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To determine the risk of catastrophic complications (including death) among pregnant women who have undergone a previous cesarean section, the medical records of all deliveries (10,835) at one hospital in a three-year period were reviewed. Seven hundred and eleven deliveries (6.6 percent) involved women with a previous cesarean section. Four hundred twenty-four women in this group attempted vaginal delivery, of whom 312 succeeded. Catastrophic complications included: maternal or fetal death; hemorrhage that required transfusion of five or more units of blood; hysterectomy (removal of the uterus); ligation (tying) of a major artery; or uterine rupture. By these criteria, 17 women with a previous cesarean section (eight had more than one) suffered catastrophic complications. These included two maternal and three fetal deaths. Eleven women had serious hemorrhage, eight of whom underwent hysterectomy. Nine had uterine rupture, and eight had placenta previa (attachment of the placenta near the opening of the uterus, associated with bleeding during delivery) or other abnormal conditions of the placenta. The overall rate of very serious complications of pregnancy after cesarean section was 1 patient out of 42, with a risk of maternal or fetal death in 1 out of 143 such pregnancies. These results indicate much higher rates than have been reported in other studies, and may partly be the result of the population studied (primarily black and Hispanic, and poor). The criteria for inducing labor in these women were the same criteria used for women without a prior cesarean, another factor that might have led to the high rate of uterine rupture. The overall frequency of catastrophic complications in this group of women with previous cesarean sections was 2.4 percent. Awareness of this possibility should affect decision-making when a patient's first cesarean section is contemplated. (Consumer Summary produced by Reliance Medical Information, Inc.)

The use of cesarean delivery increased in the 1970s. It was commonly believed that once a woman had a cesarean, all subsequent deliveries had to be by cesarean as well. This recommendation was based on the premise that the uterus that was scarred by cesarean incisions was at risk for rupture if labor was allowed to proceed. However, recent studies have indicated that the risk of rupture is low and the success rate for vaginal delivery is high after previous cesarean section. In an effort to reverse the trend toward unnecessary cesarean sections, many patients with a previous history of cesarean delivery are now offered a trial of labor and the option of a vaginal delivery if certain criteria are met. The American College of Obstetricians and Gynecologists recommends that a woman who has had a low transverse incision should be encouraged to delivery vaginally. However, a 1987 report found that despite the safety and success of vaginal birth after cesarean (VBAC) most women still have subsequent cesareans, and in half of the cases VBAC is not even offered. The reasons why VBAC was not chosen were investigated by sending a questionnaire to 257 women who had had a cesarean delivery and who received their prenatal care from either a private physician or hospital-based clinic. Of the 160 who responded by returning the questionnaire, 53 stated that they themselves were the primary decision-makers about the delivery. However, their decision was also influenced by the opinion of their husband or partner. Women delivering at a public hospital were more likely to be influenced by the physician than women delivering at a private hospital. The main reasons why women chose a VBAC were the longer recovery time after cesarean section, and wanting the experience of a vaginal birth. The most common reasons why women chose repeat cesarean section were that they knew what to expect, they wanted to avoid the pain of labor, and they liked the convenience and timing of the delivery. Social needs were more important in making VBAC decisions than the medical risks involved. It was not possible to tell how well-informed the patients were in this study. To help patients understand the medical probabilities and to help the physicians understand the patients' social requirements, counseling should begin after the first cesarean delivery. Since the physician plays a primary role in delivery decisions, it is suspected that VBAC has not been successfully promoted. (Consumer Summary produced by Reliance Medical Information, Inc.)