Once a C, Always a C?
To C or Not to C
March 5, 2001 -- When Cheryl went into labor with her first
child, all seemed to be going well. But things changed when the baby came down
the birth canal at an odd angle, and began to show signs of distress. "Her
head was crowning, but they just couldn't get her out," Cheryl recalls. The
solution? An emergency cesarean section.
Luckily, both Cheryl and her baby emerged from the experience
healthy. But even with the joy of a new child, she admits she still had a sense
of loss. "It was like my body had failed me."
So when the Sudbury, Mass., mom became pregnant with her second
child, she weighed the risks and benefits of trying to deliver this child
vaginally. Her doctor said that, based upon her medical history, Cheryl (she
asked that her last name not be used) was a good candidate to attempt labor.
The possibility that Cheryl would again need a c-section could not be
eliminated, but she was willing to try. "It was very important to me,"
she says. "I wanted to give my body the chance to do what it was designed
To C or not to C
For decades, the old adage "once a cesarean, always a
cesarean" pretty much was accepted as medical fact, and those who
previously had given birth in such a fashion were routinely scheduled for
"elective" c-sections when delivering subsequent children. Then in the
1980s, women, doctors, and insurance companies began to question the validity
of this practice. Soon, increasing numbers of women began choosing vaginal
birth after cesarean (VBAC). But as elective c-sections fell out of favor and
more women attempted VBAC, complications such as uterine rupture -- where the
uterus tears at the point of the previous scar under the pressure of
contractions -- began to surface. Once again, doctors and patients questioned
whether VBAC was a safe choice.
But a recent review of 15 previous studies, done over the last
decade, suggests that low-risk mothers-to-be needn't agonize so much over the
decision. The review, published in the November 2000 issue of the American
Journal of Obstetrics and Gynecology, "was motivated by growing
controversy over a question that we had believed to be settled," says Ellen
Mozurkewich, MD, a fellow in the Division of Maternal-Fetal Medicine in the
University of Michigan Health System, and co-author of the analysis.
"There seem to be significant benefits to the mother from a
trial of labor," Mozurkewich tells WebMD. "But there may also be a
small, increased risk to the baby." In the review, University of Michigan
and University of Toronto researchers looked back at data that documented the
outcomes of nearly 48,000 women who had had babies after a previous c-section.
While the rates of uterine rupture were twofold higher in the women who
attempted VBAC, the review suggested that overall, the risk was low -- roughly
four in 1,000 (0.4%) trials of labor resulted in uterine rupture vs. two in
1,000 (0.2%) for elective repeat cesareans. Yet if uterine rupture does occur,
it can be catastrophic -- the baby must be delivered by emergency c-section
within about 18 minutes to avoid neurological damage or even death.