New guidelines aim to reduce repeated C-sections

[lmh2402]

http://www.google.com/hostednews/ap/...oeAZwD9H3M1100

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]

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]

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]

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]

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]

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]

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]

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]

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]

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.