Questions You May Have About Cesarean Births
4 Ways To Increase the Chance of a VBAC
5 Alternatives to Consider When Delivering a Breech Baby
How to Make a Surgical Birth a Great Experience

Q. I had a cesarean with our last baby, and I'm worried I might need to have one again. Am I at higher risk for having another cesarean?

A. The main reason for sentencing a first-time cesarean mother to life-long birthing in the operating room was the fear of uterine rupture. Years ago, cesarean incisions were made vertically, in the upper part of the uterus -- the area most prone to rupture. Nowadays, most cesarean incisions are made horizontally, in the lower part of the uterus (even in emergencies). This cut, a low-transverse incision or "bikini cut," is unlikely to rupture. With a low- transverse incision, authorities now estimate the risk of uterine rupture in subsequent labors to be around 0.2 percent, which means there is a 99.8 percent chance of mother going through a labor without rupturing her uterus. In a survey of 36,000 women attempting VBAC (vaginal birth after cesarean, pronounced Vee-back), no mother has died of uterine rupture, regardless of the type of prior uterine incision. In a study of 17,000 women attempting VBAC, no infants died as a result of uterine rupture. (Don't let the term rupture scare you -- it does not mean that your uterus will suddenly explode. Instead, the first cesarean scar gradually pulls apart. Fortunately, uterine rupture can be suspected by electronic fetal monitoring.) So the numbers are greatly in your favor -- having a VBAC is of negligible risk to you and your baby and certainly less risky than a surgical birth.

Whether you are a candidate for a VBAC may depend upon the reasons for your previous cesarean. If you needed a surgical birth because your baby was in a breech position, you had an active herpes infection, you had toxemia, or the baby was experiencing true fetal distress, there is no reason to expect you will need a cesarean again. These factors were unique to the earlier pregnancy and may not recur. If the diagnosis leading to your previous cesarean was "cephalopelvic disproportion" (CPD) -- your baby's head was thought to be too big to pass through your pelvis, there's still no reason to worry. New studies show that this diagnosis does not lessen your chances of having a VBAC. True CPD is very uncommon, and in most instances the births could just as easily have been labeled "failure to progress." Studies report a 65-70 percent chance of successful VBAC despite a previous diagnosis of CPD. A woman's pelvic outlet often becomes more flexible with each delivery, and various changes of position during labor can make it easier for baby to find the way out.

Q. I had a previous cesarean and I haven't yet gotten over feeling that I was a failure. I'm afraid this will affect my next birth and I'll have another cesarean.

A. You are no less a woman if you had a cesarean. After all, you nourished this baby through pregnancy, and your baby grew in your womb, even though the exit was not the one you planned on. Medical circumstances beyond your control may have led to your previous surgical birth. In all likelihood, you were doing the best you could at the time.

This time around you can avoid feelings of regret by being informed and prepared, and following the suggestions we have given throughout this book on having a healthy pregnancy and efficient delivery. In our experience, women who begin studying up for a VBAC often realize that there were things they could have done to lessen their chances of having the cesarean. Mothers who can satisfy themselves that they did all they could to influence a positive birth outcome typically do not experience feelings of guilt and failure, because they realize they had a truly necessary cesarean.

Truthfully, you are not guilty for what happened to cause a cesarean. This is easy to see when you know you didn't "bring on" a breech position, a cord tightly wrapped around your baby's neck, a multiple pregnancy, or even an active case of herpes. Your most likely reaction would be "Thank God for modern obstetrics." Yet if the situation is less clear cut, no concrete physical reason you can point to, it would be easier to need to cast blame. If there is some doubt as to your performance ("I didn't walk enough," "I took the drug too soon," "I didn't relax enough" and on and on the list could go) the easiest person to blame would be yourself, and you would feel loaded with guilt. But that is hardly realistic. In many ways you are the victim in the scenario. Resolve in your mind that you did the best you knew how and blame the system if that helps. Move on from there to forgiveness and the resolve to learn from the past -- perhaps the greatest gift of all next to your precious baby.

Q. Could my baby be less healthy if delivered by cesarean rather than vaginally?

A. Your baby should not be any less healthy if delivered by cesarean. In fact, depending on why the cesarean is done, he could turn out to be healthier. If a baby is found to be in distress during labor, waiting for a vaginal birth could compromise his health. Cesarean-birthed babies do often display the picture book round newborn head when compared to the typical "conehead" of a baby who worked his way through the narrow vaginal passage. Surgically birthed babies do sometimes require more suctioning right after birth. They tend to be a bit more mucusy, probably because fluid was not squeezed out of the lungs, as it would have been in vaginal birth. Cesarean-birthed babies are sometimes slower to breastfeed, which may be more a result of mother and baby being separated and the drugs used in labor.

One possible health complication from cesareans is when a baby is delivered too early. This may happen when a section is performed before the mother goes into labor, perhaps because she is diabetic or has a heart problem. The due date may suggest that the baby is mature enough to be born, when in fact he wasn't ready. If there is uncertainty about your dates or the maturity of your baby, and you need a pre-scheduled cesarean, your doctor may elect to do ultrasound and tests on the maturity of the baby's lungs to be sure she is ready for life outside the womb. If there is any doubt and there is no reason to suspect baby is in jeopardy by being in the womb a week or so longer, it is best to wait. There are benefits and risks of not doing a cesarean until mother begins labor. But, you may think, why should I go through any labor if I'm going to have a cesarean anyway? Besides indicating the baby is ready to be born, contractions give baby and mother the benefit of the natural hormones of labor, endorphins . Studies show that babies delivered by cesarean after mother has labored a while have fewer breathing problems in the first few days after birth than those whose mothers never entered labor. On the other hand, the surgical complication rate for mother may be slightly less for a scheduled cesarean than when the surgery has to be done because of a complication during labor. When in doubt, best not to hurry baby out.

Q. So many women are having cesareans nowadays. It seems to be no big deal. What complications might happen?

A. True, with modern surgical techniques and better anesthesia, cesarean sections have never been safer. Yet a surgical birth is a big deal. Cutting through all the layers of your abdomen and into your uterus is major surgery. Though minimal, there are risks of complication such as hypersensitivity to the anesthetic, excessive bleeding, post-operative infection, and pain. Also, you are required to do double duty: healing yourself while learning to care for a newborn. Not the most joyful way to enter motherhood. Best to do what you can to lessen your chances of needing a surgical birth.

Q. My due date is almost here and my baby is still butt-down in the breech position. My doctor says it's safest for my baby to be delivered by cesarean. Is a cesarean necessary, or are there alternatives that are just as safe?

A. Studies show that breech babies have a lower risk of birth injury and newborn complications if delivered surgically rather than vaginally. Hence, the trend toward cesareans for babies in the breech position. Some specialists wonder whether the statistical increase in complications with vaginal delivery could be related to the breech position itself rather than to the mode of delivery, but presently in most hospitals, from 80 to 90 percent of breech babies are delivered by cesarean. The main concern in the vaginal delivery of a breech newborn is that, with the feet or buttocks presenting first, the head will not have enough time to mold itself to the pelvic canal and may get stuck once the rest of the body is out. Also, a breech delivery can cause damage to the major nerves leading to the arms and hands. Both of these complications are less likely when baby presents buttocks first rather than feet first (frank breech). Prolapse of the umbilical cord (the cord slips through the cervix before baby's body and gets pinched), an emergency requiring an immediate cesarean delivery, is more common in all breech deliveries.Baby's being in the breech position does not mean you absolutely must have a cesarean birth. The American College of Obstetricians and Gynecologists officially sanctions vaginal births for breech babies as safe in selective situations. Your doctor will weigh the risks of the surgical versus the vaginal birth and recommend the course of action that is best in your situation.

Q. I had a vaginal herpes outbreak early in my pregnancy, but seem to be okay now. Will I need a cesarean section because of herpes?

A. A newborn baby can contract herpes during passage through an infected birth canal, so it is considered prudent obstetrical medicine to deliver all babies whose mothers have active herpes at the time of delivery via cesarean section. Herpes infections are life threatening in newborns. If you have herpes, your doctor may do monthly or weekly vaginal cultures throughout your pregnancy to monitor your body's response to the stress of pregnancy (stress can cause genital herpes to flare up). Women with prior herpes outbreaks actually pass some immunity to their newborns. Women who acquire herpes for the first time during their pregnancy and have active sores at the time of delivery pose the greatest risk of infecting their babies. When you begin labor, your doctor may judge that it is safe for you to deliver vaginally if he or she sees no new herpes sores. If, however, your vaginal cultures continue to show herpes throughout your pregnancy, or you have herpes sores when you begin labor, you will need a surgical delivery.

Q. I'm scheduled to have a cesarean section. I know that in my situation it's best for my baby, but I'm disappointed. I wanted so much to have a natural birth. Besides, I'm scared of surgery.

A. It's normal to feel disappointed when the birth you hoped for will not be the birth you get, but the end result will be the same: you'll see your baby! A healthy baby is your main goal, even if you will need some technological help. You have grown this baby inside of you. He or she will be your most important accomplishment; regardless of what route this special little person takes to get here.

All the natural childbirth information that is now available to women is great, yet it does set women up to feel like failures if they have to have surgery. Remember that a hundred years ago surgical birth was not a safe option, and be thankful that your cesarean will help ensure your baby's health. It's nice that you know about the surgery ahead of time so you can cope with the change of plans and not fight disappointment at the time of birth. You can also plan ahead and make the birth a positive experience for you and your baby. It takes maturity and a willingness to set aside your own desires to make the best of this situation. Having your baby surgically will be no less of an accomplishment than having a natural birth.

1. Select birth attendants and a birth place friendly to VBAC's. Be sure both your practitioner and your hospital are up on the latest studies. The nationwide success rate is around 20 percent. Yet if a mother is under the care of a practitioner who regards VBAC as no riskier than any other delivery, the mother delivers in a hospital that does not consider VBAC women "high risk," and the mother uses the suggestions for helping the labor progress that are mentioned below, the VBAC success rate is 75-90 percent. This means that a mother choosing a VBAC may, in fact, have an even smaller chance of having a cesarean than the general population. Find out what your prospective birth attendant's VBAC success rate is. For normal low-risk pregnancies, it should be at least 70 percent. Shun practitioners and hospitals that try to label you "high risk" even if you have no risk factors besides a previous section. Studies show that even mothers with two or three previous cesarean births have a 70 percent success rate with VBAC if they deliver in a birthplace supportive of VBAC's. Obstetrical centers that specialize in VBAC's do not consider most VBAC candidates as high risk, and treat them no differently than any other obstetrical client. In fact, they consider it counterproductive to attach the "high risk" label to VBAC mothers. Most women wishing a VBAC should be treated like any other woman delivering a baby. They require no more or less technology, intervention, or monitoring. Beware especially of birth attendants who have a "pelvic prejudice" against small-hipped mothers wanting a VBAC. Many petite women have successfully pushed out big babies.

2. Employ a professional labor assistant. If you're serious about delivering your next baby vaginally, a PLA is a must. In our experience, mothers using a PLA were much more likely to have the birth they wanted.

3. Don't let technology or the measurements it produces scare you. VBAC studies fail to show any correlation between the size of the baby and the chances of uterine rupture. Also, estimates of fetal size and weight by ultrasound are not always accurate, especially in the final month.

4. Join a support group. There are support groups for mothers who need help in grieving about their previous cesarean or in avoiding another one. ICAN (International Cesarean Awareness Network) is one of the best, and has chapters nationwide. This support group will help you deal with feelings of regret from your previous cesarean while arming you with information on how to avoid another one. You will hear helpful suggestions from mothers who have gone the surgical route once and were highly motivated to try a VBAC the next time. One great piece of advice from this and other support groups is to keep your mind in your present labor and not allow yourself to have flashbacks from the labor that led to the cesarean. Otherwise, you may panic at the first monitor alarm and undo all the good work of a previously efficient labor. If you want to feel fully empowered for VBAC, a support group is your best bet.

1. Consider the possibility that your baby might turn. Around half of all babies start out bottom down early in pregnancy. Most turn head-down by 32-34 weeks. If baby hasn't turned by 36 weeks he or she is likely to remain in the breech position. For some unknown reason, three to four percent of babies never turn head-down.

2. If your baby hasn't turned on her own by 36-37 weeks, your doctor (or a specialist you are referred to) can attempt a maneuver called external version, in which he or she manipulates your abdomen to turn baby into the head-down position. External version is successful 60-70 percent of the time (40-50% for first pregnancies), but some babies turn back and require a second attempt. A few stubborn babies keep reverting to the breech position and remain there. A version is generally a safe and only mildly uncomfortable procedure, yet sometimes it can be painful to mother and can cause distress to baby.

3. Another alternative is to search out a doctor who has experience in vaginal delivery of breech babies. He or she will most likely be affiliated with a hospital that has the technology and support staffs to properly care for the baby should a complication occur. We have found that most doctors experienced in vaginal delivery of breech babies either practice at a university hospital obstetrical center, or have gray hair and began delivering babies at least twenty years ago, when over 90 percent of breech babies were delivered vaginally. You may get discouraged. Many of the doctors who have this kind of experience are now retired. Since in the past ten years most breech babies have been delivered surgically, newly trained obstetricians may never even have witnessed a vaginal breech birth. Also, if the obstetrical standard in your community is that breech babies are to be delivered surgically, don't be surprised if your doctor is forced to comply with this standard.

4. Obstetricians and hospital centers with a lot of experience in vaginal breech deliveries usually follow the American College of Obstetricians and Gynecologists Guidelines for breech delivery. The criteria you need for a safe vaginal delivery of a breech baby include: baby is in the frank breech position, bottom down instead of feet first or legs crossed in tailor sit; baby weighs between 5.5 and 8 pounds (baby's head getting stuck during delivery is more likely to occur in small and premature babies, probably because the head is proportionally larger than the rest of baby's body); baby is mature or at least older than 36 weeks; baby's head is tucked down, chin on chest, prior to delivery; mother is judged to have an adequate pelvis as determined by a technique called the fetal pelvic index; mother's labor progresses normally; and the hospital facility and staff is equipped for an emergency cesarean within 30 minutes. (Mother having delivered a previous baby vaginally adds another plus to the okay list.) If your baby is a footling or a complete breech, weighs over nine pounds, or is premature, your doctor will probably choose to deliver your baby surgically. Be aware that each specialist is likely to have his or her own variations on these criteria. Also, remember that an x-ray diagnosis of "inadequate pelvis" may be inaccurate since your pelvic outlet will enlarge during delivery, especially in the squatting position.

5. If you wish to have a vaginal delivery of your breech baby and your doctor feels that you meet the criteria, expect that your labor will be monitored more closely than most. Even though you will experience careful surveillance during labor, take special care not to let the fear factor interfere with your labor. Here's where a professional labor assistant can help, making sure that birth attendants are not hovering over you "waiting for something to happen."

• Ask your doctor for a spinal or epidural anesthetic so you can be awake for the birth.
• Have your partner sit next to you at the head of the operating table. If he's hesitant, remind him that the actual procedure takes place behind a sterile curtain. He won't see anything upsetting.
• Ask your obstetrician to lift baby high enough so you can see him or her right after delivery. It is a beautiful sight to see your newborn lifted "up and out" during a cesarean birth.
• Immediately after your baby is delivered and quickly checked over (temperature, breathing and pulse, and heart rates are stable) ask that baby be brought to you to be held and hugged. You may need some help since you may be a bit groggy and one arm may be immobilized for an intravenous. This mother- father-baby bonding time, though brief, is an ideal time for pictures, and the anesthesiologist or attending pediatrician will often act as photographer for you.
• While your uterus and abdomen are being stitched closed (this takes about 30 minutes) and the operation completed, your husband should accompany baby to the nursery so he or she will not be alone with strangers. This extra father-baby bonding time will have a deep impact on both of them.
• To decrease postoperative pain, ask your anesthesiologist about using a long-acting analgesic given in the anesthetic tubing. This do-it-yourself analgesia, called "patient-controlled analgesia" (PCA), is set up so you can administer your own medication through your intravenous. Just turn the pump on and off, as you need relief. This medication is safe for your breastfeeding baby.
• In most cases baby can be brought to your bedside within an hour or two of surgery. If your husband or a nurse is present in the room and baby is healthy, it's even possible for a cesarean-birthed baby to room in with mother. The best postoperative "pain reliever" is an "injection" of baby in your arms.
• Be planning ahead for some good long-term help, one thing you'll need more of since you'll be recovering from major surgery.