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Panel Finds Many Women Can Avoid Repeat C-Sections
Date:3/10/2010

Vaginal delivery after Cesarean often safe, but roadblocks remain, experts say,,

WEDNESDAY, March 10 (HealthDay News) -- Most women who have had a Cesarean delivery can safely have a vaginal delivery later, an expert panel concluded Wednesday.

Surging C-section rates in the United States have worried experts, but the panel said that just because a woman has had a C-section in the past, there's no reason she must have one in subsequent deliveries.

However, current medical practice and fear of lawsuits are major obstacles to encouraging women to have a vaginal delivery after a C-section, the National Institutes of Health-sponsored panel said.

"This meeting was stimulated by the rising Cesarean rate all over this country, as well as the world," Dr. F. Gary Cunningham, Panel and Conference Chairman and Beatrice and Miguel Elias Distinguished Chair in Obstetrics and Gynecology at the University of Texas Southwestern Medical Center at Dallas, said during an press conference Tuesday afternoon.

Women who have one C-section are likely to have more C-sections down the line, Cunningham said.

"This has created some problems," he said." Another problem has been the voices of many women who have bemoaned the fact that they have not had access to care where a trial of labor can be offered as an delivery."

In the United States, the rate of vaginal delivery after a prior Cesarean has dropped from 30 percent to about 10 percent over the past 15 years, Cunningham noted.

To come up with their recommendations, the panel looked at all the available data as well as hearing testimony from doctors, hospital administrators and academics.

Cunningham was careful to note that the panel's findings are not guidelines to be followed, but rather a call to consider alternatives to current practice.

"What we found was the use of a vaginal delivery after Cesarean is certainly a safe alternative for the majority of women who have one prior Cesarean," he said.

There are several major reasons why this choice has been precluded in most hospitals, Cunningham said. "The number of hospitals offering 'trial of labor' is diminished because of the perceived good and bad outcomes that accrue to either the mother or the fetus," he noted.

Although these outcomes are relatively rare, they include a ruptured uterus, and they can be devastating to the mother, Cunningham noted.

In many cases, access to vaginal delivery is not available to these women because of lack of money, as well as doctors' and hospitals' fear of being sued should a complication occur, he added.

In addition, some professional societies, such as the American College of Obstetricians and Gynecologists (ACOG) have guidelines that in some cases are impossible to follow, which have caused many hospitals to shy away from offering vaginal delivery to women who have had a Cesarean delivery, Cunningham said.

For example, the ACOG guidelines require that a surgeon and an anesthesiologist be immediately available when a woman who has had a previous C-section gives birth vaginally.

However, there's no evidence that this type of oversight is necessary or changes outcomes, Cunningham said. In any case, bad outcomes remain rare -- Cunningham estimated that there are about 10 deleterious outcomes for every 100,000 births, vaginal or otherwise.

"That doesn't mean it doesn't apply, just that there is no evidence to support that," he said. "It is a crippling rule for many hospitals and physicians, and is therefore a big driver of the problem. We hope that some of the recommendations cause some of these barriers to be removed."

Yet, there are no reliable means to spot which women are at risk for complications if they opt for vaginal delivery, the panel members noted.

"Pregnancy is something of a risky endeavor," panel member Carol J. Rowland Hogue, the Jules & Uldeen Terry Professor of Maternal and Child Health and director of Women's and Children's Center at the Rollins School of Public Health at Emory University in Atlanta, said during the teleconference.

"Women do suffer complications of pregnancy and their babies do have problems. Fortunately these are rare, but they are irrespective of mode of delivery," she said.

Panel member Dr. Nancy Frances Petit, chairwoman of the division of obstetrics at St. Francis Hospital in Newark, Del., said there is a need for women and their doctors to communicate better to decide which type of delivery is best.

"It is important for the health-care provider to share with the women, first of all, what are the capabilities of the institution that would be participating in her delivery. What is the level of comfort the health-care provider has in terms of her identified risk. It is also important that in return that he or she really takes the opportunity to listen to what the pregnant woman has to say in terms of what her desires truly are," Petit said.

More information

There's more on childbirth at the U.S. National Library of Medicine.



SOURCES: March 10, 2010, teleconference with: F. Gary Cunningham, M.D., panel and conference chairman, Beatrice and Miguel Elias Distinguished Chair in Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas; Carol J. Rowland Hogue, Ph.D., M.P.H., Jules & Uldeen Terry Professor of Maternal and Child Health, professor, epidemiology, and director, Women's and Children's Center, Rollins School of Public Health, Emory University, Atlanta; Nancy Frances Petit, M.D., chairwoman, Division of Obstetrics, St. Francis Hospital, Newark, Del.


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