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Once a Caesarean Always a Caesarean?

If you are planning a VBAC (vaginal birth after caesarean) or you have had a caesarean birth, you have more than likely heard this truism before from all sorts of people: once a caesarean, always a caesarean.

When caesarean surgery was first performed several hundred years ago, it was reserved for times when there was nothing else left to try and if a mother or baby survived it was quite miraculous. In the late 1800s and early 1900s, a caesarean was an intrusive, risky procedure used when a woman had a distorted ‘contracted’ pelvis due to malnutrition or illness. This physical condition would remain a problem in future births, so the advice ‘once a caesarean always a caesarean’, given by Dr Edwin Cragin in 1916, was true at the time.[1]

Fast forward many decades and now caesareans are much safer than they once were. Almost all caesareans are a lateral incision through the lower segment of the uterus, creating a stronger scar than the vertical caesareans used in the past. Caesareans are also more common. The caesarean rate in the US was only around 1% in the early 1900s but it has climbed significantly, up to 30% and above in Australia and the US. This is much higher than the WHO recommended rate of 10-15%. The majority of caesarean births today are clearly not for a misshapen pelvis, so using Dr Cragin’s statement (in its original meaning) for caesarean births today is questionable.

Today, most caesareans are for circumstances that are unique to a particular birth and the path the pregnancy or labour has taken: baby’s presentation (eg, breech or transverse), premature rupture of the membranes, an abnormality of the placenta like placenta previa, illness in the mother or baby such as pre eclampsia, a ‘failure to progress’, multiple births, a ‘large’ baby, disproportion between mother and baby, an ‘overdue’ baby, or evidence that the baby is at risk before or during labour. The same factors may not be present in future births.

If the causes of a caesarean are not repeated, then why repeat the caesarean? Is it because caesarean is perceived as being safer (safer for who – mother, baby or doctor) or because it is less frightening (for who, mother, baby or doctor)?

Discussions of risks often focus on the horror of having a VBAC with a devastating outcome rather than communicating the slim chance of this occurring and also evaluating the immediate and the long term risks of a repeat caesarean which are likely to affect many women.

For women approaching a birth after caesarean, there may be fear of birth, fear of caesarean and fear of VBAC – that’s a lot of fear! It is very hard to make any decision when you feel afraid of every option and no one can give you any guarantees.

So you might prefer to turn it around and ask different questions: would a repeat caesarean or a VBAC (with all the preparation you would wish to do for either of these births) have the potential to make the most positive contribution to your health and wellbeing as a woman and mother?
And what if the journey to each birth is equally important, offering you the opportunity to transform yourself? No one can answer these questions but you.

[1] Birth – the surprising history of how we are born, (2006) Cassidy, Tina, Atlantic Monthly Press. (please note – I do not suggest reading this book if you are pregnant or feeling vulnerable or very sensitive. It is fascinating but also quite gruesome in places!)

PS I’ll be posting more a detailed discussion on the factors causing our rising caesarean rate in particular “failure to progress”, putting the risks of VBAC in perspective, and women’s VBAC wisdom in the future.