WASHINGTON -- 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 cesareans 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 cesarean 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 cesareans to find doctors and hospitals that will allow vaginal birth after cesarean, 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.
Fessing up
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 cesarean 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 N. Waldman, president of the obstetricians' group. The guidelines are being published today in the August issue of Obstetrics and Gynecology.
Like earlier guidelines, the new ones say that normal birth is safe for most women who have had a cesarean, provided that the cut in the uterus was low and horizontal, the way nearly all cesareans are performed today. Sixty to 80 percent of women who have what doctors call "a trial of labor" after a cesarean 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 cesareans.
Even if a hospital does not offer trials of labor after cesarean, 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 cesarean, 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 cesarean instead, before labor starts, the risk of rupture is even lower--from 0.4 to 0.5 percent.
Compared with babies born after a repeat cesarean, those born vaginally after cesarean have increased risks of stillbirth (the overall risk is well below 1 percent), but decreased risks of breathing problems and jaundice.
Until the 1970s, the rule was "once a cesarean, always a cesarean," largely because of worries about rupture. But medical opinion gradually shifted, and an expert panel convened by the National Institutes of Health in 1980 found that vaginal birth after cesarean was safe for many women.
In 1985, 6.6 percent of women with prior cesareans were giving birth normally. By 1996 the rate had risen to 28 percent. But some uterine ruptures were reported, with lawsuits and enormous payments, and the rate began to drop.
Then, in 1999, the obstetricians' group issued guidelines that had a chilling impact. By 2006 the percentage of women with cesareans who later had normal births had plummeted, from 24 percent in 1999 to 8.5 percent in 2006.
A matter of semantics
The chill came from two words in the 1999 guidelines: the college said hospitals offering a trial of labor after cesarean should have a surgical and anesthesia team "immediately available" to perform an emergency cesarean if needed. The previous policy had said "readily available," which gave hospitals some leeway to call a team quickly.
The 1999 wording led many hospitals, particularly smaller ones, to ban vaginal deliveries after cesarean, saying they could not afford to pay doctors to wait around during labor and could not risk being sued for malpractice if they flouted the guidelines and complications occurred.
