Once A Cesarean Delivery, Always a Cesarean?

Cesareans differ from mom to mom, and so do the range of options you have for your second birth after a cesarean.

Just when doctors think this question has been answered for good, new research emerges to turn the medical community on its ear again.

Medical history. In the 1960s, the cesarean delivery rate was 6.6 percent. By 1978, that rate had skyrocketed to 15 percent. More than 98 percent of women who'd had one cesarean continued having the procedure with each new baby to protect against the higher risk of uterine rupture faced by women whose uteruses were scarred by prior surgery.

There were a number of reasons why the cesarean rate continued to climb: Moms and babies got bigger; multiple gestations increased in number; and breech babies were rarely delivered vaginally.

In 1988 the American College of Obstetricians and Gynecologists (ACOG) began discouraging routine repeat cesareans, saying that the risks of this elective surgery -- which include infection and increased complications for both mom and baby -- outweighed the benefits. The rationale for this advice? Despite the fact that more babies were being born by cesarean, about the same percentage died or were born brain-damaged or with other problems. This philosophy coincided with a new movement toward natural childbirth as the best choice for most mothers and babies.

For the next few years -- roughly from 1988 through 1996 -- VBAC (vaginal birth after cesarean) was very common, until large studies revealed that a small percentage (less than 1 percent) of women with a prior low-transverse scar could rupture that scar in labor. Those studies also showed that only a small percentage of those women had catastrophic outcomes for the mother and/or baby. In response the ACOG recommended that VBAC be conducted in the safest possible environment for mom and baby. This means there should be a surgical team immediately available to do a cesarean delivery and an individual skilled to attend the baby.

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