Bring back the vaginal birth!

In many US hospitals, a repeat caesarean is the only option, and nine in 10 women end up getting one - a fact that had experts worried at a national conference this week on vaginal birth after caesarean, or VBAC.

Because VBAC doesn't require surgery, mother and baby can spend more time together and leave the hospital sooner than after a caesarean.

After reviewing earlier studies, the expert panel found that VBAC was about as safe as first-time vaginal childbirth. The panel emphasized that women should have access to the delivery method they prefer, and recommended that health-care providers and policy-makers collaborate to eliminate current barriers to VBAC, including guidelines that limit availability of the procedure.

"The data indicate that hospitals are not able or willing to provide VBAC", said Dr. F. Gary Cunningham, of the University of Texas Southwestern Medical Center at Dallas, who chaired the panel.

"We are just hoping that putting these data out there after this exhaustive review will prompt some people to look at the problem," he told journalists after the conference.

Bingham said Lamaze was pleased with the result, which was also welcomed by others at the meeting.

"There is quite a presence of young women who are not willing to be told what to do," she told Reuters Health from the conference, which was organized by the National Institutes of Health. "They don't want their reproductive decisions made by others."

Changing recommendations

VBAC has long been the subject of heated debate. For decades, the mantra was "once a caesarean, always a caesarean." Doctors were concerned that the scar left in the womb from a previous caesarean would tear during labour, leading to life-threatening bleeding.

But in 1980, an NIH conference panel suggested that the chance of uterine rupture was small in most women and that VBAC was as safe as other vaginal births. Maternity wards soon began embracing VBAC as a means to slash high caesarean rates.

As more and more women gave birth vaginally, however, reports of uterine ruptures increased, and VBAC rates began to slump in the mid-1990s.

While uterine rupture is more rare in repeat caesarean, the risk of maternal death is about three times higher. Women who undergo several caesareans also seem to have a higher risk of having their womb removed.

"It is concerning that the rate of VBAC is falling," obstetrician Dr. Alison G. Cahill of Washington University in St. Louis told Reuters Health.

"The big picture is that vaginal birth after caesarean remains an important delivery option," said Cahill.

She added that several factors - including the type of cut made during the previous caesarean, the mother's health status, and the size of the child - were important when deciding whether a woman should attempt VBAC.

Many barriers

Despite the enthusiasm surrounding VBAC, surveys have shown that as many as one-third of US hospitals and half of all physicians will not perform it.

"We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL," the consensus panel concluded in their statement, referring to the so-called "trial of labour," a planned VBAC attempt.

Part of the reluctance is fear of lawsuits, the panel said.

The current guidelines from the American Congress of Obstetricians and Gynaecologists, updated in 2004, recommend that a full surgical team be present during VBAC should an emergency caesarean prove necessary.

But many hospitals are not staffed for this, they say, and so discourage VBAC.

"My personal opinion is that it was a shame that we took that stance, but it was all because of insurance and liability," said Moore, who has never seen a uterine rupture and was not at the conference.

Have you had a VBAC? What was your experience like? Tell us in the comment box below.

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