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.
What's right for you? Are you a good candidate for a VBAC, or should you schedule a repeat cesarean delivery? First, you must know what kind of uterine scar you have. You are not a candidate for a vaginal delivery after a cesarean delivery if you had a high vertical incision on your uterus. Always ask your prenatal provider what type of scar you have because the scar you see on your skin may not be a reflection of the scar on your uterus. Like all of your medical decisions during pregnancy, this is one where it pays to be informed about your provider's philosophy and birth facility.
It might seem simpler to elect a cesarean and be done with it. After all, you can pick a convenient date and have pain medication, and that's what the guidelines suggest, right? Well, it's not that easy. A cesarean delivery is safer now than ever before, yet it's still a major surgery. Operative complications might include a risk of injury to other organs, blood clots in the legs or lungs, infection, excessive blood loss, and complications from anesthesia. In addition, healthy babies born by cesarean are more apt to need admission to intensive care units for various reasons, and moms who give birth by cesarean may have more challenges breastfeeding.
A VBAC does pose a greater risk than a vaginal birth for a woman who has never had a cesarean, but that risk is small if you're a healthy woman with an uncomplicated pregnancy. The risk of uterine rupture at the site of your previous cesarean scar rises slightly if you have your labor induced. When prostaglandins (medications used to prepare the cervix for delivery) are used, there's a higher risk of a uterine rupture, in which case you'll need an emergency cesarean. However, Pitocin (it's like oxytocin, which your body produces naturally) is sometimes used to strengthen contractions; it doesn't increase the risk of uterine rupture.
Even though the risk is low, many practitioners won't support a VBAC delivery without easy access to good emergency care both by a physician and anesthetist.
Still, about 60-70 percent of women who get support and care during a VBAC have successful, uncomplicated vaginal births. So it's worth seriously considering a vaginal birth if you've had a previous cesarean. You're a good candidate if the following is true:
- Your previous cesarean delivery was performed with a low transverse incision.
- Your pelvis is adequate, and you have no other uterine scars or previous uterine rupture.
- You are giving birth in a place where you have rapid access to an emergency cesarean if labor fails.
- Your labor has begun spontaneously and you are already dilated when you arrive at the birth center or hospital.
Originally published in You & Your Baby: Pregnancy.
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