Group: Women should be al­lowed to make de­ci­sion based on pros, cons

Austin American-Statesman - - FRONT PAGE -

Women should be al­lowed to try la­bor with next child, even af­ter hav­ing a cae­sarean

WASHINGTON — Most women who have had a Csec­tion, and many who have had two, should be al­lowed to try la­bor with their next baby, say new guide­lines — a step to­ward re­vers­ing the “once a cae­sarean, al­ways a cae­sarean” poli­cies tak­ing root in many hos­pi­tals.

Wed­nes­day’s an­nounce­ment by the Amer­i­can Col­lege of Ob­ste­tri­cians and Gyne­col­o­gists eases re­stric­tions on who might avoid a re­peat C-sec­tion, rewrit­ing an old pol­icy that crit­ics have said is partly to blame for many preg­nant women be­ing de­nied the chance.

Fif­teen years ago, nearly 3 in 10 women who had had a pre­vi­ous C-sec­tion gave birth vagi­nally the next time. To­day, fewer than 1 in 10 do.

Last spring, a Na­tional In­sti­tutes of Health panel strongly urged steps to re­verse that trend, say­ing a third of hos­pi­tals and half of doc­tors ban women from at­tempt­ing vagi­nal birth af­ter a cae­sarean.

The new guide­lines declare the op­tion safe and ap­pro­pri­ate for most women — now in­clud­ing those car­ry­ing twins or who have had two C-sec­tions — and urge that they be given an un­bi­ased look at the pros and cons so they can de­cide whether to try.

Women’s choice is “what we want to come through loud and clear,” said Dr. Wil­liam Grob­man of North­west­ern Uni­ver­sity, co-author of the guide­lines. “There are few times where there is an ab­so­lute wrong or an ab­so­lute right, but there is the im­por­tance of shared de­ci­sion-mak­ing.”

Over­all, nearly a third of U.S. births are by cae­sarean, an all-time high. Cae­sare­ans can be life­sav­ing, but they come with cer­tain risks — and the more C-sec­tions a woman has, the greater the risk in a next preg­nancy of prob­lems, some of them life-threat­en­ing, such as pla­centa ab­nor­mal­i­ties or hem­or­rhage.

The main de­bate with vagi­nal birth af­ter cae­sarean: that the rig­ors of la­bor could cause the scar from the ear­lier surgery to rup­ture. There’s less than a 1 per­cent chance of that hap­pen­ing, the guide­lines say. Also, with most re­cently per­formed C-sec­tions, that scar is on a lower part of the uterus that’s less stressed by con­trac­tions.

Of those who at­tempt vagi­nal birth af­ter cae­sarean, 60 to 80 per­cent will de­liver vagi­nally, the guide­lines note. The rest will need a C-sec­tion be­cause of stalled la­bor or other fac­tors. Suc­cess is more likely in women who go into la­bor nat­u­rally — though in­duc­tion doesn’t rule out an at­tempt — and less likely in women who are obese or are car­ry­ing large ba­bies, they say.

Thus the bal­anc­ing act that women and their doc­tors weigh: A suc­cess­ful vagi­nal birth af­ter cae­sarean is safer than a planned re­peat C-sec­tion, es­pe­cially for women who want more chil­dren — but an emer­gency C-sec­tion can be riskier than a planned one.

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