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Health experts: Repeat C-sections usually unnecessary

Tue., March 16, 2010

Michelle Williams is three months pregnant and determined to experience childbirth the way nature intended.

But because her previous baby was delivered through an incision in her abdomen and uterus – a cesarean section – she has to travel more than an hour from her home in Channahon, Ill., to find an obstetrician willing to let her try for a vaginal birth.

One out of every three pregnant women now has a C-section, the most common surgical procedure in the U.S.

That has been hotly debated in birthing and medical communities, yet little attention has been paid to one of the consequences: Once a woman has a C-section, she often has to fight to deliver subsequent babies the old-fashioned way, if a hospital or obstetrician allows her to try it at all.

Repeat C-sections have become so routine that 90 percent of pregnant women who have the surgery give birth that way again. That is a concern to health experts, who say vaginal births after a cesarean, or VBACs, should be far more common.

A panel of specialists convened by the National Institutes of Health last week urged that doctors offer mothers-to-be an unbiased look at the pros and cons of VBACs, so they can decide for themselves.

A third of hospitals and half of physicians ban women from attempting VBACs, the panel said, but it remains a safe alternative for the right candidates – in general, women who’ve had one prior C-section done with a “transverse” scar, the most common kind today.

“We believe that many women should have an opportunity to give it a try,” said panelist and Delaware obstetrician Dr. Nancy Frances Petit of the U.S. Uniformed Health Services.

Successful VBACs result in better health outcomes for the mother and the baby and cost several thousand dollars less than cesarean deliveries, according to the American Congress of Obstetricians and Gynecologists (ACOG).

Experts point out that although a VBAC carries a risk of uterine rupture, the chance it will happen is relatively low: 0.5 percent. Meanwhile, C-sections carry all the risks of a major surgery.

Compared with having a vaginal birth, a woman delivering by C-section experiences more physical problems, longer recovery and more emotional issues on average, studies show.

Research also has found babies born by cesarean are less likely to be breastfed and more likely to experience breathing problems at birth and asthma as they get older.

Yet the VBAC rate, 9.2 percent, is a far cry from the objective set by the Centers for Disease Control and Prevention: 37 percent.

From the early 1980s until 1996, the VBAC rate crept up to nearly 30 percent as doctors – and insurance companies – encouraged C-section veterans to try one.

However, according to ACOG, “Physicians were pressured into offering VBAC to unsuitable candidates.” As more of them occurred, the number of highly publicized uterine ruptures rose – along with liability concerns among physicians.

Once a woman undergoes a C-section, the resulting scar tissue is weaker than the uterine muscle. If the scar opens during labor, it would require an emergency C-section.

Certain factors – induction of labor, or a vertical (rather than horizontal) incision – can increase the risk of rupture.

In 99.5 percent of the cases, nothing goes awry. But if the scar gives way, results can be catastrophic: The baby has a 10 percent chance of dying or suffering brain damage.

“The liability issue is huge,” says Dr. Joseph Pavese, chairman of the obstetrics department at Advocate Christ Medical Center in Oak Lawn, Ill., where 97 percent of pregnant women with a previous C-section have another one.

“Parents expect good outcomes, and physicians are reluctant to try difficult deliveries,” he says. “If the baby is not perfect, there is possible litigation.”

In the 1990s, research published in the New England Journal of Medicine that suggested VBACs were dangerous immediately affected practice, says Gene Declercq, a professor of community sciences at the Boston University School of Public Health.

But more recent and balanced research showing VBACs are as safe – if not safer – than repeat C-sections hasn’t had the same effect, says DeClercq, who researches maternity care practice and policy in the U.S. and abroad.

What crippled the idea of a VBAC, however, was a simple word change. In 1998, ACOG advised that physicians should be “readily available” to provide emergency care because of the dangers of a uterine rupture.

Eight months later, the American Congress of Obstetricians and Gynecologists changed the wording to “immediately available,” and many small hospitals in rural areas stopped doing VBACs.

Supporters of VBACs say women need true informed consent and a choice.

“It’s illegal to enforce a ban on how our bodies are designed,” says doula and childbirth educator Desiree Andrews, of Colorado Springs, Colo., president of the International Cesarean Awareness Network.

“But evidence-based practice has been crowded out of the hospital setting in favor of defensive medicine. As a result, too many women are subject to coerced cesareans because hospitals have banned VBACs.”

C-sections are considered medically necessary when there’s a problem with the baby’s heart rate, the umbilical cord exits the uterus before the baby does, the mother’s pelvis is too small to deliver a large baby, or the baby is in the breech position.

Women also can request the surgery, which influences doctors, says Strassner. A woman who had prolonged labor with her first child and ended up with a C-section anyway often does not want to endure another labor without a guarantee that things will be different.

“Why do in 30 hours what you can do in 30 minutes?” asks Jean Dalrymple, of Kansas City, Mo., whose second child is due March 22.

Dalrymple has “lobbied early and often for the repeat C-section” even though her doctor offered her a VBAC.

Terrified by the thought of labor, Dalrymple, 38, says she respects women who want to experience a vaginal birth, but is “positive that God created the C-section for chickens like me.”

Other women who request C-sections may be afraid of uterine rupture and misinformed about how frequently they occur, says Dr. Sarah Kilpatrick, who heads the department of obstetrics and gynecology at the University of Illinois College of Medicine in Chicago.

“Or they want to plan their delivery or haven’t thought about the complication of a repeat section,” says Kilpatrick.

“Women still think it’s like a zipper – you pull the baby out and zip it back up. But surgery is harder the second time. There’s an increased chance of injury to the bladder and bowel in the patient and other complications.”

Williams, 30, hopes to deliver her baby naturally in August. She plans to drive more than 40 miles to the University of Chicago Medical Center to try for a VBAC to avoid the trauma she experienced with her first child, Sadie.

Williams and Sadie had complications from the cesarean surgery. Sadie was rushed from Joliet’s Silver Cross Hospital to Children’s Memorial Hospital in Chicago, and Williams felt unable to bond with her baby. Two months later, an infection landed Williams back in the hospital.

But she is realistic about her chances of a VBAC and just wants a healthy baby.

“If the VBAC doesn’t go as planned, my husband and I are working on a birth plan to make the next C-section as peaceful and as beautiful as possible,” she says.

“Little things – like asking the doctor to hold up the baby as soon as it’s born so that I can see – can make a difference between a traumatic birth and a relaxing one.”

The Associated Press contributed to this story.

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