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Once a C, Always a C?

To C or Not to C
WebMD Feature
Reviewed by Craig H. Kliger, MD

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 do."

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.

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