Once a C-section, always a C-section?

Q: My first child was delivered vaginally. My second was breech and had to be delivered by Cesarean section. I am about to give birth to my third. Should I deliver this one vaginally?

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A: Probably. But there are several factors to consider before making a choice between C-section and a vaginal birth after C-section (sometimes known by its shorthand name as a VBAC).

The dictum used to be “once a C-section, always a C-section.” Doctors worried that the forces of labor and vaginal birth could cause rupture and hemorrhage in the weakened area of the uterine scar.

Now, studies show this risk is small. A greater risk — but still a small one — is that of harm to the baby.

In the 1980s, the National Institutes of Health recommended that women be encouraged to deliver vaginally after a C-section. By 1996, almost a third of women with a previous C-section went on to have a vaginal birth. But the rate fell, and is now around 13 percent.

The latest study
Two weeks ago, a helpful article appeared in the New England Journal of Medicine. It reported on 33,000 women at 19 medical centers, divided into those attempting VBAC and those having an elective Cesarean. All had singleton births, not multiples. Women with clear indications for a C-section were excluded.

In the women attempting VBAC, the success rate — births without complications that required another C-section — was almost 75 percent. Success was greater in women with a prior vaginal delivery or a prior successful VBAC. In addition, the successful women tended to have relatively small babies and only one prior C-section.

The risk of uterine rupture was a very low 0.7 percent. For the mothers, there was no increase in the number of deaths, uterine infections, blood transfusions and frequency of hysterectomy. But for the babies, there were two deaths and 12 cases of brain damage from lack of oxygen. There were no such cases for the babies delivered by C-section.

This meant there was one poor outcome for every 588 deliveries. In other words, if you attempt a VBAC instead of another C-section, you are taking a 1-in-588 chance that this could cause significant problems for your newborn. (This compares with a 1-in-2000 rate for vaginal deliveries that do not come after a C-section.)

VBAC vs. C-section: The pros and cons
There are some benefits to vaginal delivery, including faster recovery and the elimination of guesswork. (If the delivery date is off, the baby may be premature.) Of course, there are some downsides to vaginal delivery, including the risk of urinary incontinence.

With each C-section, you do increase the risk of complications in later pregnancies: placenta previa, (a low-lying placenta, which covers the cervix) and placenta accreta (a placenta abnormally attached to the uterine wall.) Both can cause bleeding.

Each woman must decide for herself whether a small risk to the baby is worth the potential problems of recovery from abdominal surgery and risk to future pregnancies. One decision does not fit all women and all situations.

Dr. Reichman’s Bottom Line: Despite considerable publicity to the contrary, a vaginal delivery after you’ve had a C-section could well be an appropriate choice. It’s a topic you should discuss with your doctor. In addition, if you decide to attempt VBAC, do so with a physician at a hospital where an emergency C-section can be performed.

Dr. Judith Reichman, the “Today” show's medical contributor on women's health, has practiced obstetrics and gynecology for more than 20 years. You will find many answers to your questions in her latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," published by William Morrow, a division of HarperCollins.

PLEASE NOTE: The information in this column should not be construed as providing specific medical advice, but rather to offer readers information to better understand their lives and health. It is not intended to provide an alternative to professional treatment or to replace the services of a physician.