July 22, 2010 — Women who have had caesarean-section deliveries should be allowed to attempt a vaginal birth for subsequent deliveries, according to new guidelines from the American College of Obstetricians and Gynecologists, the New York Times reports. The guidelines revise previous ACOG recommendations that some experts say have increased in the number of repeat c-section births and, in some cases, prompted hospital bans on vaginal birth after caesarean procedures.
According to the Times, medical and legal experts say that decisions by doctors to avoid VBAC deliveries have been based largely on fears of medical risks and lawsuits (Grady, New York Times, 7/21). The previous ACOG guidelines said that hospitals should only attempt VBACs if access to emergency c-sections is "immediately available," a difficulty for small and rural hospitals. VBAC deliveries occur in fewer than one in 10 deliveries among women with previous c-sections (Neergaard, AP/Miami Herald, 7/21).
ACOG acknowledged that its previous guidelines might have contributed to the rising c-section rate in the U.S., although the group said it did not intend to discourage VBACs. The Times reports that 60% to 80% of women who attempt to deliver vaginally after a c-section -- known as a "trial of labor" -- succeed (New York Times, 7/21).
Richard Waldman, president of ACOG and chair of obstetrics at St. Joseph's Hospital in Syracuse, N.Y., said, "Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals and insurers to swing the pendulum back to fewer caesareans and a more reasonable VBAC rate" (Roan, Los Angeles Times, 7/21).
Details of Recommendations
The new recommendations -- published Thursday in the journal Obstetrics and Gynecology -- say that VBAC deliveries are safe for most women as long as the incision of a prior c-section is low and horizontal, which is the case in nearly all c-sections performed today. The risk of uterine rupture during a trial of labor is between 0.7% and 0.9%, which is only a slightly higher than the risk in women who undergo a repeat caesarean, according to the new guidelines. The guidelines also say that VBACs are reasonable for most women carrying twins and those who have had more than one c-section. Hospitals that allow VBACs still should ensure that access to emergency c-sections is "immediately available," the guidelines say.
If a hospital has a ban on trials of labor, ACOG says that "such a policy cannot be used to force women to have a caesarean delivery or to deny care to women in labor who decline to have a repeat caesarean delivery" (New York Times, 7/21). William Grobman of Northwestern University, co-author of the guidelines, said that women's choices are "what we want to come through loud and clear," adding, "There are a few times where there is an absolute wrong or absolute right, but there is the importance of shared decision-making" (AP/Miami Herald, 7/21).
The new guidelines have drawn mixed reactions from women's health advocates, some of whom question whether they are enough to change hospital and physician policies on VBACs. Maureen Corry, executive director of Childbirth Connection, said, "Overall, it's dubious that these guidelines will in fact open up access for women." Debra Bingham, president-elect of Lamaze International, which advocates for natural birth, said that the "immediately available" wording included in the guidelines could still present challenges to women who want to deliver via VBAC (New York Times, 7/21).
However, Barbara Stratton of the International Cesarean Awareness Network said that ACOG "really listened to how their previous policies have impacted women" (AP/Miami Herald, 7/21).