“Once a Cesarean, Always a Cesarean”

“Once a cesarean, always a cesarean.”

 Have you ever heard this phrase? I heard it bouncing around before I ever got pregnant, and then even up until a couple of months before giving birth. Of course, my midwife and some other women I knew refuted the statement, but I thought for a quite some time it was still a topic up for debate.

This famous phrase was coined by Dr. Edwin B. Cragin in a journal article from 1916. (How or why the phrase has hung around so long, I’m not sure.) At this time, a cesarean surgery was extremely dangerous to both the mother and the baby, and was only done unless absolutely necessary. The book Natural Childbirth After Cesarean: A Practical Guide spoke on Cragin’s statement:

Cragin was denouncing unnecessary cesareans, which were so terribly hazardous, arguing that the first surgery would lead to a second surgery, with further risk to life. When Cragin was writing, all cesareans were of the classical type, with a vertical cut into the upper part of the uterus, a method rarely utilized today. Cragin was saying that physicians should do everything possible to avoid an initial cesarean, since the woman who didn’t die with the first one might very well die with the second one. In any case, Cragin’s statement was declared “outmoded” by ACOG in 1984. But by then the cesarean rate had skyrocketed” (Crawford & Walters, p. 24).

I have two comments on this excerpt:

1.) Cesareans are much safer now through improved medical practices, better hygiene, and the advent of antibiotics. Thank God that this procedure can be done relatively safely and that it is available to save the lives of mothers and babies. I am grateful for cesareans. However, I think that the improved safety level of a cesarean (and it’s still not as safe as a vaginal delivery) has given us a false sense of security. The “decision to incision” has been taken much more lightly in recent years, possibly contributing to the rise in the cesarean rate.

2) “Once a cesarean, always a cesarean” was declared “outmoded” by ACOG in 1984!!! Just as a reminder, it is now 2011. That’s 27 years later. Why, oh why, are we still hearing this phrase? Women who had their babies in the 70’s are still reciting it to their daughters. If the daughter doesn’t have a VBAC suppotive doctor, who will tell her otherwise?

ACOG itself supports VBACS (vaginal birth after cesarean). In a 2010 statement on VBACs, ACOG considered VBAC to be “a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans.” They say that women should be counseled on the benefits and risks of a VBAC, and that those women who chose to attempt a VBAC should have a 60-80% success rate (many hosptials currently have a much lower VBAC rate than this).

The risk of uterine rupture in a VBAC (0.5-0.9%) is similar to the rate of other serious complications in a vaginal birth- regardless of whether or not the woman has had a previous cesarean. For example, the rate of umbilical cord prolapse in pregnacy or labor is between 0.14% and 0.62%, and placental abruption occurs in less than 1% of all pregnancies. The small possibility of these other complications does not stop a woman from striving for a vaginal birth. Why should a VBAC be so frightening and so widely discouraged?

I urge you to read the entire ACOG press release on VBACs and internalize some of the main statements. It seems that some OBs need to be reminded of their own organization’s stand on attempting a VBAC.

A friend of mine was laughed at when she asked her doctor about attempting a VBAC, and was told that she would always have automatic cesareans from that point on. This sort of blatant disregard for evidence needs to stop. When cesareans are necessary, they are life saving and wonderful. When they are unnecessary, they put mother and baby at unecessary risk. VBACs should be widely encouraged and supported. If your caregiver does not support your desire to VBAC, find one who will.


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