Vaginal Delivery after Caesarean Section
Agatha M. Thrash, M.D.
Caesarean section as a method of delivering babies has become such a common procedure that in some areas one out of three babies is born by this method. Yet we know that there is a greater risk of sickness or death in both the infant and the mother when this method of delivery is used. Once a woman has a C-section, she is generally spoken of as "an obstetrical cripple," since there are some disabilities that occur in her function of having a baby at all subsequent times. If for no other reason than to avoid the section risks to subsequent babies, every effort should be made to avoid delivery by the C-section route. Physicians are properly concerned over the very high rate of C-section deliveries at the present time.
Once a woman has given birth by C-section, many obstetricians feel that all subsequent babies should be delivered by the same method. Back as early as 1916, however, there was much discussion among physicians about the desirability of delivery by the vaginal route, even after a previous C-section.
During the 1950's the "classical method" of performing the C-section was abandoned, in which the uterus was opened on the surface exposed in the abdomen. A new method was devised, that of opening the uterus low in the pelvis, a transverse rather than vertical position, so that with healing the scar would be surrounded by the normal connective tissue support of the pelvic structures. In this way, the major hazard after a previous C-section was lessened, that of rupture of the old scar with the extrusion of the baby out of the uterus into the abdomen, death of the baby from separation of the placenta, and sometimes death of the mother from hemorrhage. In the unlikely event of rupture with the new method, the "low transverse," there is usually just a slipping apart and thinning, rather than the ripping open of a seam as in the vertical incisions done high up on the uterus. In these instances, there is a long warning period of pain before the uterus actually ruptures. During this period the appropriate steps for doing a repeat C-section can easily be instituted.
More than 50% of subsequent pregnancies have been shown to be successfully delivered by the vaginal route, even though the first diagnosis was that of "cephalopelvic disproportion" (mother's pelvis too small for the baby's head). After a trial at labor, many women can demonstrate the fact that they can have a baby perfectly and normally though the pelvis that was judged at an earlier pregnancy to be too small to admit the passage of the baby.
With our improved methods of prenatal care and improved methods of instruction of women in the perinatal period, it seems unfair that more women than ever are being subjected to a mode of delivery of babies having so much danger. Babies born by the C-section route are far more likely to have hyaline membrane disease, respiratory difficulties, neurological problems, and other abnormalities.
The old medical adage "once a Caesarean, always a Caesarean" needs to be revamped. When appropriate emergency facilities are available to women who have had a previous low segment transverse Caesarean section, she should be allowed to attempt a vaginal delivery.
Other reasons for section than cephalopelvic disproportion include "abnormal pattern" of labor, prolonged labor, previous Caesarean section, breech presentation, and fetal distress. Fear of malpractice suits also figures into reasons why doctors do Caesarean sections. Many times it must be admitted, as is accused by the International Childbirth Education Association, physicians are guilty of engaging in "aggressive management" and "intervening" in the normal course of labor.
About 98% of American women who have once had a Caesarean section will be forced by their physician's choice to repeat the Caesarean with the next baby. Those who have had a low vertical or inverted-T-incision, may be considered more strongly for repeat Caesarean sections, but even they, under ideal circumstances, can be given a trial at labor and watched closely.
In order to reduce the number of C-sections that are done, a more stringent set of criteria for abnormal labor should be made. During the past decade breech babies have been born by Caesarean section increasing from 11.6% to 60%, a trend that should be reversed. Electronic fetal monitoring is being criticized in many places. As fewer women have this kind of monitoring, the section rate will doubtless diminish. If the labor is progressing well and the baby is doing well by ordinary means, the mother should have an understanding early in her prenatal care that she will not have the fetal monitor attached. Among other complaints against the fetal monitor is that otherwise normal labors are converted to C-section deliveries by unwarranted fears generated by the monitor.
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