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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 the cesarean."

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 important."

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