A Risk Found in Natural Childbirth After Caesarean !

More than a decade after doctors declared it safe for women to give birth vaginally after having had a Caesarean section, a new study has found that doing so is riskier to both the mother and child than a second surgical delivery, especially if hormones are used to induce labor. The study in The New England Journal of Medicine, found that women undergoing Vaginal Birth after Caesarean, or VBAC, were three times as likely as those who deliver surgically a second time to suffer a ruptured uterus, an extremely uncommon but dangerous complication that can kill the mother, her baby or both.

''We used to believe that a vaginal birth after Caesarean was pretty much risk-free,'' said one of the authors, Dr Thomas Easterling, associate professor of obstetrics and gynecology at the University of Washington state in Seattle. ''Now we know that it's not. There are risks. They are small but can be catastrophic. With this in mind, women should carefully discuss those risks with their health care providers,'' Dr Easterling and other experts said.

Uterine rupture occurred in just 91 of more than 20,000 women whose birth records were examined for the study. But beyond the increased risk of such rupture with VBAC as a whole, the researchers found the rate to be 15 times as high among women given prostaglandins, hormones that help ready the cervix for labor, as among those who had second Caesareans. Among women whose labor was induced with other hormones, the rate was five times that of women with second-time Caesareans. The researchers said the study strongly suggested that Obstetricians should avoid the use of drugs to induce labor in women who have had previous Caesareans, a precaution some obstetricians say they've adopted.

For decades, the medical mantra about childbirth was ''once a Caesarean, always a Caesarean.'' The prevailing thinking was that scar tissue from the surgical incision rendered the uterine wall too weak to withstand the strain of powerful contractions during labor. Should the uterus rupture, the mother may bleed uncontrollably and the baby lose oxygen; to save both, experts say an emergency Caesarean section is needed within 15-20 minutes. ''So with no drugs, it's better to let her go into spontaneous labor. Don't induce her. And if you are in a situation where you would consider induction, just do a repeat C-section.'' says Dr Roger Freeman, a member of the American College of Obstetricians.

In the mid-1980's, however, VBAC (pronounced VEE-back) came into vogue, for reasons. By that time, doctors had abandoned the practice of making vertical incisions in the uterus in favour of low transverse cuts (many women called them bikini scars), which were believed to heal better. Subsequent studies found that the risk of uterine rupture with vaginal birth after Caesarean was small, about 0.5 percent. At the same time, there was growing concern that too many women were undergoing Caesareans unnecessarily, exposing them to risk of surgical complications. And some health insurers, concerned about rising costs, began insisting that women with previous Caesarens try natural childbirth.

''Over time, perceptions changed,'' said Dr Michael Greene,  an obstetrician at Massachusetts General Hospital, where he is director of maternal-fetal medicine and an associate editor of The New England Journal of Medicine. ''The Washington study brought those uterine ruptures into sharp relief and was the first to compare the risks of vaginal birth with those of a second surgical delivery in a statistically significant, scientifically valid way.'' The study, Dr Greene noted, found that the incidence of infant death was 10 times as high among women who suffered uterine rupture as among those who did not. He said, in the light of the findings, ''if a patient who has had a Caesarean asks him what is the safest for her next baby, my unequivocal answer is to have an elective repeated Caesarean section along that same  bikini line she acquired the first time.''

The study did not address why prostaglandins pose the biggest risk. But experts say that because those hormones are administered as gels, suppositories or can be typically applied directly to the cervix, they cannot be regulated, as oxytocin can, if the contractions become too strong and dangerous. A number of obstetricians said women should not conclude that VABC is inherently unsafe. In fact, said Dr Lawrence Platt of U.C.L.A., it can be quite safe, so long as labor-inducing hormones are used with great caution, if at all, and the birth occurs in a hospital where doctors are on hand to perform an emergency Caesarean section should a uterine rupture occur.

The Way I See It.....there are many reasons women might want to deliver vaginally after a surgical delivery. Vaginal childbirth entails less discomfort after delivery, and mothers can go home with their babies sooner. At the same time, the risk of surgical complications, including those that can eventually require a hysterectomy, increases with each Caesarean section. So omen who want three or more children may want to try a vaginal birth the second I the hope of avoiding surgery for each subsequent delivery.

Some women I know mentioned to me another reason. They said they wanted a personalized, family-centered, mother-and-baby-focused birth experience with their partner at their side. That means they don't want to be in an operating room and all that it obviously entails.