Though the myth “once a cesarean-section, always a cesarean-section” was shattered years ago, rates of United States births involving the surgical procedure have not diminished significantly.
Many women who have delivered a child by C-section – and who are deemed healthy candidates for vaginal delivery for subsequent births – choose to deliver again by C-section, often because they fear the pain of contractions associated with natural delivery or want the convenience of scheduling their births, which elective C-sections allow.
A different dynamic is playing out in Newark, where obstetricians at Rutgers’ New Jersey Medical School (NJMS) are countering that trend, counseling women who have had a C-section about the benefits and risks of natural or vaginal delivery for their next child.
“If the mother is a strong candidate, a vaginal birth offers significant advantages: shorter recovery time and much less risk than with a cesarean delivery, which increases risks of injuries to the bowel or bladder, blood loss and infection,” says Lisa Gittens-Williams, associate professor, NJMS Department Obstetrics, Gynecology and Women’s Health, and director of Obstetrics.
While New Jersey’s overall cesarean delivery rate – approximately 40 percent – ranks among the highest in the country, the NJMS obstetricians are delivering by C-section 30 percent of the time.
In 2015, they performed 83 vaginal deliveries for women who previously had undergone C-sections. Gittens-Williams says generally the “trial of labor after C-section” success rate is about 70 percent.
Hesitancy over attempting vaginal births after cesarean section is likely responsible for the overall cesarean birth rate remaining high, Gittens-Williams says. According to the Centers for Disease Control and Prevention, the cesarean birth rate was 32.2 percent of all births in 2014 and 32.7 percent in 2013.
The belief that a woman was destined to have all babies by C-section if she previously delivered that way, was disproved in the 1980s, aided by research, when repeat C-section rates started to fall, she says. However, concerns about uterine rupture gained momentum in the 1990s, pushing the number of repeat C-section births upward. A uterine rupture is a tear in the wall of the uterus, most often at the site of a previous C-section incision, and the consequences can be dire for the mother and baby.
“Yes, there is that risk,” Gittens-Williams says, “but in appropriately selected candidates we believe are healthy for labor, that risk is approximately 0.8 percent. For many women, the benefits of a vaginal birth outweigh the risks with a C-section.”
Multiple repeat C-sections increase the risk of complications during C-section surgery, including the risk of the placenta attaching itself too deeply into the uterine wall, a condition known as placenta acreta. Vaginal birth after cesarean section reduces this risk, Gittens-Williams says.
Recently, Christine L. (not her real name) chose to try a vaginal delivery, anticipating a much less painful experience than when she gave birth previously by C-section. “This was nothing like the pain from a C-section,” she said, just hours after Gittens-Williams delivered a healthy baby boy. “The first time, I had to be hospitalized for five days. And this time I did not have to worry about the surgery.”
Gittens-Williams says her team encourages the parents to share in the decision-making.
“If we evaluate expectant moms and find them candidates to try a vaginal birth, we give them that option. We explain what to anticipate with surgery vs. natural birth and the risks and benefits of each,” she says.
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Rutgers, The State University of New Jersey