Once a Cesarean… Twice a Cesarean… Always a Cesarean?


I will save you the lecture I give to medical students and residents. I will save you all the complex medical information and bring it down to why this matters to you.

If you never had a C-section, you should not ask for one unless needed or recommended by your health care provider. Think twice before you ask for a C-section (Cesarean delivery) for non-medical reasons as social convenience, avoiding a timely or painful labor, or other personal reasons. I will not delve into the controversial debate on the ethics of “Cesarean delivery on maternal request (CDMR)”, “patient-choice cesarean” or “cesarean on demand”. I am all for choice and autonomy, you are entitled to decide what is best for you, but you should be empowered with the right to full knowledge of all details and entailed risks.

If you had one previous C-section, you should have a discussion with your health care provider early in your pregnancy about the method of delivery. Most women with one previous C-section are good candidates for a trial of labor, an attempt at a vaginal (natural) delivery.

If you had two previous C-sections, or if you are carrying twins and had one previous C-section, you might be a good candidate for attempting to deliver vaginally according to recently released recommendations by the American College of Obstetricians and Gynecologists (ACOG) in August 2010. Talk to your provider about these options.

I will not be able to provide you with all facts in this brief blog, and each pregnant woman is unique in her needs. The take home message is this:

“You do not anymore need to dismiss the option of having a natural delivery just because you had one or even two previous Cesarean deliveries.”

You have the choice and you should be actively involved in making this decision with your health care provider.

Carrying a newborn baby. (Photo published with patient's permission)



Categories: Health

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44 replies

  1. ah thank you for clearing this misconception. And very briefly too! Great Post!

    PS: the baby’s expression is priceless! I guess this is the beautiful part of the job (:

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    • Does this mean that all OB’s will do a VBAC now? My wife had an emergency c-section with our first born. Most of the doctors in our town will not do a vbac. We now have three children, the last two were both VBAC’s. The OB’s that delivered our other two children were GREAT! The first OB was great too, she tried everything we were willing to try before going for the c-section.

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    • The new recommendation does specify that you need to have easy access to emergency cesarean delivery if needed. If you live in a rural area where the hospital does not have 24 hour coverage by anesthesiologists then your OB might not be willing to allow a TOLAC. If your OB refuses to allow a VBAC she/he has the duty to find you another OB who would be willing to do it (given the resources are available). Good to read about your wife’s two successful VBAC. Best of luck.

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  2. I agree….. completely. However, might I add that if a person’s had a vaginal delivery that resulted in extensive tearing, knowing that their skin does not stretch.. there should be an option of c-section the second time around… because even the second time around, there may be a tonne more stitches and all the scar tissue can result in a very painful existence. Even 10 years after the fact.

    Just sayin.

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    • It will depend on the peculiarities of each case. As a general rule, a previous tear is not an indication for avoiding a vaginal birth. Usually a second vaginal delivery tends to cause less tearing.

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    • So true. I had massive tearing the first time, took nearly three hours to stitch me up. Yet had two further deliveries with almost no tearing, including my last baby who was almost 11 pounds.

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    • All I am saying is, there are situations where a vaginal birth is not always the best thing to aspire to. (granted, in most situations it is ideal). My first had me being stitches up for 3.5 hours, and had me in the hospital for over a week. I had 2 c-section roommates come and go in that time… I had 8 drainage tubes in the site and could not sit properly for a month. My second baby, while caused less tearing, just added to the damage from my first… compounded it. They induced me early to avoid a repeat, but baby was the same size as my first, even though he was 2 weeks early.
      Now, to this day I look back and I’m just angry. If I even so much as sit the wrong way, I tear. Sometimes just a simple gentle wipe after using the bathroom has me tearing and bleeding again. I got pregnant with baby #1 the first time my husband and I actually were able to ‘complete the act’ (TMI, I know.. whatever). It was so incredibly painful. Try telling a doctor that my skin just doesn’t stretch? No way…. *They* know what’s best for me and my body better than I do. After the trauma of the first birth, I think there should be at least other options available so that a woman doesn’t become rendered unable to enjoy any form of subsequent sex life. I was torn to oblivion at age 21, less than a year after losing my virginity, and so yeah… I’ve always had pain…. why make it worse?

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    • Oh, and trust me when I say, I am not an advocator of c-sections without merit or reason… I’ve had many medical issues in my life and have a high pain tolerance… but this is enough to make me crazy.

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    • Last time I checked the available literature, nothing indicated that the circumstances of one birth would be repeated in any subsequent births, whether that referred to length of labour or to size of baby.

      Also, most of what I’ve read in Henci Goer’s work, midwifery manuals, the Cochrane report, etc states that some women may be more likely to tear than others, but the biggest factors in tearing are not genetics or size of baby, but rather, dehydration, being forced to birth on one’s back or semi-reclining, being given an episiotomy, being forced to push on cue rather than in synch with the body’s urges, and not having perineal support as the baby comes out.

      I’ve even read remarks from other mothers that they were glad they tore along the line of an old episiotomy scar, if they DID tear, as that generally got rid of a painful “husband stitch” they were given – but on the blogs and fora I’ve frequented, those mothers were outnumbered by mothers who didn’t tear at all the second time or who only had minor first degree tearing, because they gave birth in a squat and because they followed their body’s cues.

      As a mother of four, whose first child was removed abdominally via surgery and who subsequently had one hospital VBAC followed by two HBACs, I can say that for me, at least, recovering from a natural tear (after my third child was born) was easier than recovering from the greater damage from tearing I sustained after giving birth on my back in a hospital (after my second child was born, which required stitching up after the birth), and that, in turn, was far, far easier than the pain I endured while recovering from abdominal surgery. Of course, my fourth birth, which did not tear me at all despite the baby being larger than any of my other newborns (she was 10 lbs 5 oz) was easiest to recover from. I credit my lack of tearing to adequate hydration and good nutrition – I ate foods rich in fatty acids and vitamin E, both of which are good for skin tone. I figured anything that would help prevent wrinkles by creating greater elasticity, and help paper cuts and the like heal faster, would likely help prevent tearing.

      Just sayin.

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    • Kari, I am sorry to hear about the complications you had. I had good success treating such cases with serial vaginal dilators (sex toys can be used as an alternative). The dilation will gradually stretch the scar tissue and eventually provide more elasticity to your vagina especially at the introits (opening). This is only a suggestion that you might want to research and learn more about it. I can not diagnose or treat through a blog.

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  3. It’s nice to see these kind of comments from an OB-GYN. However, one little comment on my part about the tagline on your photo… Was it you or the mother who delivered the baby? ; )

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    • I totally agree and I do fall into this language trap from time to time.

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    • I am happy about the new guidelines, as I am hoping to have a better birthing experience with my next child. I had an emergency c-section with premature twins (30 weeks) and was told I wouldn’t be considered for a VBAC by the OB I was seeing at the time. Are there any resources for finding VBAC friendly doctors in a local area?

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    • Thank you Sarah for this comment, I changed the Caption on the photo to “Carrying A Newborn Baby” I did not know what to write if I want to express that I was there for this birth!

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    • Something to the effect that you “witnessed” the birth? 🙂

      I would love to hear the lecture that you give to the students. I would love to see your reasoning for why you believe that VBAC is a safe alternative.

      What are your thoughts on VBAC after Special Scars (a scar resulting from any incision other than a low transverse)? I, personally, have had 2 VBA2C the second c-section was an inverted T.

      I look forward to your reply.

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    • Any doctor who follows ACOG guidelines should be able to accommodate your request for a TOLAC or VBAC given that you are a good candidate. Do you know the kind of scar you had on your uterus from the previous Cesarean? With an emergent cesarean in a premature pregnancy there is a chance your incision on the uterus was vertical, in this case the chances of a uterine scar separation increases significantly.

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    • Well here is what ACOG says: “The preponderance of evidence suggests that most women with one previous cesarean delivery with a low transverse incision are candidates for and should be counseled about VBAC and offered TOLAC. Conversely, those at high risk for complications (eg, those with previous classical or T-incision, prior uterine rupture, or extensive transfundal uterine surgery) and those in whom vaginal delivery is otherwise contraindicated are not generally candidates for planned TOLAC. Individual circumstances must be considered in all cases, and if,for example, a patient who may not otherwise be a candidate for TOLAC presents in advanced labor, the patient and her health care providers may judge it best to proceed with TOLAC. ”

      It does not matter what I personally think, or what I would choose if I was pregnant. I try not to bring my personal package to my office. I provide all the uptodate info to my patient and the resources available at our local hospital and allow her to make a well-informed decision.

      I have to congratulate you though on your successful VBA2C especially after an inverted T scar. Courageous People like you are the ones that get counted in research that provides us with statistical figures to help us counsel our patients to the best of available medical knowledge at the time.

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    • I do have a vertical incision on my uterus from what I was told, but the incision on the outside is transverse. I would love to try for a VBAC because recovering from my c-section was difficult and I was re-hospitalized a week and a half later due to an infection.

      Would the amount of time between pregnancies have any effect on whether I would be a good candidate?

      I’m hoping that TOLAC or VBAC isn’t completely ruled out for me.

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    • If you have a strong desire to deliver naturally, nothing can be “completely ruled out” for you. You need to spend adequate time learning about the risks and benefits of attempting a vaginal birth after a vertical uterine scar. You will get to know that the risk of uterine rupture is much higher than that with other type scars and that doctors will recommend that you do a repeat cesarean, however, you still have the choice to make your own decision and ask for a TOL as long as you understand the increased risk on you and your baby. That is how I see it. I am sure other doctors might not share my opinion.

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  4. Dr A – please move to Australia right away… boy could we do with you here.

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    • Dr Abdessamad,

      So happy to see these types of comments from an OB.🙂 I am pregnant with my second and will be attempting a VBAC. The area in which I live is sadly not VBAC friendly. Despite the recommendations from the ACOG, why do you think this is? If ACOG is recommending that many mothers that have have a previous C-section be allowed an opportunity to VBAC, then I don’t understand why most won’t allow it. At least that is the case in the area in which I live. I know many women who have been told a definite NO on VBAC.
      Oh and I love the picture with you and that beautiful baby!

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    • ACOG recommendations are not strictly applied when you are in a rural area. ACOG specifies the need for direct and fast access for a Cesarean if needed. So if you do not have 24 hour in-house anesthesia coverage then they assume ACOG guidelines does not apply to them. Where I practice we also do not have 24 hour coverage of anesthesia, the way I work around it is that I share this information with my patients and explain what resources we have in the hospital and what might happen in the rare occasion of scar separation (less than 1 %) so I allow my patient to make an informed decision. Most will stick around, few will ask to be transferred to a center with full coverage and fewer will unfortunately end up with another cesarean. It is a pity when lack of resources becomes the reason why a woman chooses a repeat Cesarean.

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  5. Thank you for this post – it is nice to see there are some OB’s who are not just willing to attend VBACs but promoting them as well!

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  6. You are a baby catcher. Mamas ‘deliver’ the babies, you catch them (ideally).😀 Thanks for the great post. We need more of your kind!!

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  7. You are a dream come true. I’ve been midwifing for 34 years & rarely do I find an OB/Gyn as open & honest as you. Thank you! What midwives say is “I caught that baby.” The woman “birthed” her baby.

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  8. Thank for posting this, Dr Abdessamad. I followed the link from The Unnecesarean and I have to say that the United States needs more doctors like you. Here in the Midwest, even in mid to large sized cities, there are plenty of doctors who will not do TOL if a mother has had a c-section in the past, or will impose ridiculous limitations that effectively kill the possibility of a VBAC (baby must be seven pounds or lighter, as if an ultrasound or palpation can accurately predict size; pregnancy cannot extend past thirty nine weeks; mother must go to hospital for continuous monitoring once she starts noticing a pattern to her previously irregular Braxton-Hicks, and immediately avoid all food from that moment just in case she needs emergency surgery; etc). And there are plenty of hospitals that do not “allow” TOL or VBAC.

    Never mind what the most recent statement by ACOG has to say.

    Some states (including my own) even outlaw direct entry midwifery and classify it as a felony, which might not sound pertinent, but when the local doctors refuse to take part in a VBAC and the local hospitals ban it due to liability issues, mothers who want to VBAC turn to the midwives, who are generally more supportive of it.

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  9. I, for one, would love to hear your lectures. Medical information amazes me.

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  10. I had a VBAC after 2 prior cesareans– my first 2 cesareans were for CPD due to posterior position (I had a failed TOLAC with baby #2)- and yet I still was able to easily VBA2C with my 3rd. You never know unless you give it a try.

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  11. So refreshing to see a “younger” OB who is moving toward women’s health and well-being. The consequences of cesarean are not just physical. I deal all the time with the emotional and spiritual fallout as well. Women need to given the truth.

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  12. I am always thrilled and refreshed to see an OB who desires natural birth over unnecessary interferences. And, you are teaching other up and coming OBs!! Thank you so very much. I am also impressed to see the obvious joy you have over the new baby. So much of modern obstetrics is a complete disconnect from from what birth can and should be, one of the most special times in a couple’s life. I’m thankful for emergency care when needed, and I’m thankful for OBs who appreciate the miracle of birth and seek to not disturb it without a true need. Although I love homebirth, most women will continue to use hospitals. We need many more OBs with a naturally minded approach. Hopefully, your students will be among those to humanize hospital birth. Thank you!

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  13. Awesome! Thanks Dr. A! The Coalition for Improving Maternity Services (CIMS) has a statement regarding ACOG’s new VBAC Guidelines. See http://www.motherfriendly.org/CIMSResponseToVBACGuidelines.php. In light of the NIH’s findings that TOLAC is a reasonable option for the majority of affected women, we hope that ACOG will take additional steps to increase access to VBAC. Looking forward to more posts from you, Dr. A!

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  14. Kari,
    I had 30 stitches with the vbac birth of my 7 lb 5 oz baby. She was a multiple presentation with a 3 contraction pushing phase. I went on to birth a 10 lb 4 oz baby vaginally…with 2 stitches (on an old suture line). Investigate pushing position as it results in increased risk of tearing. Also look at ineffectiveness of purple pushing. I was able to chose my position of pushing my baby out, and I pushed when my body told me to push…no epidural…no nurses counting to 10.. So my tear experience reinforces what the good doctor suggested.

    Consider another care provider. I have attended women who had previous repair jobs resutured with much better results following a second vaginal birth.

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  15. Oh, and I guess I could add that the forceps didn’t help my situation either.

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  16. Thank you for your refreshing support for VBAC and VBA2C! Would that all OBs were as open to the possibility! You are a breath of fresh air.

    Thank you for posting about this important change. Truly, it’s great that ACOG has finally changed their guidelines and in such a generally postiive direction, but it doesn’t take away years of VBAC options being taken away from women because of the 2004 guidelines.

    I blogged about the changes for women with 2 prior cesareans on my blog, for those who want more specifics:

    http://wellroundedmama.blogspot.com/2010/07/about-damn-time-good-news-for-vaginal.html

    I’m a VBA2C mom myself, but I was lucky I had birthing options in my area at that time. Virtually no hospitals in my area support VBAMC now, even those with 24/7 anesthesia and who otherwise support VBAC. I’m not optimistic that the new guidelines will change those policies.

    The negative ripple effects from those 2004 guidelines will be felt for years, I’m afraid.

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  17. I had 3 vaginal deliveries and then a C-section because he was posterior and weighted 10 pounds 5 onces. I want so much to have this one naturally and the doctor told me that a good candidate to have a deliver vaginally this time. After watching the documentary ‘The business of being born’, It’s scaring how much the *some* doctors are inducing women in order to have a chance to do a C-section that will fit in their schedules.

    Thank you for that information.

    (sorry if my english is not that good🙂

    Bonne journée et merci d’écrire ces ‘posts’ afin de nous rassurer et répondre à nos questions.

    Like

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