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Panel Recommends Rethink On Repeat Cesareans

Just because a woman has given birth by cesarean section, doesn't mean she shouldn't be able to try a vaginal delivery for the next child, a group of experts says.

A nurse prepares the abdomen of a woman before a C-section at Malcolm Grow Medical Center near Washi i i

A nurse prepares the abdomen of a woman before a C-section at Malcolm Grow Medical Center near Washington. Tech. Sgt. Suzanne M. Day/Wikimedia Commons hide caption

itoggle caption Tech. Sgt. Suzanne M. Day/Wikimedia Commons
A nurse prepares the abdomen of a woman before a C-section at Malcolm Grow Medical Center near Washi

A nurse prepares the abdomen of a woman before a C-section at Malcolm Grow Medical Center near Washington.

Tech. Sgt. Suzanne M. Day/Wikimedia Commons

A subsequent vaginal birth is as safe or safer than a C-section, for mothers and infants, according to a National Institutes of Health panel of obstetricians, gynecologists and other medical doctors, as well ethicists, lawyers and scientists who met for three days just outside Washington this week.

Worries about complications have led to a sharp drop in vaginal births after cesarean. "A primary cesarean will begat subsequent cesareans," said Dr. F. Gary Cunningham, chairman of obstetrics and gynecology at University of Texas Southwestern Medical School. Indeed, only about 10 percent of subsequent deliveries are vaginal births.

The sometimes contentious public meeting, which concluded Wednesday, gave a platform to activists for vaginal births after cesarean (or VBACtivists as they call themselves) to challenge some of the experts.

Shannon Mitchell, who hails from Florida, says she was repeatedly offered more cesareans after her first child, a breech baby, was delivered that way. She argued with an ethicist on the panel over whether she had the right to refuse C-sections.

"This is a human rights issue," Mitchell declared. "I'm being cut open because obstetricians have decided that I need to be," Mitchell shouted back when the ethicist told her there is no absolute rule saying she can refuse the procedure.

The major barrier to vaginal births, the panel concluded, is a set of guidelines by the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists. Those require "the immediately availability" of surgical and anesthesia personnel before doctors offer a "trial of labor," the medical term for attempting a vaginal birth after a C-section. Those teams are supposed to be on hand in case of serious trouble, such as a rupture of the uterus.

The staffing standard is tough for some hospitals to meet. Recent surveys indicate that, as a consequence, up to 30 percent of hospitals won't allow vaginal births after C-sections. The problem is particularly acute in rural areas where it's especially difficult to provide around-the-clock staff surgical and anesthesiology.

Cunningham says that after looking at the data, the panel found that the guideline hasn't changed outcomes for patients. "It is a crippling rule for many hospitals."

Fear of being sued, however, is a major factor behind the ACOG guidelines. Dr. Michael Socol, of Northwestern University School of Medicine, in talking about the medical claims against the Northwestern Memorial Hospital, explained that the proportion from obstetrician and gynecology — mostly obstetrics — represent just 18 percent of all lawsuits filed, but 60 percent of those that were paid out.

Without reform of the legal system, he said, it is going to be very difficult to reverse current trends in the practice of medicine.

The NIH panel encouraged further study of legal obstacles, saying there's not enough evidence to make a recommendation. In very explicit language, however, it urged professional societies and hospitals to reassess policies that create barriers to offering women the opportunity to go through labor in giving birth. "The bottom line," Cunningham conceded, "is we can't make them do anything."

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