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Once A Cesarean, Always A Cesarean?

Centers for Disease Control data shows cesarean sections in Indiana at 38 gestational weeks decreased 5.6 percent from 2009 to 2011, but increased 5.9 percent at 39 weeks.

That’s because of a change in recommendations from national health and research organizations, says Dr. Brian Cook, an OB/GYN with IU Health Southern Indiana Physicians.

“The timeframe where the risk to baby has been shown to be the least is delaying elective deliveries after 39 weeks. Because of that, a lot of the repeat cesarean sections that are being scheduled are now being scheduled for after 39 weeks, so it’s taking the same deliveries and just moving them back a week or so,” Cook says.

In fact, Indiana’s cesarean rate has increased from 20 percent to 30 percent since 1997 with it starting to level off around 2008. One of the key drivers of those trends has been the recommendation that once mothers have a c-section, they should have a c-section for all subsequent births.

Doctors and health professionals began adopting that mentality in the 1970s. Their recommendations were based on the risks involved with a vaginal birth—some, like uterine rupture, were life-threatening.

Then, in 2010, the American College of Obstetricians and Gynecologists released new guidelines indicating VBACs did not pose as much risk as previously thought. That leaves both mothers and doctors facing a decision. If a woman had a cesarean once, should she automatically have one again.

Weighing The Risks Of C-Sections And VBACs

Bloomington resident Rose Stewart’s answer was no.

“My first pregnancy was a complicated pregnancy,” Stewart says. “I ended up on bed rest for several weeks toward the end of my pregnancy.”

Forty-two weeks into her pregnancy, Stewart finally went into labor with her son. But after 12 hours in labor, doctors started to look at other options.

“We started on Pitocin and that led to an epidural, and various other interventions, and ultimately I was pushing but I wasn’t making any progress,” she says.

It turned out that her son was breeched—not in the proper position for birth. So, she and her doctor decided to proceed with a c-section.

“Immediately after my c-section, I developed a fever and we ended up both on IV antibiotics, and so we were in the hospital for almost a week after my c-section. And when I got home, I would say it took good six weeks before I felt back to normal,” Stewart says.

When she became pregnant again with her daughter, Stewart had to decide whether to have another c-section or opt for a vaginal birth after cesarean (VBAC).

Stewart says she studied the risks of both vaginal births and cesareans and decided she wanted a VBAC. That did not sit well with some of her family and health care providers.

‘I felt like I got a lot of support up until about 38 weeks. Then I think a lot of my friends and family were wondering why I wouldn’t just opt to do an elective c-section. It was right around the holidays. My due date was Christmas day,” she says. “And so I think there are a lot of people questioning our decision and my care providers were supportive up until after I passed my due date, and then I did get a little bit of resistance from them.”

She persisted, and with the support of her husband, her doctors agreed to plan for a vaginal birth.

Dr. Cook was on call when she went into labor, and Stewart says he was supportive of her choice. In the end, she says, it was the best decision. Her daughter Reilly was born healthy, and Stewart says her recovery was ten times better.

“I was out of the hospital the next day. I was able to come home and sit on the floor with my son and play. It was just so much easier to recover from the vaginal birth,” she says.

How Insurance Plays A Role In C-Sections

In recent years, several hospitals around Indiana have set policies on c-sections. Many, including Bloomington Hospital, no longer allow inductions or elective c-sections before 39 weeks, except in special cases.

“There’s been tremendous effort in the state here to really look at reducing the number of early elective deliveries without a medical reason,” Indiana Perinatal Network Executive Director Larry Humbert says.

The Indiana Perinatal Network seeks to bring together health care providers, researchers and state officials to develop policies to improve women and children’s health. Humbert says guidelines on early births are a good step forward, but those making policy decisions should not stop there.

He says the policies hospitals are putting in place haven’t dropped the c-section rate overall.

One reason for that could be the role of health insurance. In the 1980s and 90s, some insurance companies wouldn’t cover vaginal births after cesarean sections, effectively dictating what kind of delivery doctors performed.

Dr. Cook says since he started practicing around 20 years ago, he’s never felt that pressure from insurance companies.

But insurance can still play a role. Humbert says insurance companies reimburse c-sections at a higher rate than vaginal births. That provides doctors with a financial incentive to perform a c-section. But he says that doesn’t translate to lower costs for the patient—when it comes to both medical bills and insurance premiums.

“If you look at it from a medical complications standpoint, if you look at it from a health cost standpoint, either short-term or long-term, I think it really does need to be done for medically appropriate reasons,” Humbert says, adding that the cesarean rate is still too high.

Cook says doctors are already having conversations about what is “medically appropriate” on a daily basis.

“We cover with them the risks associated with a vaginal delivery and the risks associated with a cesarean, because there are risks associated with both. We kind of allow them to weigh those options as well as what the success rate is with a vaginal delivery compared with a cesarean when people have had a previous cesarean,” Cook says. “Ultimately, for the most part, it’s just an individual decision on the part of the mother.”

Stewart agrees. She says every case is unique, but a vaginal birth was the best choice for her family, her daughter and herself.

“I know vaginal births are not without risks but cesareans are also not without risk, and we just felt like it was the right choice for us,” she says. “To me this is all about choice and being able to be well informed and make an informed decision about birthing options.”

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