Once a cesarean section, always a C-section?

Once a cesarean section, always a C-section?
By Julie Deardroff
Copyright 2010 Chicago Tribune
February 10, 2010
http://featuresblogs.chicagotribune.com/features_julieshealthclub/2010/02/once-a-cesarean-section-always-a-csection-.html

Once a woman has delivered three or more babies by cesarean section -- a surgical cut in the mother's abdominal wall and uterus -- doctors rarely encourage a subsequent vaginal birth.

But new research suggests that women who deliver vaginally after three or more C-sections have similar rates of success and complications as those who undergo another elective C-section, according to a study in the current issue of the International Journal of Obestetrics and Gynecology.

Of the 860 women with three or more prior cesareans, 89 attempted a vaginal birth after cesarean (VBAC) and 771 elected for a repeat cesarean. The study sample size was small because it's difficult to find women who try -- or are allowed -- to deliver vaginally after repeated C-sections.

Since 1996, VBAC rates in the U.S. have consistently declined to 8 percent. Repeat C-sections, meanwhile, have climbed by more than 40 percent according to the Agency for Healthcare Research and Quality.

Currently, women who have had two or more C-sections are only considered viable VBAC candidates if they've previously delivered vaginally, according to guidelines from the American College of Obstetricians and Gynecologists.

But a VBAC may be a reasonable option in specific cases for women who have previously had more than one C-section, said study author Dr. Alison G. Cahill, an assistant professor in the Department of Obstetrics and Gynecology and the Division of Maternal-Fetal Medicine at Washington University in St. Louis School of Medicine.

"When we looked at the safety of the women, we found none who underwent a VBAC experienced uterine rupture or the other morbidities we worry about," said Cahill, who feels it's time to revisit the current VBAC guidelines. "Given appropriate patient selection, VBAC following two or even three previous cesareans in certain cases may be reasonably safe."

Uterine rupture is a frequent concern about VBAC because a C-section delivery leaves a scar on the wall of the uterus, weakening the tissues at the incision site.

But repeat C-sections may also carry a risk of bleeding or hysterectomy, uterine infections and respiratory problems with the newborn. Multiple C-sections may be associated with placental problems in future pregnancies, according to the National Institutes of Health, which is holding a conference in March to evaluate whether VBACs should be more widely available.