Guidelines Seek to Curb C-Section Deliveries

In an effort to reduce the nation’s rising number of births by Caesarean section, the American College of Obstetricians and Gynecologists Wednesday called on doctors to encourage women who have had C-sections to attempt normal, vaginal births with their next children.

The new guidelines, which seek to dispel the “once a C-section, always a C-section” myth, laid out for the first time explicit conditions in which vaginal births are preferable, according to Dr. Mary Jo O’Sullivan, a member of the college’s committee on obstetrics.

Obstetrical Implication

“We are saying for the first time in 70 years that patients who have had a previous Caesarean section should not have an elective repeat Caesarean section unless there is a medical or obstetrical implication for so doing, and it is perfectly safe for both mother and infant,” O’Sullivan told a press conference.

Provisions of the guidelines recommend that women, even if they have had up to two or three Caesarean deliveries, should attempt a vaginal delivery if there are no medical dangers. Data studied by the college show that between 50% and 80% of women with previous Caesareans were successful in later vaginal deliveries.

However, the guidelines also state, if a woman’s previous Caesarean consisted of a vertical, or “classical,” incision, she should avoid vaginal births for her next children. The vertical incisions are rare, occurring in only 1% to 2% of such births, O’Sullivan said.

Second Recommendation

The college, one of the nation’s top organizations in obstetrics and gynecology, first recommended in 1982 that vaginal births be attempted after Caesareans, then revised those guidelines in 1985. The government’s National Institute of Child Health and Human Development first called for increased vaginal deliveries after Caesareans in 1981.

Despite the continuing recommendations, the nation’s Caesarean section rate continues to increase. Figures released by the college show that 24.4% of all births in 1987 were Caesareans, up from 24.1% in 1986 and 18.5% in 1982. However, the rate of vaginal births after previous Caesarean delivery has increased from 4.8% in 1982 to 9.8% in 1987.

The figures show that 35% of all Caesareans in 1987 were repeat Caesareans.

O’Sullivan said that she expects the rate of vaginal births after Caesareans to rise at least 20% in the next several years, but the increase depends on how rapidly the guidelines are adopted by hospitals and physicians.

The importance of bringing down the Caesarean rate arises from the high cost of medical care, the potential dangers of the surgery, and the slight increase in infant mortality that comes from Caesareans, O’Sullivan said.

Statistics from the Health Insurance Assn. of America show that in 1986 the average cost of a hospital maternity stay, excluding the cost of a physician, was $1,730 for a vaginal delivery and $3,230 for a C-section delivery.

Critics of the high Caesearean rate contend that both doctor and patient are responsible. Patients are misled by the “myth of the Caesarean,” said Dr. Mortimer Rosen, professor of obstetrics and gynecology at Columbia University’s College of Physicians and Surgeons in New York. Rosen noted that most Caesareans result in the loss of two pints of blood, but vaginal deliveries cost one pint of blood.

At least half of all Caesareans are unnecessary, Rosen maintained.

In addition, doctors who fear malpractice suits will often push for a Caesarean over a vaginal delivery, said Dr. Nobert Gleicher, head of the department of obstetrics and gynecology at Chicago’s Mount Sinai Medical Center. Some doctors think that “every problem will be automatically resolved by doing a C-section,” he said.

“Regulations and guidelines alone will not result in a significant shift in the national Caesarean rate,” he added, suggesting that the rate will decrease only when the nation’s liability system is modified and hospitals are held accountable for the number of Caesareans that they perform.