Vaginal birth after cesarean or repeat cesarean section: medical risks or social realities?

Article Abstract:

The use of cesarean delivery increased in the 1970s. It was commonly believed that once a woman had a cesarean, all subsequent deliveries had to be by cesarean as well. This recommendation was based on the premise that the uterus that was scarred by cesarean incisions was at risk for rupture if labor was allowed to proceed. However, recent studies have indicated that the risk of rupture is low and the success rate for vaginal delivery is high after previous cesarean section. In an effort to reverse the trend toward unnecessary cesarean sections, many patients with a previous history of cesarean delivery are now offered a trial of labor and the option of a vaginal delivery if certain criteria are met. The American College of Obstetricians and Gynecologists recommends that a woman who has had a low transverse incision should be encouraged to delivery vaginally. However, a 1987 report found that despite the safety and success of vaginal birth after cesarean (VBAC) most women still have subsequent cesareans, and in half of the cases VBAC is not even offered. The reasons why VBAC was not chosen were investigated by sending a questionnaire to 257 women who had had a cesarean delivery and who received their prenatal care from either a private physician or hospital-based clinic. Of the 160 who responded by returning the questionnaire, 53 stated that they themselves were the primary decision-makers about the delivery. However, their decision was also influenced by the opinion of their husband or partner. Women delivering at a public hospital were more likely to be influenced by the physician than women delivering at a private hospital. The main reasons why women chose a VBAC were the longer recovery time after cesarean section, and wanting the experience of a vaginal birth. The most common reasons why women chose repeat cesarean section were that they knew what to expect, they wanted to avoid the pain of labor, and they liked the convenience and timing of the delivery. Social needs were more important in making VBAC decisions than the medical risks involved. It was not possible to tell how well-informed the patients were in this study. To help patients understand the medical probabilities and to help the physicians understand the patients' social requirements, counseling should begin after the first cesarean delivery. Since the physician plays a primary role in delivery decisions, it is suspected that VBAC has not been successfully promoted. (Consumer Summary produced by Reliance Medical Information, Inc.)

Methods, Management, Complications and side effects, Childbirth, Delivery (Childbirth), Cesarean section, Vaginal birth after cesarean

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The women's health care component of the Oregon Basic Health Care Plan

Article Abstract:

Oregon's health care plan was an outgrowth of a legislative decision to allocate money for prenatal care rather than to spend the money on a bone marrow transplant for a child with leukemia. Thus, the plan had its roots in women's health care. The plan, which was denied implementation by then-President Bush's administration, sought to make health care more accessible to the unemployed and working poor. Health services were ranked from most to least important by a system that included community input. The number of services to be funded was determined by economic constraints. Services and procedures below a certain cutoff point would not be funded by the plan. Implementation of the plan was denied by the Bush administration on the grounds that it violated the Americans with Disabilities Act. The use of the term "quality of life" in interviews to assess the importance of various services was felt to discriminate against persons with disabilities.

Laws, regulations and rules, Social policy, Women's health services, Health care reform, Oregon

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Friends in need: presidential address

Article Abstract:

The president of the Pacific Coast Obstetrical and Gynecological Society discusses the images of physicians in the literature, from the novel Middlemarch by George Eliot to the House of God by Samuel Shem. He believes the idea of a covenant between doctor and patient may be the best role.

Physician and patient, Physician-patient relations, Speeches, lectures and essays

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