Once a C-Section, Always a C-Section?

After having a caesarean section, why few women have a subsequent vaginal birth
A baby being delivered via caesarean section (Jorge Cabrera/Reuters)

Every third woman who goes to the hospital to have a baby will likely have a C-section.

After a few days of recuperation, she will leave with her new baby, her new scar, and her chances of safely having more than two children greatly diminished.

C-section rates have skyrocketed in the last two decades. These costly and invasive surgeries, once rarely done, are now routine with a third of all births resulting in the procedure. Of those, nearly half are repeat C-sections.

This is based in large part on the fact that for almost two decades hospitals have refused to let women attempt natural labor after a C-section, based on recommendations from the 90’s by the American College of Obstetricians and Gynecologists (ACOG) restricting the practice. Hospitals held so steadfastly to these guidelines that the C-section rate went from 20 percent in 1996 to 31 percent by 2006. In other words, once a C-section, always a C-section.

But in 2010, ACOG eased restrictions, giving the green light to trial of labor after a C-section (TOLAC) and vaginal birth after a C-section (VBAC). The result? The C-section rate went up, from 32.4 percent to 33.7 percent where it's holding steady.

There are incentives for doctors and hospitals to perform C-sections. They’re faster, bring in more money, and present a lower risk of lawsuit. But now that natural birth after a C-section is considered okay, there are roadblocks.

"You can't pin it on one thing. It's so multifactorial," said Whitney Pinger, director of midwifery services at George Washington University and a member of the American College of Nurse-Midwives. "There's no one thing to blame, there's no one person to blame, there's no one provider to blame. We are all in this together, we got ourselves into it as a society. "               

Back in the late 1960s, C-sections accounted for about 2 percent of births. When they were performed, it was because the health of the mother or baby or both was in danger. By 1970, fetal monitors were all the rage, and with them every blip the baby experienced was broadcast for all to analyze. It was also around this time that doctors stopped doing vaginal breech deliveries—that is, allowing a woman to deliver a backwards baby vaginally—and forceps deliveries also fell out of fashion. With these changes, the C-section rate rose to 5 percent in 1970. By 1996, that number had jumped to 28 percent. But the number of VBACs also rose and reached an all-time high of 28 percent by that same year.

There are risks inherent to both VBACs and C-sections. The one that most people worry about with VBACs is uterine rupture. This happens when there is a tear in the uterine wall, usually at the site of a previous C-section scar. This can lead to extensive bleeding for the mother and oxygen deprivation for the baby. When this happens, the woman has to have a C-section before the oxygen loss causes brain damage to the baby, said Barbara Levy, vice president for health policy at ACOG.

Statistically, when women attempt labor with one previous C-section, rupture happens in about 7 to 9 women per thousand. That number goes up to between 9 and 11 per thousand for women attempting natural birth with two or more C-sections. So uterine rupture does happen, but with those numbers, it's considered a rare occurrence. It also happens during repeat C-sections, to 4 or 5 women per thousand.

That said, by 1996, VBACs were happening a lot, which in turn meant uterine ruptures were happening more often. In response, ACOG issued a series of increasingly restrictive recommendations regarding VBACs.

"It's all about safety," Levy said of why the more restrictive guidelines were issued. "When you think about it, if the result is life-long brain damage to a child, who is willing to take that risk? Even if that risk is one in a thousand, not one in a hundred, can we—knowing that that is a risk--put policies and procedures in place that don't obviate that risk? And I think that's the fundamental issue. Who is going to take that liability?"

The guidelines, in essence, said hospitals offering VBACs needed to have a physician available who was capable of performing a caesarean "immediately," as well as 24/7 in-house anesthesia.

"I'm not someone that would have said there were restrictions on VBAC," said Jeffrey Ecker, speaking of the guidelines. Ecker is a high-risk obstetrician at Massachusetts General in Boston and a member of ACOG. "But as you've probably gathered, a lot of the focus was around the language of what resources needed to be available and specifically, 'immediately' available for women undergoing a trial of labor. And it was that I think that drew the label of restricting VBACs."

Ecker may not think the guidelines were restrictive, but they certainly had an effect on the majority of the hospitals in the country. Between 1996 and 2010, the C-section rate went from 21 percent to 32.8 percent and the VBAC rate dropped from 28 percent to 8 percent.

In 2010, ACOG changed the guidelines again.

"[The 2010 ACOG report] still says ACOG thinks that immediately available is safest," said Ecker, who helped write the 2010 report. "But it recognizes that 'safest' is a relative term, and that places that don't have [anesthesia and surgeons] immediately available shouldn't necessarily bear the label of unsafe."

One of the biggest reasons for this clarification was the growing push by entities like the National Institutes of Health—which had released its own change of heart about TOLACs earlier in 2010—to reduce the number of C-sections nationally. Overall, C-sections are safe. However, they have risks, and the risks increase with every C-section. Women who've had multiple C-sections are at greater risk of complications like placenta previa, where the placenta covers or blocks the cervix; placenta accrete, where the placenta implants too deeply in the uterine wall; and placenta abruption, where the placental lining pulls away from the uterine wall. All of these conditions can cause massive hemorrhaging, the need to remove the uterus, and even death in severe cases.

A 2006 Robert Wood Johnson Medical School study found that pregnancy after a caesarean delivery was associated with increased risk of placenta previa, about 6.3, per 1,000 births, compared with a post-C-section vaginal delivery, which had a rate of 3 per 1,000. The study also found that two C-sections doubled the risk of placenta previa and was associated with a 30 percent increased risk of placenta abruption in the third pregnancy. In other words, after two C-sections, more children becomes a risky proposition.

"The risk of rupture or having to do a hysterectomy are also incredibly low numbers," Levy said. "So really it's just a question of the magnitude of the risk. It's a very low risk if you're only going to have two children and they're both by C-section. If you're planning on six children that's a different issue and a higher risk."

Since the release of the 2010 guidelines, no national statistics show the number of hospitals doing VBACs. However, the findings of a 2012 study by researchers at the University of California, San Francisco show trends in California birthing hospitals.

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Melanie Plenda is a writer based in New Hampshire.

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