Cesarean Delivery vs. Vaginal Delivery
A cesarean delivery (Cesarean section or “C-section“) is the delivery of the baby through an incision in the abdomen and through an incision in the uterus. Much has been written in the lay press about C-section and the number of C-sections performed in the United States. Nationally, about 32% of pregnancies are delivered by C-section.
Reasons for Cesarean Delivery
There are no hard and fast rules with regard to cesarean deliveries because each pregnancy has its own unique characteristics. The reasons for performing cesarean delivery can be categorized as individual reasons, but it should be recognized that often a combination of individual factors must be considered.
- Conditions of the mother – The woman may have medical conditions that worsen as pregnancy progresses or a condition that will not allow the woman to tolerate labor and vaginal delivery. In addition, there may be problems with the uterus or other pelvic organs, which would prevent a successful vaginal birth.
- Conditions of the fetus – The baby may have medical conditions that result in its inability to tolerate the stresses of labor. The baby may also be coming down through the birth canal in an unusual position so that a vaginal birth is not possible.
- Conditions of the mother/baby – It is not uncommon that the baby cannot be delivered as a vaginal birth because it will not “fit” through the birth canal. This may be due to the baby’s size, the shape of the bones of the mother’s pelvis, or the contractions of the uterus not being adequate.
- Conditions of the afterbirth – In some cases, the afterbirth (placenta) may be in the way of a vaginal delivery (placenta previa) or may separate prematurely (placental abruption) which would require a cesarean delivery.
Because there is a higher risk associated with cesarean delivery over vaginal delivery, the physician tries to consider every possibility to get both a healthy mother and a healthy baby. In some instances, the cesarean delivery is decided upon before labor and attempted vaginal delivery is started. In many cases, however, the cesarean delivery is only decided upon after extensive attempts to achieve vaginal delivery.
Once a Cesarean, Always a Cesarean?
In years past, once a woman had a cesarean delivery, it was expected that all subsequent deliveries would also be by cesarean. This was due to a fear that the uterus had been weakened by the previous cesarean section. It is now felt that patients who have had a cesarean delivery in which the incision of the uterus (womb) is across (low transverse) the uterus rather than up and down (high or low vertical), are considered candidates to have attempts at vaginal delivery in subsequent pregnancies (vaginal birth after cesarean section – “VBAC“). The physician and the patient should be able to discuss the need for future cesarean deliveries if that is a consideration for the patient.
Risks and Benefits of VBAC
Approximately 60% to 80% of woman who are given an opportunity to attempt a trial of labor after a previous cesarean delivery can successfully deliver as a vaginal birth. Unfortunately, there are no ways to tell which patients are more likely to be able to deliver vaginally in pregnancies after a cesarean delivery. The primary benefits of a VBAC include shorter hospital stays, less need for blood transfusions, and a lower chance of infections. The most serious risk associated with VBAC is the possibility of the uterus rupturing at the site of the previous incision, along with the risk of adverse neurological sequela for the baby or even death. The likelihood of this is less than 1%. There are also other risks associated with doing an emergent cesarean section during a VBAC trial, like damage to the bowel and bladder, among others. In order to minimize risks to the mother and the baby, close monitoring of the mother and baby’s condition, as well as the ability to perform emergency surgery, are needed if a trial of labor is being considered. Even though the risk of uterine rupture is less than 1%, there is a significant risk to maternal and fetal health if a uterine rupture does occur. The decision to proceed with a VBAC or a Cesarean section should be discussed with the physician and a shared decision making helps delineate pregnancy goals.
Skin Closure after a Cesarean-section?
Patients often ask me about the type of closure used on the skin for my cesarean section patients. I am an advocate of reapproximating incisions with a sterile suture that helps with wound healing and provides a more cosmetic outcome after a major surgery. Our goal remains to set your body up in a manner that allows faster recovery with a natural-looking outcome. Staples are often used after a cesarean section and can sometimes leave small marks above and below your incision, making your cesarean scar less appealing.