Once a C-Section, not always a C-Section

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star-sponsored-native The following article is sponsored by University of Utah Health Care.

Once upon a time in the world of maternal health, most doctors believed that women who had delivered babies through the surgical procedure known as a Cesarean section had sealed their fate for any future births.

“For a long time, it was once a C-section, always a Cesarean delivery,” says Jessica Pittman, M.D. an obstetrician and gynecologist at University of Utah Health Care.  “That has changed.”

Increasingly doctors now think that VBAC —or vaginal birth after Cesarean — is a reasonable option for many women, despite some slightly elevated risks.

“We’ve really tried to swing the pendulum,” Pittman says.

Cesarean birth can be a necessary and life-saving procedure if a vaginal delivery would put either a mother or baby’s life or health at risk. The procedure is commonly used when fetal monitoring shows a baby has signs of distress, with concerning fetal heart rate changes, or when a baby is too large and labor isn’t progressing or when the birth involves multiple babies.

Health concerns for women, like diabetes or high blood pressure can also contribute to the decision to use the procedure, although it is also sometimes used simply for reasons of parent choice or convenience, despite the significant risks that surgery can present.

Doctors have watched with concern for decades as nationally, the rate of Cesarean births has steadily risen —from about 5 percent in 1970s to nearly 33 percent in 2012, data from the National Institutes of Health shows. Utah’s rate is slightly lower than the national average. In 2011, according to information from the state health department, about 23 percent of babies were delivered by C-section.

But national data also shows that between 60 to 80 percent of women who attempt VBAC are successful, Pittman says. That data, along with relatively new recommendations from an NIH study group, has prompted more doctors to encourage their patients to consider the option.

“Neither having a Cesarean or under going a trial of labor after a C-section are without any risk,” says Pittman. “But the risks are low, so I think it’s something to talk about and an individual decision between a patient and her doctor.”

From a patient perspective there are good reasons to attempt a vaginal birth. Those include shorter hospital stays, faster recovery, lower risk of contracting an infection of the uterus and a reduced chance of the need for a blood transfusion.

But before a definitive birth plan is made, Pittman works through a series of questions and considerations with her patients as part of early prenatal care. Among her questions for patients: What were the reasons or conditions that made the prior Cesarean necessary?

“Sometimes there may be non-recurring indications – maybe the first baby was breech – that might not happen again in another pregnancy,” Pittman explains.

Another consideration: What are a patients expectations or ideas about family size?

“If they want a larger family size, then we definitely encourage them to consider a trial of labor because with each subsequent Cesarean delivery there is an increased risk of complications for both mom and baby,” Pittman says.

A patient’s plan for labor and delivery are also important, she says. Patients attempting VBAC will be closely monitored for problems that might necessitate another Cesarean, so it’s good to choose a hospital capable of providing emergency-level care if it’s needed, Pittman says.

One very real concern for women considering VBAC is the chance of a uterine rupture. C-sections performed with a so-called “classical” incision (up and down the uterus) present higher risk than if the procedure was done with a transverse incision — which cuts across the organ.

“The scar is a weaker area and there’s a chance that it could separate during labor,” says Pittman. “But, again, that risk is low, about 1 percent with a low transverse incision. Still we keep in mind the type of prior uterine incision when counseling patients if VBAC is an option for them. “(Moms) are monitored closely during labor and we have a low threshold for changing plans if there’s thought to be any concern,” she says.

Of course, babies come when they come, so Pittman says that even women who might be considered less successful candidates for VBAC could try to deliver without surgical intervention if they present in advanced labor and seem to be doing well.

Of course, the ultimate goal is always to have healthy moms and babies at the end of the process, Pittman says.

“So even though it’s something that has a potential for risk, if a patient desires a trial of labor after cesarean section she should have a conversation with her provider to determine if she is a candidate for VBAC.”

3 comments

  • Jo Ann

    Please consider this very carefully! We almost lost our youngest daughter and myself because of a uterine rupture due to a previous c-section. It may be rare, but it does happen. Yes, weigh the options, but erring for safety may be what keeps you and your baby alive!

    • Andi

      You have just as much risk-in some cases more-of losing your own life or other serious complications during major abdominal surgery. To say undergoing surgery is ‘erring for safety’ is just not true. Doctors just never discuss the actual risks involved in repeated c-sections. The risk of uterine rupture is .8-.9%; the risk of a catastrophic rupture is around .2%.

    • Carolyne

      Jo Ann I am so sorry to hear you experienced rupture – I did too, and my son did not survive. I’m a member of a rupture support group on facebook that you would be welcome to join. I thought this was a very balanced article but when you are on the wrong side of the statistics (1/200 sounds far worse than 0.5%) it’s tough to be told how rare rupture is. Andi, it would have been nice for you to offer Jo Ann your condolences first. The sad reality is that statistically VBAC is still more risky for baby (in terms of mortality and morbidity) than RCS, but yes RCS carries its own risks for mom too. It definitely has to be a very individual decision and of course one – as this article emphasizes – that has to be made in conjunction with your doctor. Setting is also very important, that 1/200 risk for TOLAC if done during an attempted homebirth, means almost certain death for baby because of the short time available for intervention which is impossible to achieve once transfer is figured in.

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