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When Eveline Andrews, 28, of Baytown, Texas, was in labor with her first baby three years ago, her doctor told her that she had a narrow pelvis and required a Cesarean section. But when Andrews became pregnant again about a year after giving birth, she felt strongly that she did not want surgery again. At first her obstetrician refused to agree to let her try for a vaginal birth after Cesarean (VBAC) because he felt a repeat C-section would be safer. Andrews persisted, however, and her doctor gave in—and at 40 weeks, she had an uncomplicated vaginal delivery.
A C-section is sometimes the safer delivery option for a woman who has already had one. But a panel of childbirth experts convened by the National Institutes of Health (NIH) this past March concluded that there should be fewer repeat C-sections and more VBACs. “A VBAC is a very safe option for many women who have had one previous C-section and who have been identified as low risk—and that is the majority of women,” says Nancy Petit, M.D., chief of the division of obstetrics at St. Francis Hospital in Wilmington, Del. (See “Are You Low Risk?”) The NIH panel reported that about 75 percent of women who attempt a VBAC—a process known as a trial of labor—have a vaginal birth.
However, doctors and hospitals have become increasingly reluctant to offer VBACs, and some have banned it. “The VBAC rate has dropped from about 26 to 28 percent in 1996 to about 8 percent currently,” says Petit, who served on the NIH panel. Thirty to 45 percent of OBs no longer offer VBACs, and some hospitals offer it only with strict stipulations, such as going into labor spontaneously before one’s due date. (A VBAC should never be attempted if labor has been induced.)
The disappearing option
Fear of litigation drives much of the reluctance to allow VBACs. “Lots of providers and hospitals refuse to offer women the option because they fear getting sued if something goes wrong,” says Amy Romano, C.N.M., a nurse-midwife in Connecticut and author of Lamaze International’s Science & Sensibility blog (scienceandsensibility.org). Even some midwives have stopped offering VBACs because of liability issues.
That’s because a VBAC can lead to uterine rupture, a dangerous tearing of the uterine muscle or past C-section scar. “Uterine rupture can be catastrophic for the baby and may be life-threatening to the mother,” says Marilynn Frederiksen, M.D., an associate professor of clinical obstetrics and gynecology at the Feinberg Medical School of Northwestern University and a member of the NIH panel.
However, the incidence of uterine rupture is low—less than 1 percent—and the NIH panel found that repeat C-sections expose women to greater risk of death than VBACs and pose risks to mothers and babies in future pregnancies, when the likelihood of such serious conditions as placenta previa and placenta accreta increases. “VBAC is a safe and reasonable option for most women and is in fact safer than repeat Cesarean for many,” Frederiksen says.