Repeat Caesarean? Not So Fast

Should women who've had a Caesarean section try to give birth naturally, or stick with surgery to deliver subsequent babies?

The risk of going the natural route was thought to be higher than having another C-section, but a new study indicates that what had become conventional medical wisdom may be off-base.

The Early Show co-anchor Rene Syler got insight from one of the authors of the study, Dr. Catherine Spong, who heads the Pregnancy and Perinatology Branch of the National Institute of Child Health and Human Development (NICHD).

The study, published in this week's New England Journal of Medicine, reports that risks from going through labor after a prior C-section are low, though slightly higher than for a repeat Caesarean delivery. The NICHD describes the study as "the largest, most comprehensive study of its kind ever conducted." It included almost 34,000 women.

"What's so exciting about this study," Spong says, "is that it gives us real numbers that we trust. Now we know what we're dealing with."

But the bottom line, she adds, is that "each woman needs to talk with her physician. Each woman is different and you need to take that into account."

The lead researcher, Dr. Mark Landon of Ohio State University, says the chief risks (a torn uterus in the mother and brain damage in her newborn) are so unlikely that this study may boost the slumping rate of attempted natural births after C-sections. "I think it will certainly open up the dialogue once again," he says.

Researchers and doctors agreed that the findings can cut in favor of either kind of delivery, depending on the risk tolerance of particular patients.

"This study shows a slightly decreased risk for uterine rupture in the mother and for brain damage in the baby when a woman has a repeat Caesarean -- but that slight risk is so low that there's not a major difference," Spong observed. "Women should definitely have the option of having natural child birth as opposed to a repeat C-section.

"The risk is 1 in 2,000. I don't want to belittle that risk. If you're that one, then it's still terrible, but this study gives us data that we never had before. Now we know the risks and woman can make a much more informed decision.

The medical community has long debated the merits and safety of vaginal deliveries after C-sections.

Doctors and patients often elect repeat surgery for fear that the uterus, weakened by scarring from the previous Caesarean, will rupture under the strain of natural labor and birth. That can seriously endanger both mother and child.

C-sections bring their own set of risks, such as hemorrhaging and infection.
Vaginal deliveries involve less hospital time and expense. In 1980, a committee of the National Institutes of Health encouraged natural birth attempts in carefully selected women who'd had C-sections. The rate of natural births after C-section peaked at 28 percent in 1996.

Since then, reports of uterine ruptures have pushed down the rate. Many hospitals, nervous about the liability or need for surgical teams on standby, stopping doing such deliveries. By the end of last year, the rate had dropped to 11 percent.

A recent New York Times article says many doctors and hospitals aren't allowing women who've had C-sections to deliver naturally.

"Some women say their freedom of choice is being steamrolled by obstetricians who find Caesareans more lucrative and convenient than waiting out the normal course of labor," the Times reports. "Doctors say their position is based on concern for patients' safety."

"Some doctors and hospitals freely acknowledge that fear of being sued has driven their decisions," the Times adds.

"In any medical field, things swing, where people will be more on the bandwagon to do something," Spong says.

"In recent years, there's been a push toward repeating Caesareans," she continues. "Malpractice and litigation may play a role in that. There's also a need to have an operating room ready and accessible if a woman wants to try labor after a previous Caesarean. A lot of hospitals might not have the staff or resources to have that operating room waiting; therefore, they may prefer to just automatically plan to do a repeat Caesarean. An elective repeat Caesarean can be easily scheduled; then there are no staffing issues."