The country's main professional group of obstetricians published "less restrictive" guidelines Wednesday that could lead to more vaginal births after C-sections, or VBACs.
"What the guidelines emphasize is that a trial of labor is a reasonable and appropriate alternative for many women with a prior cesarean delivery," says Jeffrey Ecker, a Harvard associate professor of obstetrics and gynecology who co-wrote the new guidelines from the American College of Obstetrics and Gynecology. That includes women with two previous C-sections and those carrying twins.
Ecker's comment echo those of a National Institutes of Health consensus conference panel, which in March called on organizations such as his to make it easier for women to try for VBACs.
The proportion of women in the USA who have had a C-section and who afterward deliver babies vaginally has fallen markedly since 1996, when it was 28%. By 2006, it was around 8%, even though studies suggest that 60% to 80% of women who are good candidates for VBACs will succeed if they try. Meanwhile, the overall C-section rate has continued to climb; it hit an all-time high of more than 31% in 2007, the latest data available.
Even the OB-GYN group has acknowledged that one word in its 1999 and 2004 VBAC guidelines is partly to blame.
Previously, the group had recommended that only hospitals with a "readily available" surgical team -- interpreted as no more than a half-hour drive away -- allow VBACs. But the 1999 guidelines called for an "immediately available" surgical team in case a uterine tear, or rupture, a rare but potentially catastrophic event, necessitated an emergency C-section.
Many hospitals have interpreted "immediately available" as needing to have an anesthesiologist and operating room standing by whenever a patient attempts a VBAC. If they can't meet the guidelines, they argue, they're opening themselves up to lawsuits should mother or baby be injured during a VBAC attempt.
Although the latest VBAC guidelines also recommend an "immediately available" surgical team, solid information about the benefits of having one is lacking, Ecker says. The risk from not having a surgical team immediately available is likely to be "real but not large," he says.
Still, Ecker says, "the document makes it pretty clear that no one should be forced to have a cesarean delivery."
Debra Bingham, president-elect of Lamaze, a non-profit that "promotes a natural, healthy and safe approach" to childbirth, calls the new guidelines "a step in the right direction."
Still, says Bingham, a perinatal consultant from Belmont, Calif., "we're a bit troubled by the fact by the words 'immediately available' remain in the document."
Mark Landon, chairman of OB-GYN at The Ohio State University and lead scientist for NIH-sponsored research cited in the new guidelines, says he was pleased that they emphasized the need for doctors to refer women desiring a VBAC to hospitals willing to accommodate them. "Unfortunately," Landon says, "many practitioners have been reluctant to do so."
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