Guidelines Issued to Curb Number of Caesarean Births

More than 100,000 women a year who have given birth in the past by Caesarean section could deliver subsequent babies naturally, a major national medical organization said Friday.

Dr. Luella Klein, president of the American College of Obstetrics and Gynecology, which issues obstetric guidelines for the medical community, said at a news conference that the long-held medical doctrine of “once a Caesarean section, always a Caesarean section” no longer applies to many women.

Klein contended that new guidelines issued by her group “would, over a period of time, help stop the rise in the nation’s Caesarean delivery rate and result in a decreased number of repeat Caesareans.”

A Caesarean section, in which a baby is delivered by cutting through the mother’s abdominal and uterine walls, generally is considered less desirable than natural delivery because it involves major surgery under anesthesia and requires a longer recovery time.

In 1983, Klein said, about 700,000 babies of an estimated 3.6 million born in the United States were delivered in this manner. Of those births, 200,000 to 225,000 were repeat Caesareans. And, she added, about 95% of women who have had Caesareans deliver their next child the same way.

But, Klein said, 50% to 80% of the women who have had Caesareans can deliver normally, as long as they do not have recurring conditions that make a Caesarean necessary or have what is known as a “classical” incision from their prior Caesarean.

A “classical” incision is a vertical scar from surgery performed on the upper, more muscular part of the uterus. In recent years, women have received what is called a “low, transverse”--or horizontal--incision on the lower part of the uterus. Such an incision is far less likely to rupture during labor in later pregnancies.

“The big worry we have had in the past is that the uterine scar from the previous Caesarean delivery would rupture, and, with the loss of blood, would endanger the life of the mother and the child,” Klein said.

“Although this rupture can occur, we have found that it is rarely catastrophic,” she continued. “As long as we have modern fetal monitoring, obstetrical support services and anesthesia, the mother’s health and safety along with her infant’s are protected.”

The new guidelines recommend that hospitals “be able to respond to an obstetric emergency within 30 minutes, instead of the previous, more restrictive 15 minutes” and provide continuous electronic fetal heart and uterine contraction monitoring throughout labor.

Klein said that women who have the classical scar, have had more than one Caesarean, are carrying more than one baby or who are carrying a baby weighing more than about nine pounds should not attempt labor.