat C-section.

Educating women about their options early enough in pregnancy for them to make an informed choice is key, said Dr. F. Gary Cunningham of the University of Texas Southwestern Medical Center, who chaired the NIH panel on repeat C-sections.

It requires a fair portrayal of risks and benefits that can differ by patient, added Dr. Howard Minkoff of Maimonides Medical Center in Brooklyn, N.Y., which has women sign a special VBAC consent after counseling yet has a higher-than-average VBAC rate of 30 percent.

"There's no doubt that how things get framed influences how people act," he said.

While the guidelines cannot force hospital policy changes, some women's groups welcomed them.

"I feel like ACOG has really listened to how their previous policies have impacted women," said Barbara Stratton of the International Cesarean Awareness Network's Baltimore chapter, adding that she'll advise women seeking a VBAC to hand a copy of the guidelines to caregivers who balk.

But she called for reducing overuse of first-time C-sections, too, so that repeats become less of an issue.

___

Online:

ACOG: http://www.acog.org

Copyright 2010 The Associated Press. All rights reserved.

mmsmom
07-21-2010, 08:02 PM
At the large University hospital where DS was born, they encouraged VBAC's and gave me a brochure about how safe they are. At the small, regional hospital about 15 miles away where I gave birth to DD they were not allowed. It was fine for me because I didn't want one, but policies that don't take the facts into consideration are irritating. I hope these new guidelines will give more women the choice... it should be the woman's decision, not the hospital's.

SnuggleBuggles
07-21-2010, 10:59 PM
Ok, the thing that always, always bothered me with the whole "not equipped to handle an emergency c-section thus no VBACs" is, well, why would I want to give birth there at all?? Emergencies happen in 1st time births, births after successful vaginal births...if a hospital is going to handle L&D then they need to be able to handle emergencies. I think it is a major cop out to say that VBACs can't be allowed because of the 'what if" factor. I know a lot of the reason the VBACs are not done as of late is the ACOG's policies designed to cover their butt- like always having certain people on hand during a VBAC attempt, just in case. For some hospitals it wasn't easy to comply so they gave up offering them. But, really and truly, emergencies of all varieties happen and I want to know that if I chose a hospital birth then they are able to handle the safe birth of my child to the best of their abilities, whether it be an easy birth or a complicated one.

Off my soap box. I hope that changes do happen to allow people choice.

Beth

llama8
07-22-2010, 08:17 AM
I had a scheduled c-section with my DD and it wasn't a bad experience at all. The vbac would make me a little nervous. I do, however, like that women are being given more of a choice it they want a vaginal delivery. I would probably have a repeat c-section, but for those that don't want it, it is nice to see options.

swissair81
07-22-2010, 08:49 AM
I had a scheduled c-section with my DD and it wasn't a bad experience at all. The vbac would make me a little nervous. I do, however, like that women are being given more of a choice it they want a vaginal delivery. I would probably have a repeat c-section, but for those that don't want it, it is nice to see options.

It should be the woman's choice. Just like you wouldn't like if they forced you to try a VBAC if you didn't feel comfortable, many women don't like that 1 c/s means always a c/s. There should be more leeway.

luckytwenty
07-22-2010, 09:28 AM
Where I live, in South Florida, if you've had two c-sections they won't even consider VBAC because the malpractice insurance is insane. Unless you want to do VBAC in your bathtub, you're SOL around here.

This is part of the issue I never see acknowledged by moms but it's a very real concern. Malpractice insurance rates for OB/GYNs have skyrocketed--to the point that in some parts of the country, it's actually hard to find a gyn who also does OB. Doing a VBAC does put you at an increased risk of something going wrong (aka grounds to sue your doctor for a ton of money) even if that risk is very small.

Until there's some kind of torte reform for docs, I just don't see logistically how VBACs are going to be easy to come by. Again, in some parts of the country, you're lucky to be able to find an OB within a close drive from your house. (And yes, I'm married to a physician who rails against this all the time--but the malpractice insurance DOES get in the way of how a doctor can best serve his/her patient, and that's why it's so frustrating. He graduated med school in 2000 and in a class of 100 or so, only 2 students chose to go into OB/GYN because of the litigious climate, lifestyle and not particularly lucrative compensation compared to other fields. To me, that's really sad.)

llama8
07-22-2010, 10:55 AM
It should be the woman's choice. Just like you wouldn't like if they forced you to try a VBAC if you didn't feel comfortable, many women don't like that 1 c/s means always a c/s. There should be more leeway.

That is exactly what I said in my post. I think all women agree that options and choices are good.

citymama
07-22-2010, 01:19 PM
Good news! I felt very empowered by my successful VBAC earlier this year. I hope this new guideline will help make VBAC an option for the many women now denied the choice. As with other reproductive rights, it's about women having a choice in making important decisions about their bodies.

c&j04
07-22-2010, 02:01 PM
While the Drs at my ob/gyn practice mostly feel VBAC is an option, I'm already thinking I will be too chicken to even try next time. But I'm glad the option is there because I well remember how helpless I felt when the one Dr said NO VBAC and want others to have options if they choose :)

sste
07-22-2010, 03:37 PM
Ok, the thing that always, always bothered me with the whole "not equipped to handle an emergency c-section thus no VBACs" is, well, why would I want to give birth there at all?? Emergencies happen in 1st time births, births after successful vaginal births...if a hospital is going to handle L&D then they need to be able to handle emergencies. I think it is a major cop out to say that VBACs can't be allowed because of the 'what if" factor. I know a lot of the reason the VBACs are not done as of late is the ACOG's policies designed to cover their butt- like always having certain people on hand during a VBAC attempt, just in case. For some hospitals it wasn't easy to comply so they gave up offering them. But, really and truly, emergencies of all varieties happen and I want to know that if I chose a hospital birth then they are able to handle the safe birth of my child to the best of their abilities, whether it be an easy birth or a complicated one.

Off my soap box. I hope that changes do happen to allow people choice.

Beth

Do you think the issue is the whether the hospital has a neo-natal intensive care unit? I am wondering if that is what this is referring to. ANY competent ob/gyn is equipped to deal with a emergency c-section upon uterine rupture . . . we don't think of OBs that way, but it is a surgical field. I think the issue is that the baby may need specialized care post-uterine rupture for oxygen deprivation or other issues. I have no idea how frequent it is that babies removed by c-section upon uterine rupture need a neo-natal intensive care unit, though. Maybe swissair knows?

I personally am an extremist and would not deliver at any hospital that didn't have its own neo-natal intensive care unit for any baby, vbac or not. But, I think to require every hospital to have one would be a big problem cost-wise and also possibly limit the role of birthing centers and home births.

egoldber
07-22-2010, 04:50 PM
Do you think the issue is the whether the hospital has a neo-natal intensive care unit?

It has to do with the availability of anesthesiology 24/7. Many smaller hospitals only have an anesthesiologist on call and not on site 24 hours a day. Which means that their "decision to incision" time, as it is called, exceeds the ACOG guideline for the availability of an emergency c-section in case of a uterine rupture.

And as the other Beth points out, this is a risk for ANY birth at these hospitals where an emergency c-section may be required: placental abruption, cord prolapse, etc.

Sweetum
07-22-2010, 05:48 PM
It has to do with the availability of anesthesiology 24/7. Many smaller hospitals only have an anesthesiologist on call and not on site 24 hours a day. Which means that their "decision to incision" time, as it is calls, exceeds the ACOG guideline for the availability of an emergency c-section in case of a uterine rupture.

And as the other Beth points out, this is a risk for ANY birth at these hospitals where an emergency c-section may be required: placental abruption, cord prolapse, etc.
:yeahthat:

And like you and others, I don't understand what would happen when a vaginal delivery needs to be changed to a emergency C. The anesthetist would have to be available then, wouldn't s/he? Wouldn't it be the same. I think it's BS to say that.

sste
07-22-2010, 06:59 PM
It has to do with the availability of anesthesiology 24/7. Many smaller hospitals only have an anesthesiologist on call and not on site 24 hours a day. Which means that their "decision to incision" time, as it is called, exceeds the ACOG guideline for the availability of an emergency c-section in case of a uterine rupture.

And as the other Beth points out, this is a risk for ANY birth at these hospitals where an emergency c-section may be required: placental abruption, cord prolapse, etc.

Oh my goodness, I have only been to large academic centers, I am having my hard time wrapping my mind around the reality that there is no anesthesia person 24-7 at many hospitals!! Wow. Also, they are giving an epidural, right? That is NOT rocket science and in theory a whole variety of health professionals *could* be trained to do that. It is silly that medicine is so divided. This is why there needs to be more training slots/funding for nurse anesthetists!

egoldber
07-23-2010, 06:38 AM
There may not be an anesthesiologist on site to give an epidural. One may need to be paged in.

Most births occur in smaller hospitals, because most hospitals in this country are smaller hospitals.

maestramommy
07-23-2010, 07:09 AM
There may not be an anesthesiologist on site to give an epidural. One may need to be paged in.

Most births occur in smaller hospitals, because most hospitals in this country are smaller hospitals.


This. Laurel was born naturally, because the anesthesiologist on call that night was 20 minutes away. By the time he arrived, I was told, Laurel would be here. I was a little shocked that the hospital didn't have one on the grounds 24/7 (my hospital in CA did), because this hospital's big cache is that it has a high level NICU (can't remember the name). But I have also been told later that this hospital has is very low intervention. I've talked to 2 separate women who told me how they begged for a C-section and the OB refused, and it was a pretty messy recovery after a "forced" vaginal delivery.

Course, I'm glad it all worked out. That was a pretty good call by the nurse. I wouldn't have guessed Laurel was coming that fast; we got to the hospital barely in time:p

sste
07-23-2010, 09:29 AM
Interesting, I met with our new doula last night . . . who is basically my research soulmate but in birth issues. Since I am trying vbac, we asked her a bunch of questions and a few things emerged that I had not realized:

1. There is some evidence that uterine rupture/tear occurs in "normal" non-vbac, vaginal delivery. Some women are prone to having thinning/windows/tears without c-section history. But, it isn't usually caught because doctors have less of a press to c-section and apparently the only way to confirm the tear is to go in surgically.

2. Of the 1% uterine rupture in vbac, most don't have adverse outcomes. I hadn't realized this and had been thinking to myself, wow, 1% is not that low.

3. Apparently, there is not enough data on non-pitocin VBAC uterine tears to draw great conclusions about whether the no pitocin group is at much, much lower risk. Apparently, there is that much pitocin dispensed?!

4. She thought that in addition to the reason for the original c-section the following risk factors are often overlooked by physicians: less than 18 months between pregnancies, overweight, poor nutrition (can affect healing of original c-section).

Anyway, hope that is helpful for anyone considering vbac!

citymama
07-23-2010, 12:02 PM
sste, congrats on hiring a doula. I loved mine and she was a huge help during my vbac labor/delivery. Mine also talked about how uterine ruptures can occur in non-vbac deliveries, and while this is true, there is an order of magnitude difference in rates of occurence. Take a look at the March 2010 NIH VBAC conference proceedings - I think both sets of rates are listed in the final report. I think some doulas and NCB midwives make the mistake of pitching the safety/benefits of VBACs in ways that aren't completely accurate - when there isn't a need to overstate the facts - there is a strong case for VBAC without doing so!

Funnily enough, I obsessively worried about rupture risks practically the whole 9 months of my pregnancy but the thought didn't even cross my mind during my labor or delivery. You can do it! All the best.

sste
07-23-2010, 12:51 PM
Thanks Citymama! That is such a nice message. I actually feel much better now that I have doula support . . . and interestingly so does DH and even my OB is excited.

Anyway, newly hired doula is very supportive of vbac, very encouraging of supporting me in natural childbirth if I choose that . . . but extremely non-judgmental and also "gets" that there are cases that benefit from intervention and levels of risk that many people don't want to take. In fact, she told me in no uncertain terms she would have sent me for c-section too if she had been functioning as my midwife during my last delivery. The kind of "too gung ho" for natural vaginal birth doula was a big issue for me and I think even more so for dh who was worried that a doula might make us feel bad about an intervention we wanted or even oppose a needed intervention. And I did interview some people who were lovely but I could see a risk of that because their orientation was so extremely and globally anti-medical model.

I *think* (??) her point about non-vbac uterine tears is that we don't know the true rate because its now coming to light that many women tear, with zero complications or effect on the baby, no c-section and thus they never discover it. I think they are starting to find it when the women subsequently gets a c-section for a different birth and they see the old tear or on autopsy. ?? I will check out that article you mention.

Anyway, my dh is just like you and has been on a uterine tear worrying bender for 9 months. I have managed to worry about everything else under the sun so between the two of us we have Pregnancy Anxiety well-canvassed!

Katigre
07-23-2010, 01:13 PM
That is NOT rocket science and in theory a whole variety of health professionals *could* be trained to do that. It is silly that medicine is so divided. This is why there needs to be more training slots/funding for nurse anesthetists!
Yes! This is also a major factor for improving maternal-fetal health outcomes in the developing world. If you can have nurses trained in anesthesiology and in basic csection procedure many lives can be saved by mothers in impoverished areas who have zero access to a csection in case of problematic birth. In some areas of the world this is already a reality and it is making a big difference for the 5-10% of moms and babies who need a csection for a safe and healthy birth. (the book Half the Sky talks about this issue a bit).

KpbS
07-24-2010, 12:10 AM
There may not be an anesthesiologist on site to give an epidural. One may need to be paged in.

Most births occur in smaller hospitals, because most hospitals in this country are smaller hospitals.

Yes--this was my experience with DS2. I woke up at 4 am bleeding profusely--we lived 3 minutes from the hospital but the OB and anethesiologist on call had to be paged to come in and drove like maniacs to get there to deliver DS2 by emergency section. We were very fortunate.

This was a small town hospital but by no means the smallest--largest in a 45 mi radius. There is no way I would attempt a vbac under those circumstances after experiencing the birth of DS2.

american_mama
07-24-2010, 11:50 PM
Well, these new recs seem in the right direction, but I think the biggest hurdle is not the softer concept of whether women will choose VBAC, but the reality of whether hospitals and providers will allow them. I think that needs to be the dominant issue because without it, women's choice doesn't mean squat.

And I think provider education may need to be addressed too. I think a lot of obgyn's have become very risk adverse, very intervention-oriented, and that biases them towards repeat c-sections. I think they may need some education and quality research about the safest ways to manage repeat c sections, especially in terms of inductions (which I am guessing is the biggest controllable factor influencing uterine rupture).

I am a tad suspicious of the language in the article about the tension between wanting a safe VBAC or a planned C section and avoiding the riskier emergency C section. I don't doubt that hierarchy of safety, but if ob's so feared an emergency c section, I don't think we'd have 30% c section rate, would we? I am assuming the majority of first c sections are emegency ones, although I might be wrong about that.

As for Florida, I don't know what to make of this, but I recall reading that most obgyn's in south Florida "go bare" and do not carry medical malpractice insurance because it extremely expensive, more so in Florida than elsewhere in the country. Thereore, Florida is one of the few states that have some alternatives for doctors to self-insure for about $250,000 per claim and skip liability insurance. But this brings a whole slew of other problems and is a big mess, see http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=111314. So is it correct to say liability insurance is dictating what obgyn's in Florida do when so many have opted out of it due to high premiums? I don't know. Is it a good solution or just the least bad solution? I don't know.