Once a C, Always a C?
To C or Not to C
To C or not to C continued...
The review also suggests that, while the relative risk is not
quite as high as that for uterine rupture, there is an increased risk of fetal
mortality for the trial of labor group (roughly six cases in 1,000 or 0.6%) vs.
those who got elective repeat cesareans (about three in 1,000 or 0.3%).
Because of these risks, women may opt for elective c-sections,
thinking them safer. "Doctors can talk women out of VBAC when they mention
the risk of uterine rupture. The risk has to be presented in context," says
Jean C. Hundley, MD, of WomenKind Ob/Gyn Associates at Mercy Hospital in
Baltimore. "Elective cesarean deliveries are not risk-free either. It's a
major surgery." Complications related to the use of anesthesia, infection,
accidental perforation of other structures such as the bowel or bladder, and
uncontrolled blood loss due to the severing of a uterine artery are all
possibilities with elective cesarean.
A time and place for each
As the study indicated, women considered to be in the low-risk
group have a 60% to 80% success rate with VBAC, says Michael D. Randell, MD,
FACOG, an obstetrician and gynecologist at Northside Hospital in Atlanta. If a
woman had her initial cesarean because of a one-time problem -- such as the
baby's position (feet first, for example), or placenta previa (where the
placenta obstructs the cervical opening) -- her odds of having a successful
VBAC are good.
But VBAC isn't for everyone, Randell warns. If a woman has a
very narrow pelvis, any medical or obstetrical complication that precludes
vaginal delivery, or has had a "classical" c-section where the uterus
was cut up and down vs. side to side (note that the direction of the scar on
the skin does not accurately predict the one on the uterus, and a review of the
operative report is highly advisable to confirm such a detail), a VBAC is not
recommended. Ultimately, the decision is based on weighing risks and benefits,
says Randell, and each case is unique.
Women considering VBAC also must acknowledge the possibility
that despite the trial of labor, they may need to have another cesarean. For
these women, Mozurkewich says, recovery may take longer and be associated with
a higher risk of infection and other complications than with an elective C.
"If she has the baby vaginally, her recovery will be shorter, but if she
has a failed trial of labor, she will face the recovery of both the labor and
Just as a woman has the right to choose VBAC if it is medically
appropriate, she also has the right to refuse it, says Randell. Some women just
aren't comfortable with the risks, Randell says. Others prefer to schedule the
baby's arrival, fear vaginal childbirth, or have had a previous c-section and
want to go with the known. Likewise, if a woman is not a good candidate for
VBAC, her doctor can refuse. "The goal is to have a healthy baby and a safe
delivery, by whatever method," says Hundley. "That's most