Safer Births the Second Time

By Dick Thompson

"Once a C-section, always a C-section." That is the snappy guideline most obstetricians have followed since World War I. By the mid-1980s, 1 baby out of every 4 born in the U.S. was delivered by caesarean, making the U.S. the world leader in surgical deliveries. In 1987 an estimated 35% of the procedures were done only because the mother had previously delivered by C-section. Last week the American College of Obstetricians and Gynecologists officially declared new guidelines on caesareans for the first time in 70 years. Its recommendation: doctors should encourage mothers who have had a C-section to have a normal vaginal birth unless there is definite medical need for surgery.

Although many doctors have long advised women against having repeated C- sections, the high rate of surgical deliveries has continued for a number of reasons. Among them: advanced fetal monitoring, which is more sensitive to the signals of fetal distress; a trend toward larger babies, who are more difficult to deliver vaginally; and more requests from mothers exhausted by labor.

Another significant factor is that many doctors perform caesareans at the first signs of fetal distress to protect themselves from malpractice suits. Moreover, caesareans demand less time for physicians in the delivery room. "It's a lot easier for a doctor to schedule a woman for caesarean and come in at 8 in the morning and be done by 8:30," says Mortimer Rosen, director of obstetrics and gynecology at New York's Presbyterian Hospital.

For the past decade, studies have shown that vaginal births are possible for 50% to 80% of women who have had C-sections. At the same time, the case against the surgical procedure has mounted. Caesarean sections carry all the risks of major surgery, including complications associated with anesthesia, blood transfusions and infection, especially of the uterus. The incidence of maternal mortality is twice as high for women who undergo repeat caesareans, and infants are at increased risk for respiratory problems and distress caused by anesthesia given to the mother. On balance, the benefits of vaginal deliveries after C-sections have long outweighed the advantages of surgical births. Says R. Harold Holbrook Jr., director of maternal-fetal medicine at the Stanford Medical Center: "It's been clearly proved that it's safe to have a natural birth after having a caesarean section."

Still, physicians are concerned that women who have had a vertical uterine incision, which is now used in less than 1% of all caesareans, risk tearing along the scar. Their advice: better to have another C-section. But the vast majority of those who have undergone C-sections have had the preferred horizontal incision across the lower abdomen, or "bikini cut," and for them last week's announcement may finally break the old saw against vaginal delivery the second time around, and even the third.

With reporting by Georgia Harbison/New York and Dennis Wyss/San Francisco