New Guidelines for Vaginal Births After Cesarean Section – Abandoning the Principle of “Once a Cesarean Always a Cesarean”

This post was authored by Jon Stefanuca and posted to The Eye Opener on July 29th, 2010.

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For decades, expecting mothers were encouraged to deliver via C-section if they had a history of previous C-sections. The maxim “once a cesarean, always a cesarean” became the default approach for many OB/GYNs around the country. This may no longer be the case.

This year, the American College of Obstetricians and Gynecologists issued a number of less restrictive guidelines for vaginal births after C-sections. According to William A. Grobman, M.D. an associate professor of obstetrics and gynecology at Northwestern University and co-author of the new guidelines, women with two previous C-sections and no vaginal deliveries, women expecting twins, and women with vaginal scarring from previous C-sections are now acceptable candidates for vaginal deliveries. The new guidelines are supported by two recent studies that examined the risk of complications in women with a history of two previous C-sections who attempted vaginal delivery.

One [study] found no increased risk of uterine rupture in women with one vs. multiple previous C-sections, while the other study found the risk increased from 0.9% to 1.8% in women with one vs. two previous C-sections.

The new guidelines make the following recommendations:

  • Women with more than one previous C-section may be candidates for a trial of labor. … The chance of achieving a vaginal birth after C-section seems similar for women with one or more than one C-sections.
  • Women who have an unknown type of scar from a previous C-section can also be considered for a trial of labor.
  • Women expecting twins can be offered the trial of labor.
  • A trial of labor is not recommended in others, including women who are at high risk for complications, such as women with a previous uterine rupture or extensive uterine surgery.
  • Previous guidelines recommended that resources for emergency C-sections be ”immediately available.” “That was interpreted to mean all staff, literally immediately available,” Grobman says. In the new guidelines, the ACOG recommends that a trial of labor after C-section ideally be done in facilities well staffed to provide immediate emergency care, but that in a facility without immediate staff available, those doctors and patients discuss the resources and staff availability and carefully consider the decision to try labor.

The new guidelines clearly encourage vaginal deliveries for expecting mothers with previous C-sections. However, Grobman and his colleagues were clear that, although the risk appears minimal, trial of labor after C-sections does carry a number of risks, including uterine rupture, hemorrhage, and infection. For this reason, notwithstanding these  new recommendations, the expecting mother and the physician should carefully discuss and consider the decision to try labor. If you meet the criteria, we urge you to fully understand the potential risks, complications as well as the benefits of vaginal birth after Cesarean Section.

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