Health experts: Most repeat C-sections unnecessary

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Michelle Williams is three months' pregnant and determined to experience childbirth the way nature intended. But because her previous baby was delivered through ... cesarean section — she has to travel more than an hour ... to find an obstetrician willing to let her try for a vaginal birth.

One out of every three pregnant women now has a C-section ...

This is also the case in Australia.

The skyrocketing C-section rate has been hotly debated in birthing and medical communities, yet little attention has been paid to one of the consequences: Once a woman has a C-section, she often has to fight to deliver subsequent babies the old-fashioned way ...

This is also the case in Australia. VBAC rates nationally are around 15%.

Repeat C-sections have become so routine that 90 percent of pregnant women who have the surgery give birth that way again. That is a concern to health experts, who say vaginal births after a cesarean, or VBACs, should be far more common.

Successful VBACs result in better health outcomes for the mother and the baby ... VBACs [should] be offered in low-risk cases.

... although the attempt carries a risk of uterine rupture, the chance it will happen is relatively low: 0.5 percent. Meanwhile, C-sections carry all the risks of a major surgery. Compared with having a vaginal birth, a woman delivering by C-section experiences more physical problems, longer recovery and more emotional issues on average ... babies born by cesarean are less likely to be breastfed and more likely to experience breathing problems at birth and asthma as they get older.

Yet the VBAC rate, 9.2 percent, is a far cry from the objective set by the Centers for Disease Control and Prevention: 37 percent. In Illinois, the rate was 11 percent in 2008, down from 38.6 percent a decade earlier.

... In northwest Illinois, the VBAC rate is as low as 3.9 percent ...

Not dissimilar to some of our hospitals here in Australia.

... 73 percent of the women who try VBACs are successful.

Success rates are around 70%-80%, but they are higher, up to 90%, if the woman chooses a private midwife.

"The liability issue is huge," said Dr. Joseph Pavese, chairman of the obstetrics department at Advocate Christ Medical Center in Oak Lawn, where 97 percent of pregnant women with a previous C-section have another one. "Parents expect good outcomes, and physicians are reluctant to try difficult deliveries. If the baby is not perfect, there is possible litigation."

... If the scar opens during labor, it would require an emergency C-section. Certain factors — induction of labor, or a vertical (rather than horizontal) incision — can increase the risk of rupture.

In 99.5 percent of the cases, nothing goes awry. But if the scar gives way, results can be catastrophic; the baby has a 10 percent chance of dying or suffering brain damage.

Over the years, "The risk of uterine rupture has not changed," said Dr. Howard Strassner, director of maternal and fetal medicine at Rush University Medical Center. "What has changed is individual tolerance for risk. It reached the point where no one wants to be associated with an adverse outcome."

... more recent and balanced research showing VBACs are as safe — if not safer — than repeat C-sections hasn't had the same effect [as previous research that demonstrated that elective repeat caesarean was safer than VBAC.]

... What crippled the idea of a VBAC, however, was a simple word change. In 1998, ACOG advised that physicians should be "readily available" to provide emergency care because of the dangers of a uterine rupture. Eight months later, the American Congress of Obstetricians and Gynecologists changed the wording to "immediately available," and many small hospitals in rural areas stopped doing VBACs.

We have the same situation in Australia, with many smaller hospitals and midwife-led units not offering VBAC services.

Katherine Shaw Bethea Hospital in Dixon, which handles about 365 deliveries a year, was one of more than a dozen Illinois hospitals that subsequently dropped VBACs because an on-site anesthesiologist wasn't always immediately available.

"... too many women are subject to coerced cesareans because hospitals have banned VBACs."

... Mariana Patzelt ... had two previous C-sections, planned to drive from her home ... to deliver her third baby ... after laboring too long at home in hopes of reducing her chances of a C-section, she ended up delivering in the emergency room of a nearby hospital.

When doctors there asked whether she had had any previous surgeries, she said no.

"The whole time I was hoping they didn't see the scar," she said. "I knew if I would have said yes, it would have blown my chances and I wouldn't be able to fight hard enough for everything I worked for.

"Hospitals treat birth as a medical condition, a disease they have to fix rather than something natural we've been doing since the beginning of time."...

Melissa Maimann, Essential Birth Consulting 0400 418 448