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Vaginal Birth After Cesarean: New Data to Aid Decisions
During a cesarean section an infant is delivered by cutting through the mother's abdominal wall and then cutting into the uterus right underneath and delivering the baby through the incisions. Once a woman has had a cesarean, she is often counseled not to attempt vaginal delivery for any future pregnancies.
That picture is likely to change somewhat, thanks to a Practice Bulletin published in the August issue of Obstetrics and Gynecology by the American College of Obstetrics and Gynecology.(1) The bulletin provides doctors with clear guidelines for what needs to be considered when weighing the trials of labor and vaginal delivery and risk of C-section following Cesarean section.
The decision to perform a caesarean may be made at the beginning or during labor if it appears that proceeding with a vaginal delivery will be risky to the baby or mother. Or, they may be planned well in advance of labor.
There are many reasons for emergency cesareans. The baby may be too large to pass through the birth canal; there may be an abnormality of the placenta which may cause excessive bleeding or loss of blood supply to the baby or mother; the baby's heart rate may have become abnormally low and doesn't improve with normal measures; there may be a risk of infection. There are other reasons as well.
Cesarean sections may also be planned ahead of time because of pre-identified risk factors that make a vaginal delivery dangerous for the mother or baby. Another common reason for a prescheduled cesarean section is that the woman has previously delivered an infant by C-section.
This last reason – a previous C-section automatically pre-determining that a mother's future births will also have to be by that method – has been controversial. The medical community has had widely varying opinions as to the safety of a normal labor and vaginal delivery once a woman has had a cesarean. And it is this issue that the recent American College of Obstetrics and Gynecology Practice Bulletin addresses.
The main concern regarding vaginal delivery after a C-section has been that once the uterus has been cut open and repaired, it may not be able to withstand the strong contractions that occur during labor. Either the labor may be ineffective, or the uterus may actually rupture during the birth process, a potentially catastrophic outcome for mother and infant.
But on the other side of the issue, C-sections also pose certain risks for mothers and infants, from both a physical and emotional perspective. Those who advocate trying labor and birth canal delivery after a cesarean believe that the much-publicized risks have prevented doctors from making decisions on an individual basis.
As a result, many normal vaginal deliveries that could occur safely following cesarean have never happened, they believe. The idea is that with clearer delineation of the degree of risk within populations of women, and better ways of assessing a woman individually based on the specifics of her health and obstetric history, vaginal delivery may not be so risky.
Among the factors the American College of Obstetrics and Gynecology believes need to be considered when determining whether a woman who has had a C-section could deliver her next child vaginally are the outcome of the initial cesarean section and the woman's medical and obstetrical history. The guidelines review the most likely issues that led to the original C-section and their recommendations are based on the most current reviews of the evidence garnered from studies of delivery outcomes.
These guidelines will provide the basis for clear conversations between doctors and mothers-to-be as they figure out the best route to the common goal of the best outcome for mother and infant.
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