The major medical organization representing obstetricians said Wednesday that a vaginal birth after caesarean is a safe and appropriate choice for most women who have had a prior C-section, including some women who have had two prior C-sections.
The guidelines were issued by the American College of Obstetricians and Gynecologists. Hospital policies, legal concerns, insurance restrictions and factors related to doctor and patient convenience often prevent women who could have a VBAC from getting one. "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," Dr. Richard N. Waldman, president of ACOG, said in a news release.
The guidelines follow the release in March of a report from a National Institutes of Health advisory panel calling for an easing of restrictions surrounding VBAC. That panel concluded that there are risks and benefits to VBAC and that women should be fully informed of their options and allowed to make a choice.
Almost one-third of all U.S. births today are by caesarean section. Two decades ago, one-quarter of U.S. women who had a previous caesarean attempted a VBAC in a subsequent pregnancy. But that rate has fallen in 9%.
According to ACOG, about 60% to 80% of women who are appropriate candidates for a VBAC will be successful. The greatest risk of VBAC is from a uterine rupture, which occurs in 0.5% to 0.9% of cases. A uterine rupture is a life-threatening emergency. Thus, according to the ACOG guidelines, a VBAC should be attempted in "facilities with staff immediately available to provide emergency care." For hospitals that can't meet that standard, VBAC should be "carefully considered" by doctors and their patients, the document states. But, the authors added: "Respect for patient autonomy supports that patients should be allowed to accept increased levels of risk; however, patients should be clearly informed of such potential increase in risk and management alternatives."
The National Institutes of Health report combined with ACOG's new guidelines have the potential to usher in a new era of childbirth in the United States, returning it to a more natural, less-invasive event. Women's health experts nationwide have long agreed that one-third of all births by surgery is unnecessarily high. But, no matter what the medical evidence says, whether the attitudes of doctors and women will change to favor a less-invasive and medicalized — as well as slower and less convenient — approach to childbirth remains to be seen.
The guidelines are published under ACOG's Practice Bulletin No. 115.
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