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By Dr J Kabyemela, MD

This is a subject we have already covered to some degree in our main section on caesarean section. However, with the rate of caesarean section steadily rising in most countries, it is clearly the case that women requiring repeat caesarean section, some for a third or even fourth time, will continue to go up. It has also been shown that in countries such as the United States, a vaginal birth after a caesarean section (VBAC) is becoming an increasingly rare event, something that is highly regrettable. However, that is the situation and we have to address the reality on the ground. This is the detailed look at repeat and multiple caesarean sections.

Caesarean section rates

The World health Organisation recommends that caesarean section rates should not exceed 15% in any country. That is, at most only 1 in 7 women having babies should have them via caesarean section.

In the United States, in 1965, only one in 22 mothers had a caesarean birth (4.5%). Fast forward to 40 years later and the rate had gone up to just over 30%. That is more than six times the rate 40 years earlier.

In England, in the United Kingdom, in 1955, caesarean sections made up 2.2% of all births. Ten years later, in 1965, the rate was 3.5%. In 1985, it was already 10.4%. Fast forward to 2007 and the rate had hit 24.3%. Rates are not much different in other parts of the United Kingdom. In Scotland in the same year, the rate was 25.8% and in Wales 26.9%.

In emerging economies, the trend has been even more striking. China is such an example. The caesarean section rate was 4.9% (1 mother in 20) as recently as 1993. Ten years later, it was 20.4%; that is about 1 in 5 mothers!

Indications for caesarean section:

A caesarean section will either be planned (elective) or will be an emergency. Needless to say, an emergency caesarean section is performed because of an unforeseen event during late pregnancy or in labour. Such events include haemorrhage such as due to placental abruption, fetal distress (usually in labour) or failure to progress in labour. A full list of indications for emergency caesarean section is discussed here:

For pre-planned (elective) caesarean section, the indications are:

We are concentrating on previous caesarean section and what the prospective mother ought to know.

There is a clear divergence between the United States and many countries of Western Europe when it comes to repeat caesarean section.

There is a clear and active trend in Europe to encourage mothers who have had previous caesarean section to try to have a vaginal birth (VBAC). This is provided the mother has been assessed and found not to have any existing risk factors in the current pregnancy. Of-course, if the indication for her first caesarean section is something that is permanent, then the issue of trying for a vaginal birth does not arise. However, if the indication first time around was for a non-recurrent cause such as breech presentation, fetal distress or poor labour progress then the advice actively given is for her to aim for a vaginal birth next time around.

In the United States the situation appears to be the exact opposite. Doctors are in many cases actively discouraging women from trying to have a vaginal delivery once they have had a caesarean section, regardless of what the indication was. The reasons for this trend aren’t very clear. However, it appears to be influenced by aversion to possible litigation were things to go wrong with the labour or delivery. As less experienced obstetricians come through, they are likely to have witnessed, let alone, conducted a birth where a mother had a previous caesarean section. This means, the option of a vaginal birth after a caesarean section is likely to disappear altogether for mothers in the US within a few years.

VBAC success rate:

Evidence available shows that the majority of women who try vaginal birth after a caesarean section succeed. There is plenty of literature freely available on this subject. You will see from the studies published that the success rate for those who try vaginal birth after a caesarean section is quoted anything from 63% to 91%. The average success rate is quoted at around 74%.  This is clearly an impressive figure which should reassure most mothers finding themselves in a situation where they need to make this decision.

Failure at attempted VBAC is usually due to poor labour progress. The rate of fetal distress is actually the same as for mothers who have never had caesarean section.

Uterine rupture and previous caesarean section

This is the main concern for mothers who have had previous caesarean section. In fact, the risk of this happening when one has had only one caesarean section is quite low. Various studies have shown rates of rupture or scar dehiscence of 0.18-0.35%. In a properly equipped and staffed labour ward, this is a potential complication that can be dealt with effectively and an emergency caesarean section performed once this is suspected will usually result in a good outcome for both mother and baby.

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Multiple caesarean sections:

How many c/sections is ‘too many’?