New guidelines from the American College of Obstetricians and Gynecologists (ACOG) published in the August issue of the journal Obstetrics & Gynecology aim to reduce the national C-section delivery rate by shifting policy to enable more women to attempt vaginal births after an initial C-section.
Among the factors contributing to the surge in Cesarean births in the U.S. is the fact that many hospitals have policies in place that make it difficult for women who have already had one C-section to attempt a vaginal birth after a subsequent pregnancy. In fact, while vaginal births after C-section (VBAC) were extraordinarily rare before 1970, as obstetricians performed more successful deliveries this way, they grew in popularity — from just 5% in 1985 to 28% by 1996. Yet, since then, the rate of VBACs has fallen again, to just 8.5% of deliveries. That, experts say, may in part be due to obstetrician or patient preference, but is largely attributable to the fact that many hospitals and insurance providers have narrow criteria about which women are eligible for VBAC, and some institutions prohibit women who have already had one C-section to attempt vaginal delivery at all.
The issue lies at the intersection of legal liability, resources — whether it’s financially worth attempting a VBAC, which, thanks to liability issues requires additional medical staff at most hospitals — evidence-based medicine and safety of mom and baby. And while it has been the subject of much research and even a two day conference this past March hosted by the National Institute of Child Health and Human Development (NICHD), for the most part, until now, prohibitive policies have remained in place.
The new guidelines, however, state that the majority of women who have given birth via C-section would be eligible for trial of labor after cesarean (TOLAC). And according to ACOG figures, between 60 to 80% of women who attempt VBAC will deliver that way successfully. Of course, counseling and consideration of each individual woman’s health and specific pregnancy will be critical to determining whether she is a good candidate for VBAC. As Dr. Jeffrey Ecker, co-author of the new recommendations and an obstetrician specializing in high-risk deliveries at Massachusetts General Hospital, said in a statement about the new guidelines:
“In making plans for delivery, physicians and patients should consider a woman’s chance of a successful VBAC as well as the risk of complications from a trial of labor, all viewed in the context of her future reproductive plans.”
If more lenient policies about which women are eligible for VBAC deliveries reduces the number of C-sections even slightly, it could make a tremendous difference to the overall C-section rate in the U.S., which is currently higher than 31% of all deliveries. (It increased from just 5% in 1970.) Under current VBAC policies, according to Dr. Caroline Signore of the NICHD, among women who have had one C-section, “more than 90% will have Cesarean develieries for any other children that come later.”
Attempting vaginal delivery after a C-section is not risk-free, but neither is repeat C-section or childbirth in general, experts stress. For both TOLAC and repeat C-section, there are risks for extensive bleeding, blood clots, infection, potential for an emergency hysterectomy and even death. And while a failed attempted at a vaginal delivery after a C-section can introduce serious health consequences, a successful vaginal delivery after C-section generally has fewer complications than an elective repeat C-section, according to the ACOG guidelines.
Weighing the risks and benefits for each individual patient is key, as is recognizing the potential dangers and limitations of VBAC, Signore says. Knowing that, for many women, VBAC is a viable option does not necessarily mean it is the right option for all women. “It’s not to say that everyone must attempt a VBAC,” Signore says, “but simply that women who want to should have the opportunity once they understand the risks and benefits.”