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Vaginal Birth After C-Section: Risk Low

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May 21, 2002 -- You've had a C-section. Now you're pregnant again and want to try normal delivery. What should you do?

For most women, the surprising answer is this: decide for yourself. There are many things to consider. One of them is the latest report in the Journal of the American Medical Association by Gordon C.S. Smith, MD, PhD, of England's Cambridge University.

Smith and colleagues find that the risk of a baby dying during labor is very low: a little more than 1 in 800. But that same study shows that the risk is 11 times lower if the mother plans -- and has -- a second C-section. The risk that the mother will die during labor is also very low (less than 1 in 2,000), but it's eight times higher than if she had a planned C-section.

What does all this mean to a pregnant woman?

"The absolute risk [of vaginal birth after C-section] is low," Smith tells WebMD. "I don't want this to worry women. It is a very small risk of death. However, there is no way of getting around the fact that a planned C-section is a very safe way to have a baby. If the prime intent is to avoid risk to the baby -- and further pregnancies are not being considered -- then a second C-section may be the best way to go."

Even this cautious opinion is not held by all experts. Lisa Paine, DrPH, is a certified midwife and past chairwoman of the department of maternal and child health at Boston University.

"For a woman coming in the office, [the Smith study] is one piece of information. But the woman's decision will not rest on these findings," Paine tells WebMD. "The woman's own situation and family and feelings about things has to be taken into consideration. Other issues are the consequences of a planned cesarean."

Paine maintains that natural childbirth and a C-section are not two different ways of doing the same thing.

"We are comparing apples and oranges, vaginal birth vs. C-section," Paine says. "For the woman, it is the difference between the experience of serious abdominal surgery and the experience of normal vaginal birth. So what people should ask is, 'What are the expected outcomes of these two events for the mother, for the child, and for the family? What are the benefits, the risks, and the personal preferences?'"

An editorial accompanying the Smith study notes that there is no way for doctors to know exactly which women will succeed at vaginal birth following a previous C-section.

"Only the patient can assess those relative values," writes W. Benson Harer Jr., MD, of Riverside County Regional Medical Center in Moreno Valley, Calif. "Unfortunately, clear high-level scientific evidence to guide the decision is lacking. ... There is increasing demand for cesarean delivery by women who must live with the consequences of adverse outcomes [of vaginal birth after C-section]."

Harer suggests that it is doctors' response to this increasing demand for safer delivery that is behind the current U.S. increase in C-sections.

Other experts disagree, saying that not enough emphasis has been put on the risks of C-sections. One is certified midwife and epidemiologist Mary Barger, MPH, of Boston University.

"The biggest issue for me is when repeat C-sections go up, so do first-time C-sections," she says. "It wouldn't be such a big deal if we were keeping the first-time rate low -- but that is not happening."-->

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