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While it is much easier to perform a C section than successfully deliver a  breech baby vaginally, says Prof. Glezerman, many women can benefit medically by  the return to traditional techniques. "We are trying to unite obstetricians and  midwives in the field to revive vaginal delivery for breech presentations," he  notes. Prof. Glezerman's initiative provides scientific evidence to those  physicians and midwives looking to return to more traditional birth methods for  breech.

Back to the future

Prof. Glezerman says that retraining the obstetrics community in these  traditional methods is an urgent task, because the medical field now has two  generations of medical residents with hardly any training in vaginal birth for  breech deliveries. "The skill has disappeared," he explains. "Residents are no  longer taught these techniques, and senior physicians are doing it less and  less. We need to go back to the future and relearn what has been forgotten."

At the Rabin Medical Center in Israel, Prof. Glezerman runs workshops for the  newest generation of gynaecologists and obstetricians on techniques for vaginal  delivery for breech babies. His courses include techniques of breech delivery,  changing presentation from breech to head and management of different breech  presentations. With these workshops, Prof. Glezerman hopes to reintroduce  critical delivery skills into the field, and raise awareness that breech  presentation of babies does not always necessitate C-section deliveries.

Of course, says Prof. Glezerman, physicians still need to be able to  recognize dangerous risks when they arise. In those cases, vaginal delivery is  not a viable option ― but doctors must judge each situation individually.

Vaginal Birth After Cesarean is a Safe and Reasonable Option for Most Women

Redondo Beach, CA, July 21, 2010 – The American College of Obstetricians and Gynecologists (ACOG) released updated Practice Guidelines for vaginal birth after cesarean (VBAC) today. ACOG states that VBAC is a safe and reasonable option for most women, including some women with multiple previous cesareans, twins and unknown uterine scars.  ACOG also states that respect for patient autonomy requires that even if an institution does not offer trial of labor after cesarean (TOLAC), a cesarean cannot be forced nor can care be denied if a woman declines a repeat cesarean during labor.

“ACOG’s updated recommendations for VBAC are much more in line with the published medical research and echo what ICAN has stated for years .” says Desirre Andrews, President of ICAN.  “The benefits of VBAC cannot be overstated and if ACOG is truly ‘serving as a strong advocate for quality health care for women’ then this is a long overdue action on their part.”

Women’s health advocates praised the new guidelines, because they expand the pool of women considered eligible for normal births, but expressed doubts about whether the recommendations go far enough to change a decade of entrenched behavior by doctors, hospitals and insurers.

 The new guidelines, from the American College of Obstetricians and Gynecologists, replace its earlier ones — which were exactly what led many hospitals to ban vaginal birth after Caesarean in the first place. But the college says it never intended to limit women’s access to normal birth, and it acknowledges that its policies may have helped fuel the trend toward too many Caesareans.

 “It will be better for women in the long run if we can lower the C-section rate,” said Dr. Richard N. Waldman, president of the obstetricians’ group. The guidelines are being published on Thursday in the August issue of Obstetrics & Gynecology.

 About 1.4 million women had Caesareans in 2007, the latest year with figures available.

 The new guidelines go beyond the earlier ones, however, and state that vaginal birth after Caesarean is also reasonable for most women carrying twins and those who had two prior Caesareans.

 Even if a hospital does not offer trials of labor after Caesarean, the college says, “such a policy cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery.”

WASHINGTON — Most women who've had a C-section, and many who've had two, should be allowed to try labor with their next baby, say new guidelines — a step toward reversing the "once a cesarean, always a cesarean" policies taking root in many hospitals. 

Wednesday's announcement by the American College of Obstetricians and Gynecologists eases restrictions on who might avoid a repeat C-section, rewriting an old policy that critics have said is partly to blame for many pregnant women being denied the chance.

Fifteen years ago, nearly 3 in 10 women who'd had a prior C-section gave birth vaginally the next time. Today, fewer than 1 in 10 do.

WASHINGTON – Too many pregnant women who want to avoid a repeat cesarean delivery are being denied the chance, concludes a government panel that urged doctors to rethink litigation-spurred policies that have swung the pendulum back toward the days of "once a C-section, always a C-section."

Fifteen years ago, nearly 3 in 10 women who had a first C-section were able to deliver their next baby vaginally, a trend called VBAC for "vaginal birth after cesarean."

Now that rate has dropped to 1 in 10, in part because a third of hospitals and half of physicians ban women from attempting VBAC, a panel of specialists convened by the National Institutes of Health said Wednesday.

But VBAC remains a safe alternative for the right candidates, and when those women try labor, between 60 percent and 80 percent of the time they do give birth vaginally, the NIH panel concluded. It urged that doctors offer mothers-to-be an unbiased look at the pros and cons, so they can decide for themselves.

"We believe that many women should have an opportunity to give it a try," said panelist and Delaware obstetrician Dr. Nancy Frances Petit of the U.S. Uniformed Health Services.

What sparked the latest shift? It's partly concern over litigation, the NIH panel said, because while a uterine rupture remains very rare, it can be devastating to the family and end in a high-dollar lawsuit.

Case-by-case decisions are crucial, the panel said, because there may be instances where another C-section is better for the baby but not for mom or vice versa.

Who's a good candidate? The panel said that needs further study. But in general, VBAC is for women who've had one prior C-section done with a "transverse" scar, the most common kind today, said panel chairman Dr. F. Gary Cunningham of the University of Texas Southwestern Medical Center at Dallas. Women should be otherwise low-risk, he said: Not carrying multiples or a large baby, being obese or having high blood pressure or diabetes.

Delivery is generally recommended for women with severe preeclampsia, even if the fetus is at less than 38 weeks' gestation (Table 3). When severe preeclampsia is diagnosed in a pregnant woman at preterm gestation (usually <32 wk), however, an initial observation period and conservative expectant management in a tertiary care center may be attempted cautiously (Table 3).^[65,66] When eclampsia develops, expedient delivery is mandated, regardless of gestational age.

Once it is determined that delivery is required, labor induction should be performed without delay. The goals during the intrapartum period are to prevent seizures, stabilize blood pressure, and promote delivery. During labor and delivery, women with preeclampsia-eclampsia receive IV magnesium sulfate for seizure prophylaxis, usually as a loading dose of 4 to 6 g magnesium sulfate × ⁷H₂O infused for 20 minutes followed by a continuous IV infusion at 2 g/h. Because magnesium is excreted in the urine, blood levels also depend on urine output. Serum blood levels should be monitored. The therapeutic range for magnesium sulfate is generally considered to be 4 to 8 mg/dl. In a patient with elevated creatinine or oliguria, the patient's magnesium level should be followed carefully and the magnesium sulfate infusion adjusted accordingly.