Vaginal birth after C-section gets boost by NIH-convened expert panel

March 11, 2010|By Kelly Brewington | kelly.brewington@baltsun.com

Vaginal birth after Cesarean section is safe for most women and more practitioners should encourage it, a panel of experts convened by the National Institutes of Health said Wednesday.

While the practice should be considered on an individual basis after a woman and her provider have weighed the benefits and risks, the independent group said it hoped the medical community would eliminate barriers that many women face in seeking the procedure, commonly known as a VBAC. As the nation's C-section rate has climbed to all-time high, the VBAC rate has plunged in the past 14 years, with some doctors refusing to support the practice and hospitals, particularly in rural areas, outright forbidding it.

"What we do hope is that women who are interested in having a trial of labor will have better access to safe trial of labor in a hospital," said Dr. F. Gary Cunningham, chairman of the department of obstetrics and gynecology at University of Texas Southwestern Medical Center and the panel's chairman. "We hope that putting the data out there will prompt people to look at this problem."

Among the hurdles are doctors who fear being sued if a VBAC goes awry. In addition, the panel said, guidelines from the American College of Obstetrics and Gynecologists - which require a surgeon and anesthesiologist be immediately available during a VBAC in case an emergency C-section is needed - have discouraged physicians from allowing the practice.

The group should "reassess" those guidelines, the panel said. While such access is a given in places like Baltimore, rural areas don't have those resources.

The panel's recommendations come after the study of mountains of medical data and three days of testimony from epidemiologists, providers and VBAC advocates during an NIH conference in Bethesda. With about 500 attendees, the conference marked the biggest public discussion in decades of the thorny emotional, medical and legal debates about VBAC that have been raging for 20 years.

"They're exactly right - for the vast majority of women, trial of labor is safe," said Dr. Judy Rossiter, director of the perinatal center at St. Joseph Medical Center in Towson and head of the department of obstetrics and gynecology at the hospital. "I don't think the data has really changed. I think the interpretation of the data has really changed and the willingness to take a risk has changed."

Rossiter supports VBAC for many of her patients. She knows they can work; she had such a delivery herself a decade ago, and both she and her son were fine.

On Tuesday, her patient Deedy Macdonald delivered her eighth child, a baby girl and the seventh born vaginally - and without drugs - after Macdonald had an emergency C-section with her first 13 years ago.

When Macdonald, of Towson, became pregnant the second time, she never wavered in her decision to give birth vaginally and naturally.

"After a C-section, you are just so out of it - I couldn't even hold my newborn baby," she said. "With a natural, you're up, you're with your baby, you can walk around. It's awesome."

Her second son was born without complications, and the rest were delivered with few problems.

"I have had the blessing of being able to have six natural births after a C-section," she said. "I truly believe if there are not any medical conditions, not a history that would dictate otherwise, every mother should have a chance to deliver a baby vaginally and enjoy that time immediately."

There are risks and benefits to a VBAC as well as for repeat Cesarean. The most dangerous risk of VBAC is uterine rupture, a potentially fatal complication that happens less than 1 percent of the time. About 74 percent of VBACs are successful, according to the panel's report. Meanwhile, repeat Cesareans carry a small risk of placental problems, but those tend to grow with each pregnancy, Rossiter said.

She said Macdonald's body likely would not have withstood seven repeat C-sections without risk of placental problems - such as where the placenta attaches to the uterus scar and does not separate during delivery, causing bleeding that could require a hysterectomy. At the least, she would likely have had very difficult deliveries, Rossiter said.

Doctors and patients should have more thorough discussions after a first C-section to understand the risks of repeated Cesareans, she said.

But the problem with VBAC is that it's hard to predict how a try at a vaginal delivery will pan out, said Dr. Claire Weitz, chief of high-risk deliveries at Greater Baltimore Medical Center, who added that many GBMC patients chose to have repeat C-sections.

"I think the public thinks we say no to people, and we don't," she said. "We tell them, 'Look, here are the benefits and here are the risks.' They'll say, 'I want what's safest for my baby and me.' "

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