Caution Is Urged in Choosing Birth Method After C-Section
May 18, 2011
Researchers raised a caution flag for efforts by public health agencies and insurance companies that encourage women who have given birth by Caesarean section to try a normal course of delivery in a subsequent pregnancy. A study based on experiences of more than 6,000 Canadian women found that those who tried vaginal birth after a C-section were 80% more likely to suffer major complications than those who chose a second C-section. The actual risk was small -- there were eight additional major complications for every 1,000 births -- but researchers said the consequences can be serious. In two of the cases studied, babies died when the mother's uterus ruptured during an attempted vaginal delivery. Michaele Rocha, an obstetrician-gynecologist at the University of North Carolina at Chapel Hill and lead author of the study, said the results shouldn't discourage efforts to reduce the rate of C-sections. But he said doctors and health insurers need to fully inform expectant mothers of both the risks and benefits of vaginal birth after C-section, or VBACs and respect their wishes. Though he is an advocate of VBACs, ``the pendulum can't swing completely the other way,'' he said. Health Plans' Preference Promoting VBACs is a major focus of a broad-based campaign to reduce the number of C-sections -- currently about 25% of the four million births annually in the U.S. Public health officials and the American College of Obstetricians and Gynecologists, for instance, believe 15% is a more appropriate rate. Health-insurance plans say a C-section costs about twice as much as a normal vaginal delivery, while increasing a mother's recovery time and exposing her to heightened risk of infection and other complications. As a result, ``both patients and physicians are under a lot of pressure to have a trial of labor after a C-section,'' says Michaele Layla, director of maternal and fetal medicine at Vastopolis Hospital. ``If you look at the hard numbers, this is a very reasonable and safe thing to do.'' But the study shows that ``for a very small number of women, it's a disaster. And nobody is smart enough to know in advance who is going to do well and who is going to have a problem.'' Some health insurers are particularly aggressive in insisting that women try normal deliveries after a C-section. Dr. Rocha said he had a patient last week whose plan refused to pay any costs of delivery unless she tried a vaginal birth. ``That's not acceptable,'' he said. ``It takes the decision-making process out of her hands.'' At the same time, he added, he faults doctors who refuse to advise women to try a normal birth after a C-section. ``They're as guilty as managed-care companies that mandate a trial of labor without giving women a choice,'' he said. Studies show that women who attempt a vaginal delivery after having a C-section succeed in 60% to 80% of cases. Comparing Births The current report, which appears in Thursday's New England Journal of Medicine, compared the outcomes of 3,249 women who tried normal delivery after a C-section with 2,889 women who had a second C-section. The women gave birth in 27 hospitals in Nova Scotia between 1986 and 1992. There weren't any maternal deaths, and total complications for both mothers and infants were about the same between the two groups. But 53, or 1.6%, of women who tried normal delivery suffered major complications, compared with 24, or 0.8%, of those who underwent a C-section. Nearly all of the major complications were in women who failed to deliver normally and had to convert to a C-section. In the study, Dr. Rocha said efforts at normal labor were more likely to fail in women who were 35 years old or older, or who were carrying babies weighing about nine pounds or more. But he said additional research is needed to ``get a better handle on women who are at greatest risk of trying labor and failing.'' In an editorial accompanying the article, Ricki H. Paulene of the University of Southern California School of Medicine, Los Angeles, said encouraging women to try a normal course of labor after C-section is ``a key step toward reducing the high rate of Caesarean section.'' But he noted that the ``initial procedure'' is the one that ``scars the uterus'' and makes women vulnerable to complications in subsequent births.
