The discussion over delivering babies in this country has the feel of a pendulum swinging back and forth. Cesarean sections? With nearly 1 in 3 pregnant women having them—up from 1 in 5 in 1996—experts say it's time to cut back. And according to a new assessment from a National Institutes of Health panel, pregnant women should once again be given the option of having a vaginal birth after a cesarean. VBACs are currently chosen less than 10 percent of the time, down from a rate of 28 percent in 1996. Obstetricians began to change their practices after a handful of studies found that women who had a VBAC had slightly higher risks of uterine rupture, which in 6 percent of cases results in the baby's death.
In announcing the new consensus statement yesterday, the NIH expert panel said that pregnant women who have had C-sections should be given the option of a vaginal birth provided they had a low horizontal incision that runs at the bikini line and have no issues—such as diabetes, multiple fetuses, or a baby in breech position—that put them at increased risk of delivery complications. "It's certainly a safe alternative for the vast majority," Gary Cunningham, the chair of the panel and a professor of obstetrics and gynecology at the University of Texas Southwestern Medical Center at Dallas, said Wednesday during a news conference. "But the number of hospitals offering this has diminished because of perceived bad outcomes."
Research suggests that in nearly 75 percent of cases where women attempted a VBAC, a vaginal delivery is successful. And regardless of whether a VBAC attempt results in a vaginal birth or a C-section, women who at least attempt labor have a lower risk of dying in childbirth than those who undergo scheduled C-sections. On the flip side, the risk of uterine rupture is higher for those who underwent a trial of labor, compared with those who had scheduled C-sections. The panel wants doctors to discuss the specific risks and benefits of both options with women to help them make an informed decision. That information includes the following:
*The risk of maternal death is extremely low but is slightly higher for those who opt for elective C-sections. Death occurs in about 13 women per 100,000 elective repeated cesarean deliveries, compared with about 4 women per 100,000 women who go through a trial of labor after having a previous C-section.
*Rates of hysterectomy, hemorrhage, and transfusions don't differ significantly between the two groups.
*The rate of uterine rupture is significantly higher for those who attempt a VBAC—41 per 1,000 women who went through a trial of labor, compared with 3 per 1,000 women who opted for a scheduled C-section.
*The risk of losing the baby during childbirth is very low but more likely in those who attempt a VBAC, occurring at a rate of 1.3 per 1,000 of those cases, compared with a rate of 0.5 per 1,000 for scheduled C-sections. That translates to a risk of 0.13 percent, compared with a risk of 0.05 percent.
*When it comes to the risk of complications in future pregnancies, the VBAC has a distinct advantage. The risk of placenta previa (where the placenta grows near and on top of the cervix) rises with every C-section, heightening the possibility of complications, such as significant bleeding requiring transfusions or a hysterectomy, for the mother.
Ideally, a pregnant woman considering a VBAC should be able to sit down with her doctor to discuss all the pros and cons, including her own medical concerns and issues. For example, if she's previously given birth to a large baby, that could weigh in favor of a scheduled C-section; if she's planning to become pregnant again, that would weigh in favor of a VBAC.
Trouble is, doctors and hospitals might not be so willing to allow the pendulum to swing back towards VBACs. The consensus statement didn't offer a solution for malpractice lawsuits over deliveries that don't end happily. One hospital lost a $35 million lawsuit after a baby died during a case of uterine rupture during a VBAC. And the experts admitted during the news conference that the science isn't there to lower the rate of uterine rupture by better predicting which women are most at risk for having one.
One thing is clear, though: The precipitous increase in C-sections for first-time mothers needs to be addressed by the medical community. Lowering the rate would leave far fewer women worrying about what to do the second or third time around.
Related News: Why Pregnant Women Should Say "No" to Early C-Sections