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Once a C-Section Always a C-Section? Yes, Insist Many Experts

Obstetrics: Amid some doctors' and health plans' concerns about risks, fewer women are delivering vaginally after a caesarean.


Because of the serious risk involved in delivering a child vaginally after a caesarean section, many hospitals have guidelines governing the procedure. But their strict rules may be endangering lives.

Denied a vaginal delivery at a hospital, many women are opting for home births, say doctors and childbirth educators. In about one in 100 cases, women attempting vaginal birth after caesarean--or VBAC--will experience a ruptured uterus, a potentially deadly complication that requires immediate surgery.

"There are a lot of women who will have VBACs at home with unqualified providers," says Nicette Jukelevics, a longtime childbirth educator in Rancho Palos Verdes and the author of a textbook on VBAC. "What troubles me about this issue is that women are turning to this because their insurance won't cover VBAC."

Nationally, C-section rates are rising rapidly while VBAC rates are dropping, according to the American Academy of Obstetrics and Gynecology.

Many experts say the downturn in VBAC rates is linked to a 1999 statement from the American Academy of Obstetrics and Gynecology advising doctors that women should not attempt VBAC unless a doctor and anesthesiologist are "immediately available" to perform surgery in case of an emergency.

Previous guidelines allowed for a VBAC attempt as long as a doctor could reach the hospital quickly in the event of an emergency.

For many smaller hospitals, birthing centers and health care plans, the new rules mean that VBACs are no longer offered.

"Women who go to hospitals without 24-hour anesthesiology coverage and an obstetrician in-house are going to have a harder time getting a VBAC," says Dr. T. Murphy Goodwin, chief of maternal-fetal medicine at USC's Keck School of Medicine.

That has driven some women to arrange a VBAC attempt at home.

Deirdre McLary, 33, arranged to have a VBAC in her cramped New York City apartment in 1999 because she feared she would have another caesarean if she went to a hospital and because a local birth center, staffed with midwives, didn't allow VBACs.

"I didn't really want a home birth," says McLary. "My apartment is a dump. I wanted a nice room in a birth center. But ultimately, I realized the safest way for me to avoid another C-section was to stay at home."

McLary, whose first child was born by C-section, says she felt that the surgery was unnecessary and that it left her with feelings of failure. She felt she was physically capable of accomplishing vaginal birth if given a chance.

McLary sought information from the International Cesarean Awareness Network, a national consumer network that advocates VBAC. She then found a certified nurse-midwife who had backup arrangements with a doctor in case of emergency.

McLary admits, however, that "there was a little bit of fear. What if something goes wrong at home?" After four hours of pushing, she was so afraid of having a uterine rupture she yielded to the midwife's advice and transferred to a hospital. She gave birth vaginally at the hospital.

A generation ago, women who had a caesarean section were routinely scheduled for C-sections for subsequent births. However, studies in the 1980s and early '90s showed that VBACs could be accomplished safely in the majority of patients. VBAC rates rose from 21% of U.S. births in 1991 to 28% in 1995.

But by then, occasional disastrous outcomes--including a rash of injuries and deaths related to VBAC at Los Angeles County public hospitals in the early 1990s--led the American Academy of Obstetrics and Gynecology, as well as many doctors and health plans, to rethink their VBAC policies.

VBAC rates have dropped 17% since 1996, according to the ob-gyn organization.

The about-face disturbs many childbirth advocates who argue that the risks and difficult recoveries associated with caesarean sections are being ignored.

"The risks associated with VBAC are rare, and they can be minimized" through better management of labor, says Joyce Roberts, president of the American College of Nurse-Midwives. "Denying women the VBAC option by not providing the support is not the solution."

The American Academy of Obstetrics and Gynecology's new guidelines also "undermines the nurse-midwives' ability to do VBAC," Roberts says. The American College of Nurse-Midwives, however, does not endorse attempting home VBACs.

Restrictive VBAC policies have been questioned by women in some parts of the country. In Ogden, Utah, activists from the International Cesarean Awareness Network organized a protest against a community hospital's decision to stop doing VBACs, says Pam Udy, the group's educational director and a resident of Ogden.

"We got petitions and organized a letter-writing and phone campaign to tell them if they wouldn't offer this, we would all drive to Salt Lake City to deliver our babies," she says. "They backed off and allowed VBACs."


VBAC Rates

The rate of U.S. women undergoing a vaginal birth after a previous caesarean peaked in 1996 and is dropping rapidly.

1985: 6.6%

1996: 28.3%

1999: 23.4%

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