Prior C-section raises risk of complications with home birth
The finding stems from an analysis of roughly 2.4 million full-term births between 2007 and 2013. Of these, about 4,500 were midwife-assisted deliveries in a home setting.
The study found that home births among women with a history of C-section were associated with a greater risk for stillbirth and/or neurological complications in the baby.
"It's rare," acknowledged study author Dr. Amos Grunebaum, chief of labor and delivery at New York-Presbyterian Hospital/Weill Cornell Medical Center in New York City. "But when it happens, it's devastating. And in a hospital, a cesarean is available very quickly, to save the mother and the baby. That's just impossible at home."
Grunebaum presented the findings Saturday at the American Congress of Obstetricians and Gynecologists (ACOG) annual meeting in Washington, D.C. Research presented at meetings is considered preliminary until published in a peer-reviewed journal.
ACOG's current advisory states that "hospitals and birthing centers are the safest setting for birth," while acknowledging that women have the right to make their own medically informed decision about where to deliver their baby.
Still, home birthing remains the exception to the rule. But U.S. birth certificate data published earlier this year indicated that the number of babies born outside a hospital setting increased from less than 1 percent in 2004 to roughly 1.5 percent by 2014.
Dr. Evan Myers, a professor of obstetrics and gynecology at the Duke University School of Medicine in Durham, N.C., noted that a century of obstetric advances has made childbirth an increasingly safe experience, regardless of locale.
But, "women who have had a previous cesarean have a scar on the uterus that is at risk for rupture during labor," Myers explained. "It's still a low risk. But if it happens it can be very bad for the baby, and potentially for the mother as well, and you do want to be prepared."
To explore the issue, Grunebaum's team sifted through birth certificate data collected by the U.S. Centers for Disease Control and Prevention.
All the infants were carried to term, meaning 37 weeks or more, and all had a "normal" birth weight, meaning at least 5 pounds, 5 ounces.
All also underwent an Apgar exam at birth. This is a standard test—graded on a scale of 1 to 10—that assesses a newborn's breathing capacity, heart rate, muscle tone, reflexes and skin color. A score of 7 or higher is considered a sign of good health. Babies who are not breathing and have no heartbeat are given a score of 0.
The investigators determined that the risk for an Apgar of "0" was rare, but higher, in a home birth setting. Similarly, the risk that a newborn would experience a seizure or serious neurological complication was higher among home births.
Why? Grunebaum and his team said that a lack of adequate fetal monitoring in the home is part of the problem, as is the inability to quickly perform an emergency C-section when needed.
"Every woman has to decide for herself on the place of delivery," stressed Grunebaum. "All I can say is that we must advise women that there is a significantly increased risk from home delivery, and therefore we don't recommend that she do so."
Marlene Goldman is director of the division of clinical research in the department of obstetrics and gynecology at Dartmouth-Hitchcock Medical Center in Lebanon, N.H. She agreed that "the risks to mother and baby in this [home birth] situation outweigh the benefits."
For those intent on a home birth, Goldman said having a back-up plan that provides for emergency transport to a hospital "would be advisable, but probably too late" to be of help.
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