To C or Not to C

By Michele Bloomquist
WebMD Feature

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.

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."

A VBAC success

When Cheryl went into labor with her second child, the thought did cross her mind that she might still need another cesarean. But after a short labor and 45 minutes of pushing, her daughter was born vaginally without any problems. "I would recommend VBAC to anyone who wants to try," she says. "I'd choose it again in a minute."

Michele Bloomquist is a freelance writer based in Brush Prairie, Wash. She was born by elective c-section, in the days before VBAC.

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