Moms Columns & Blogs

Guidelines back vaginal births after C-sections

By Denise GradyNew York Times

Most women who have had cesarean sections can safely give birth the normal way later, studies have shown, but in recent years more and more hospitals, doctors and insurers have been refusing to let them even try, insisting on repeat C-sections instead.

The decisions have been based largely on fears of medical risks and lawsuits, medical and legal experts say.

The hospital rules have infuriated many women, added to the nation’s ever-increasing C-section rate and set off a bitter debate over who controls childbirth.

Now, an obstetricians’ group is issuing a new set of medical guidelines meant to make it easier for women who have had C-sections to find doctors and hospitals that will allow vaginal birth after a C-section, or VBAC (pronounced vee-back).

Women’s health advocates praised the new guidelines, because they expand the pool of women considered eligible for normal births, but expressed doubts about whether the recommendations go far enough to change a decade of entrenched behavior by doctors, hospitals and insurers.

The new guidelines, from the American College of Obstetricians and Gynecologists, replace its earlier ones – which were exactly what led many hospitals to ban vaginal birth after a C-section in the first place.

But the college says it never intended to limit women’s access to normal birth, and it acknowledges that its policies may have helped fuel the trend toward too many cesareans.

“It will be better for women in the long run if we can lower the C-section rate,” said Dr. Richard Waldman, president of the obstetricians’ group. The guidelines are being published today in the August issue of Obstetrics & Gynecology.

About 1.4 million women had cesarean sections in 2007, the latest year with figures available.

Like earlier guidelines, the new ones say that normal birth is safe for most women who have had a C-section, provided that the cut in the uterus was low and horizontal, the way nearly all C-sections are performed today. Sixty to 80 percent of women who have what doctors call “a trial of labor” after a C-section succeed in delivering normally.

The new guidelines go beyond the earlier ones, however, and state that vaginal birth after cesarean is also reasonable for most women carrying twins and those who had two prior C-sections.

Even if a hospital does not offer trials of labor after C-section, the college says, “such a policy cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery.”

The main worry is the risk of uterine rupture during labor, which can severely harm both the mother and the child and requires emergency surgery. But the guidelines state that for women with one previous C-section, the risk of rupture during a trial of labor is quite low – from 0.7 percent to 0.9 percent. If the same woman has a repeat C-section instead, before labor starts, the risk of rupture is even lower – from 0.4 percent to 0.5 percent.

But a C-section increases the risk of placental problems in later pregnancies that can cause hemorrhage and lead to hysterectomy. Compared with babies born after a repeat C-section, those born vaginally after C-section have increased risks of stillbirth (the overall risk is well below 1 percent), but decreased risks of breathing problems and jaundice. In our forums: