(from USA Today, Dec. 16, 2004)
By Rita Rubin, USA TODAY
In her 38th week of pregnancy, the only thing certain about Monique Hoch's impending delivery was that the baby was going to be a boy.
"I didn't know when I was going to have the baby. I didn't know how I was going to have the baby. I didn't know where I was going to have the baby. And I didn't know who was going to deliver," recalls Hoch, 33, of Lancaster, Ohio.
Up until that 38th week, she thought she had most of the answers. She'd been under the care of the same obstetrician who had delivered her first child by cesarean section at the only hospital in town.
Hoch had made it clear to him that she didn't want a repeat C-section. "The recovery from the C-section was so hard on me," she says. "I didn't like not being able to care for my baby right off the bat."
But two weeks before her due date, the hospital vetoed her plan to attempt a vaginal birth after cesarean, or VBAC.
About 10% of all pregnant women have had a previous C-section, says Mark Landon, an Ohio State University OB-GYN who led a VBAC study published this week in The New England Journal of Medicine.
As the U.S. C-section rate continues to climb ? preliminary government data show it hit 27% in 2003, an all-time high ? the proportion of pregnant women with a previous cesarean will continue to rise.
"Not all of these women are candidates for a trial of labor, but the majority probably are," Landon says. Because Hoch was determined to deliver vaginally, her doctor referred her to Landon. With his and her husband's assistance, she achieved her goal at the OSU hospital in Columbus, 30 miles from Lancaster.
After peaking at 28% in 1996, the proportion of U.S. women who delivered vaginally after a prior C-section dropped to 10.6% in 2003, the preliminary data show.
Several factors have fueled the decline. In the early to mid-1990s, health-care plans looking to cut costs had mandated that all women with a prior C-section try to deliver their next baby vaginally. But not all were good VBAC candidates.
In some cases, their uterine scar from a previous C-section ruptured, or tore, during labor. Usually, mothers and babies do fine after a uterine rupture, but severe tears may cause heavy bleeding, endangering both.
Indiscriminate VBACs gave rise to a slew of lawsuits against hospitals and doctors, spurring them to resume practicing the philosophy of once a cesarean, always a cesarean.
At around the same time, new research supported the notion that babies were more likely to die if their mothers opted for a VBAC instead of a scheduled repeat C-section. However, the studies were based on after-the-fact reviews of birth certificates and hospital discharge codes, which can yield incomplete or inaccurate information. Also, their definitions of ruptures varied. So the VBAC level of risk remained unclear.
But in 1999, a one-word change in guidelines from the American College of Obstetricians and Gynecologists pushed the VBAC rate even lower. The group advised that only hospitals with a surgical team immediately available allow VBACs. Previously, the group had recommended that a surgical team be readily available, interpreted as no more than a half-hour drive away.
Many hospitals and doctors simply got out of the VBAC business and began requiring that pregnant women with a prior C-section deliver subsequent babies the same way.
Fairfield Medical Center, where Hoch had delivered her first son in 2002, began prohibiting VBACs this past summer, right around the time she was due to deliver her second son. The previous year, 20 to 25 of the hospital's 1,200 deliveries were VBACs, says Jerry Roche, vice president and chief medical officer.
"We stopped doing elective VBAC for two reasons: patient safety and liability concerns," says Roche, noting that his hospital lacks round-the-clock, in-house anesthesiologists.
While Landon doubts that his findings will persuade community hospitals to resume VBACs, they should be reassuring for women who prefer to avoid another C-section.
"The most important thing is that women make informed choices with the best data available," Landon says.
Although the uterine rupture risk is higher in women who try a VBAC than in those who deliver by scheduled cesarean, the actual number of complications is quite small, Landon and his collaborators found.
"There are definitely risks associated with a cesarean delivery," such as placenta complications in subsequent pregnancies, adds co-author Catherine Spong, chief of the Pregnancy and Perinatology Branch at the National Institute of Child Health and Human Development, which paid for the study.
The study included 17,898 women who attempted a VBAC and 15,801 who underwent a planned repeat C-section. They delivered at 19 academic medical centers from 1999 through December 2002. Nurses collected information from mothers' and babies' medical records at the time of delivery.
None of the planned C-section group experienced a rupture, compared with 124, or 0.7%, of the VBAC group. Hoch says it was an acceptable trade-off for the experience of vaginal delivery and a faster recovery.
Recalls Hoch: "Afterwards, it was like, oh, I can actually sit up."
Editor's note: Mark Landon wrote the foreword to reporter Rita Rubin's book, What If I Have a C-Section?