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Hospitals review policies on vaginal births after Caesareans

November 22, 2004|by KATE COLEMAN

katec@herald-mail.com

In September, Frederick Memorial Hospital stopped offering women who have had babies by Caesarean delivery the option of having a subsequent baby delivered vaginally.

Ken Coffey, spokesman for the Frederick, Md., hospital, said the decision was based on patient safety - the safety of the mother and the safety of the baby.

As of Nov. 1, the vaginal birth after Caesarean option is no longer available at City Hospital in Martinsburg, W.Va., said Dr. Dan Jansen, chief medical officer.

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These Tri-State area health care facilities are among more than 250 hospitals in the United States that have eliminated the choice of vaginal birth after Caesarean, according to information on the Web site of the International Cesarean Awareness Network online at www.ican-online.org.

The Mayo Clinic continues to offer vaginal births after Caesarean, but Dr. Keith Johansen, head of obstetrics at the Rochester, Minn., hospital, said he expects that more community hospitals will stop offering the option.

One of the reasons can be found in clinical management guidelines issued in July by the American College of Obstetricians and Gynecologists, the Washington, D.C.-based national medical organization that represents nearly 40,000 physicians who provide health care for women.

The guidelines list selection criteria useful in identifying candidates for vaginal birth after a Caesarean. The guidelines recommend that a physician capable of monitoring labor and performing an emergency Caesarean delivery be immediately available throughout active labor. They also include having anesthesia and personnel for emergency Caesarean delivery available.

Large hospitals such as the Mayo Clinic easily meet those guidelines.

"We can go from a birthing center to operating room in less than five minutes," Johansen said. Committing staff for an event that might take 15 to 20 hours is a big issue for a small hospital, he added.

Obstetrician Dr. Sohael Raschid, president of medical staff at Chambersburg Hospital, said about 100 babies are delivered each month at the Chambersburg, Pa., facility. About 20 percent are delivered by Caesaraean sections. The vaginal birth after Caesarean option is available.

The choice is being reviewed.

"My hope is that we can continue," he said. There's a segment of the community "adamantly desirous" of the option, and not having it would be a devastating blow, he added.

There was a time when "once a Caesarean, always a Caesarean" was dominant in obstetric practice, but improvements made vaginal birth after Caesarean safer for both the woman and fetus, according to the American College of Obstetricians and Gynecologists guidelines.

The practice is not appropriate in every situation, and the professional organization advises physicians on which women are candidates for the procedure. They include women whose previous Caesarean incision was "low transverse," a side-to-side cut made across the lower, thinner part of the uterus; those who have a large enough pelvis; and women who have no other uterine scars or previous ruptures.

Nine of 10 obstetricians offer vaginal birth after Caesarean at Washington County Hospital, said Dr. V. Ashok Rangnath, chief of obstetrics and gynecology. Patients are required to sign a consent form that lists risks and benefits.

The major risk is uterine rupture, which may occur 1 percent of the time, Rangnath said. A rupture can be a "catastrophic event" for both the mother and baby, he added.

If a woman is a candidate for vaginal birth after Caesarean, in Rangnath's practice, her physician will discuss her options a couple of months before her baby is due.

"We counsel our patients to make the best decision," said Dr. David Baltierra of West Virginia University Maternal and Women's Health Center in Ranson, W.Va. Baltierra, a family physician with an obstetrics fellowship, delivers babies at Jefferson Memorial Hospital in Ranson, and vaginal birth after Caesarean is offered when appropriate.

"Everything comes down to risks and benefits," Rangnath said. He acknowledged that the high cost of malpractice insurance and the possibility of litigation factor into the decision of whether or not a physician will perform a vaginal birth after Caesarean. There have been huge advancements in obstetrics in the past 40 to 50 years, he said. "People expect perfection every time. That's not reality."

"We are always reviewing our policies and procedures," said Dr. Jean Lessard, chairwoman of obstetrics service at Waynesboro Hospital in Waynesboro, Pa. "We still offer vaginal birth after Caesarean."

The medical staff makes sure that guidelines are followed and services are offered in a safe manner. There's not one good way of determining if a repeat Caesarean or vaginal birth after Caesarean is riskier, Lessard said. The decision for each patient and her doctor is individual.

"There is no formula," Lessard said. "That's part of the practice of medicine."

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