Doctors debate C-section options

For Rachel Parrish, the rush of joy as her daughter Gabrielle arrived last month and the experience of sharing the moments after her birth illustrated the importance of forgoing a Caesarean section for her second delivery.

"I didn't realize what I missed out on until I had this natural experience. I felt great, and it was such an amazing experience," the Hilliard woman said from her room at Riverside Methodist Hospital. Her first child, Abriana, who is now 3, was a breech baby, and a C-section was the only option.

Many women who have had a C-section aren't encouraged to try vaginal delivery or are barred from it at smaller hospitals where surgeons and anesthesiologists aren't immediately on hand. The issue is controversial and prompted the National Institutes of Health to convene experts in hopes of helping guide the future of vaginal births after C-sections, a practice also known as VBAC.

In the past 15 years, the practice has declined significantly, from about three in 10 potential VBAC births to about one in 10. Since 1996, about a third of hospitals and half of physicians no longer offer women the option of attempting labor, according to the panel's report.

Last month, the experts said they agree that most pregnant women who have had a Caesarean delivery should be given the option of attempting labor and vaginal delivery.

"I think most everyone would agree that the pendulum concerning VBAC utilization has swung too far," said Dr. Mark Landon, interim chairman of obstetrics and gynecology at Ohio State University Medical Center.

"On both sides, the absolute risks are very small," said Landon, who studies VBACs and presented data to the panel.

The most commonly cited reason for repeat C-sections is the risk that the woman's uterus will rupture at the site of the incision, a complication that can cause brain damage or death for the infant. It happens less than 1 percent of the time.

Because a C-section is a surgical procedure, it carries increased risk for the mother.

The panel compared maternal deaths and infant deaths in VBACs and repeat C-sections. They found that four of 100,000 women who attempt vaginal delivery die compared with 13 who have a repeat C-section, and that 130 of 100,000 infants in VBAC attempts die compared with 50 in repeat C-sections.

The group emphasized that decisions should be individualized and that women should be told about their options and the risks and benefits associated with them.

They also recommended re-evaluating national guidelines that have prompted many hospitals to ban VBAC attempts. And they said policymakers should work to eliminate other barriers - including the fear of lawsuits - to women who want to try a VBAC.

Finally, they called for more and better research on risks and benefits of both approaches.

For at least three decades - since the last NIH statement on the topic - doctors and others have been debating the viability of delivering vaginally after a C-section. Before that, the adage "once a C-section, always a C-section" was widely accepted.

Between 1980 and 1996, the number of women attempting a vaginal delivery increased, but after 1996, numbers once again declined.

Hospital policies have also affected the numbers. Directors of many labor-and-delivery units at smaller hospitals don't allow VBACs, because they can't guarantee that a surgeon and anesthesiologist will be immediately available in case of emergency, something that is recommended by the American Congress of Obstetricians and Gynecologists.

The panel's conclusions apply only to women who have had a C-section that was done with a horizontal incision across the lower part of the uterus and who are carrying a single baby to term.

Dr. Stuart Jones, chairman of obstetrics and gynecology at Riverside, said it's important to let women know that vaginal delivery is possible and to weigh the pros and cons for each individual. He said the risk of malpractice lawsuits is a major obstacle to more widespread availability. Some insurers won't even allow doctors to try VBACs, he said. Jones is part of a group of doctors who run their own malpractice insurance company and who decide on VBACs case by case, he said.

Debra Bingham, president-elect of the advocacy group Lamaze International, said she hopes that doctors' groups will change their recommendations, to make VBACs more accessible to all women. "These are serious personal decisions, and it should be an individual decision, rather than being imposed," she said.