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Once a Cesarean, Always a Cesarean?

Related Media: Cesarean Section

Cesarean section is the delivery of a fetus through the abdominal wall and uterus. In the 1970s, when the cesarean section rate tripled, the medical mantra was "once a cesarean, always a cesarean." These days, most women who have had at least one child delivered by C-section will have to decide whether to try to deliver a child that follows vaginally. This is a decision colored by a complex set of factors, including:

What makes the decision more complex is the fact that obstetrics professionals are struggling with the issue themselves.

Reducing the C-section Rate  ^

A C-section is considered major surgery. Blood loss during a C-section is much greater than with vaginal delivery. The risk of serious complications like hemorrhaging and infection after delivery are also greater. It is not clear whether all cesareans are necessary. In fact, many organizations are advising doctors to work to lower the rate.

Looking at VBAC  ^

Having a vaginal birth after a C-section (VBAC) is an area that researchers have been investigating. What are the benefits and risks? Some studies have concluded that there is not enough evidence to come up with a clear recommendation. Other studies, have found that VBAC is as safe as a planned C-section. Nevertheless, there are risks involved with VBAC.

Women who have a VBAC may have a higher risk of uterine rupture. Uterine rupture may put you and your baby at risk of harm including death, and may lead to an emergency hysterectomy. This complicates a mother’s recovery and can put an end to her childbearing—a result that may be less likely after C-section.

Examining the Reason for C-sections  ^

The reason a woman had a cesarean in the first place often influences her decision about a trial of labor for her next delivery. For example, women who have C-sections after long and difficult labors that did not progress may face similar difficulties with subsequent deliveries. Some of these women will choose to deliver a subsequent baby by C-section, especially if the pelvis is unfavorable for vaginal birth.

The reasons for scheduled cesareans can include:

Getting the Experts' View  ^

The American College of Obstetricians and Gynecologists (ACOG) feels that women who meet the following criteria are candidates to try VBAC:

ACOG also specifies that whenever a woman is planning VBAC, a surgical team should be on hand in case an emergency C-section is necessary. In some healthcare settings, the lack of such a team may rule out any trial of labor for a VBAC.

The American Academy of Family Physicians (AAFP) largely agrees with ACOG, but does not agree on the necessity for an on-hand emergency surgical capability. Instead, they recommend that an explicit emergency management plan be developed for all women given a trial of labor after cesarean (TOLAC). This plan should be documented in the medical record. Risks should be discussed at length with women so that they can make a clearly informed consent.

AAFP emphasizes that certain factors (aged under 40, prior vaginal delivery—especially successful VBAC, obstetrically “favorable” cervix, spontaneous labor, and indication for cesarean that is unlikely to recur) make VBAC more likely after a TOLAC. They also indicate factors making successful birth less likely: gestational aged over 40 weeks, birth weight over 4 kg, and need to induce or augment labor.

Making an Informed Decision  ^

It is possible to have a vaginal delivery after having had a cesarean section. However, you should work with your healthcare provider to determine which option is best for you given your prior and current health history.


American Congress of Obstetricians and Gynecologists


The Canadian Women's Health Network

The Society of Obstetricians and Gynaecologists of Canada


American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 115: Vaginal birth after previous Cesarean delivery. Obstet Gynecol. 2010 Aug;116(2 Pt 1):450-463.

Armstrong C. ACOG updates recommendations on vaginal birth after previous Cesarean delivery. Am Fam Physician. 2011 Jan 15;83(2):215-217.

Cesarean section. EBSCO DynaMed website. Available at: Updated March 13, 2014. Accessed April 3, 2014.

Reasons for a Cesarean birth. American Pregnancy Association website. Available at: Updated January 2013. Accessed April 4, 2014.

Rossi AC, D'Addario V. Maternal morbidity following a trial of labor after cesarean section vs elective repeat cesarean delivery: a systematic review with metaanalysis. Am J Obstet Gynecol. 2008 Sep;199(3):224-31.

SOGC Clinical Practice Guidelines. Int J Gynaecol Obstet. 2005;89:319-331.

Trial of labor after Cesarean (TOLAC), formerly trial of labor versus elective repeat cesarean section for the woman with a previous cesarean section. American Academy of Family Physicians website. Available at: Published September 2005. Accessed April 3, 2014.

Trial of vaginal birth after cesarean (VBAC). EBSCO DynaMed website. Available at: Updated February 17, 2014. Accessed April 3, 2014.

Vaginal birth after cesarean section. American College of Obstetricians and Gynecologists website. Available at: Updated August 2011. Accessed April 3, 2014.

VBAC: Vaginal birth after cesarean. American Pregnancy Association website. Available at: Accessed April 3, 2014.

Last reviewed April 2014 by Michael Woods, MDLast Updated: 4/3/2014