Once a Cesarean, Always a Cesarean?
In the 1970s, when the cesarean section rate tripled, the medical mantra was "once a cesarean, always a cesarean." These days, most women who have had at least one child delivered by C-section will have to decide whether to try to deliver a subsequent child vaginally. This is a decision colored by a complex set of factors, including:
What makes the decision more complex is the fact that obstetrics professionals are struggling with the issue themselves.
Reducing the C-section Rate
Cesarean section—delivery of a fetus through the abdominal wall and uterus—is considered major surgery. Blood loss during a C-section is much greater than with vaginal delivery, and the risk of serious complications like hemorrhaging and infection are also greater. Because it is not clear whether all these cesareans are necessary, the United States Department of Health and Human Services has set a goal to lower the rate.
Looking at VBAC
Having a vaginal birth after a C-section (VBAC) is an area that researchers have been investigating. What are the benefits and risks? Some studies have concluded that there is not enough evidence to come up with a clear recommendation. Other studies, like the one published in the American Journal of Obstetrics & Gynecology, which included almost 17,905 successful VBACs in 24,349 women, found that VBAC is as safe as a planned C-section. Nevertheless, there are risks involved with VBAC.
Women who have a vaginal birth after C-section may have a higher risk of uterine rupture. Uterine rupture may put you and your baby at risk of harm including death, and may lead to an emergency hysterectomy. This complicates a mother’s recovery and can put an end to her childbearing—a consequence that may be considerably less likely after C-section.
Examining the Reason for C-sections
The reason a woman had a cesarean in the first place often influences, or even dictates, her decision about a trial of labor for her next delivery. For example, women who undergo C-sections after long and difficult labors that did not progress may face similar difficulties with subsequent deliveries. Some of these women will choose to deliver a subsequent baby by C-section, especially if their obstetrical consultant believes the pelvis is unfavorable for vaginal birth.
C-section may be “scheduled” or “unscheduled.” A scheduled section is planned in advance. The reasons for scheduled cesareans can include:
Reasons for unplanned or emergency cesareans include:
Getting the Experts' View
The American College of Obstetricians and Gynecologists (ACOG) feels that women who meet the following criteria are candidates to try VBAC:
ACOG also specifies that whenever a woman is planning VBAC, a surgical team should be on hand in case an emergency C-section is necessary. In some healthcare settings, the lack of such a team would rule out any trial of labor for a VBAC.
The American Academy of Family Physicians (AAFP) largely agrees with ACOG, but does not agree on the necessity for an on-hand emergency surgical capability. Instead, they recommend that an explicit emergency management plan be developed for all women given a trial of labor after cesarean (TOLAC). This plan should be documented, presumably in the medical record. Risks should be discussed at length with women so that they can make a clearly informed consent.
AAFP emphasizes that certain factors (aged under 40, prior vaginal delivery—especially successful VBAC, obstetrically “favorable” cervix, spontaneous labor, and indication for cesarean that is unlikely to recur) make VBAC more likely after a TOLAC. They also indicate factors making successful birth less likely: gestational aged over 40 weeks, birth weight over 4 kg, and need to induce or augment labor.
Making an Informed Decision
It is possible to have a vaginal delivery after having had a cesarean section. However, you should work with your healthcare provider to determine which option is best for you given your prior and current health history.
American College of Obstetricians and Gynecologists
The Canadian Women's Health Network
The Society of Obstetricians and Gynaecologists of Canada
SOGC Clinical Practice Guidelines. Int J Gynaecol Obstet. 2005;89:319-331.
Rossi AC, D'Addario V. Maternal morbidity following a trial of labor after cesarean section vs elective repeat cesarean delivery: a systematic review with metaanalysis. Am J Obstet Gynecol. 2008 Sep;199(3):224-31.
Trial of labor after Cesarean (TOLAC), formerly trial of labor versus elective repeat cesarean section for the woman with a previous cesarean section. American Academy of Family Physicians website. Available at: http://www.aafp.or... . Published March 2005. Accessed June 28, 2012.
Trial of vaginal birth after cesarean (VBAC). EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed/what.php . Updated April 19, 2012. Accessed June 28, 2012.
Vaginal birth after cesarean section. American College of Obstetricians and Gynecologists website. Available at: http://www.acog.org/~/media/For%20Patients/faq070.pdf . Accessed June 28, 2012.
Last reviewed September 2012 by Brian Randall, MD