The Doctors Next Door

Is Repeat Cesarean Section Really the Safest Option?

I'm so glad I had my children before C-Section rates escalated.  Taking in my petite frame while laboring with my 6 lb 14 oz first child, the nurses were taking bets on whether I'd "go to section".  Thankfully they didn't let me in on this little game of theirs until later.  Even more thankfully, I had a doctor with patience.

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They told me if he had weighed just one more ounce, I never would have squeezed him out.  

"Giving birth is like taking your lower lip and forcing it over your head."
Carol Burnett

Then came my six hour labor for 8 lb 9 oz baby number two and my three hour labor for 9 lb baby number three - all without the aid of surgical intervention.  I decided to stop testing my luck at 9 lbs.

C-section rates increased from just 5% in 1970 to 31% currently.  The rates jumped a shocking 53% between1996 and 2007. If I had a C-Section with baby number one, in the first part of this 21st century, in all likelihood, I would have had a neat little repeat C-section for each of the others. Did God release a flawed version of the "female pelvis 2.0" in 1995? Probably not. Under current policies, according to Dr. Caroline Signore, among women who have had one C-section, "more than 90% will have Cesarean deliveries for any other children that come later."

But hang on ladies, there's good news! The pendulum is swinging back!

In a recent consensus conference, the National Institutes of Health examined the safety and outcome of trial of labor after cesarean delivery (TOLAC) and vaginal birth after cesarean (VBAC) and looked at the factors associated with the plummeting rates of both.

The biggest issue is that TOLAC and VBAC present a very small risk of a serious complication called uterine rupture. Uterine rupture is an emergency situation that causes risk of harm to both the mother and child. Fortunately, its rate is low at 0.5 -0.9% of TOLACs.  However, that was just too much for our malpractice environment so hospitals and insurance companies started implementing policies that made it more difficult to perform VBAC's or TOLACs.

Well as the NIH has revealed, despite the overblown perception of uterine rupture risk, most of the complications that occur during TOLAC occur when repeat cesarean delivery becomes necessary. So a successful VBAC is associated with fewer complications than a failed TOLAC. Most published research on TOLAC have demonstrated a probability of successful VBAC at 60-80%. Not bad at all.
So ACOG has now revised their guidelines on whether women should be given a trial of labor after C-section.  One of our own Chicago doctors, William A. Grobman, MD, from Northwestern University is co-author of the Academy of Obstetrics and Gynecology Practice Bulletin.  Here are their key recommendations:

  • Most women with one previous cesarean delivery with a low-transverse incision [the usual type of incision done these days] are candidates for and should be counseled about VBAC and offered a TOLAC.
  • Women with two previous low-transverse cesarean incisions and women carrying twins should be offered TOLAC.
  • After counseling, the ultimate decision to undergo TOLAC or a repeat cesarean delivery should be made by the patient in consultation with her healthcare provider.

As Obstetrics and Gynecology Editor in Chief, Dr. James R. Scott states in his accompanying editorial, "Currently, hospitals, insurance companies, and plaintiff attorneys decide or strongly influence whether VBAC is an option...Standards of care should be based on medical evidence, not patterns of litigation."

Attempting vaginal delivery after a C-section is not risk-free, but neither is repeat C-section or childbirth in general, experts stress. For both TOLAC and repeat C-section, there are risks for extensive bleeding, blood clots, infection, potential for an emergency hysterectomy and even death. And while a failed attempted at a vaginal delivery after a C-section can introduce serious health consequences, a successful vaginal delivery after C-section generally has fewer complications than an elective repeat C-section, according to the ACOG guidelines.

Finally, Dr. Scott hits the nail on the head when he says

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"...attempts to increase the VBAC rate make little sense without addressing the reason for the problem in the first place. Reducing the number of primary cesareans deals with the problem where it originates."



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