There are 3 types of cesarean sections that can be done. Well, actually, there are a few more than that, but these 3 are the ones we’ll be talking about today. There are two cuts during a cesarean section that we think about, the cut through the skin (the scar you can see) and the cut through the uterine muscle.
The uterus is an incredibly strong muscle, and it heals quite well after a surgery like this. However, we must consider what will happen to that healed incision during the next labor. What we’ve discovered is that when the cut is made vertically through the uterus, the fibers of the muscle cannot heal strongly enough to prevent it from tearing apart during the next labor. If the cut is horizontal, though, the healed incision is much less likely to separate during the next labor.
Originally, all cesareans were done in the first method drawn above: The Classical Incision. Because of that, everyone was told “Once a cesarean, always a cesarean.” Since we’ve moved away from vertical incisions, though, people have been able to begin having VBACs (aka Vaginal Birth After Cesarean).
During a VBAC after a horizontal incision, the “Bikini Cut” as it is often called, there is still a small risk for uterine rupture, in which the incision tears open. Because of this it is important to be careful when having a VBAC. Some midwives and doctors feel confident doing VBACs in birth centers and at home, but I’m early enough in my career that it still makes me nervous. For now I’d like my VBAC patients to give birth in the hospital so I can keep a close eye on them, but maybe in 10 years that’ll change. Who knows?
Some people/hospitals still insist that VBACing is too dangerous since there is a (small) risk for uterine rupture, and therefore all their patients will always have a c section. However, there are increased risks with the multiple c-sections too. See, placentas like scars. So if you have a scar in your uterus (for example, a c-section scar), it is more likely that the placenta will attach over the scar. There are two issues with that: One is that the scar is likely to be down close to the opening of the uterus, so if the placenta goes down there, it may even cover the opening of the uterus, the cervix, which is a condition called placenta previa. It can be extremely dangerous necessitates a cesarean section to get the baby out. The other concern is that when placentas attach at scars, sometimes they grow roots into the scar tissue. This is called placenta accreta, and when this happens, even if you give birth vaginally, you will need surgery to remove the placenta from your uterus. You are at risk for lots of bleeding, having a chunk of your uterus removed, and even occasionally having the entire uterus removed.
Risks for placenta accreta:
- After the 1st cesarean: 3%
- After the 2nd cesarean: 11%
- After the 3rd cesarean: 40%
- After the 4th cesarean: 61%
- After 5 or more cesareans: 67%
How likely is it that my uterus will rupture (the scar will tear open) if I’ve had a cesarean section before?
The risk for uterine rupture while having a VBAC after a “Bikini Cut” cesarean is: 0.87%, which means fewer than 1 person out of 100, or fewer than 5 out of every 1000 people.
Interestingly, with each successful VBAC, the risk for rupture with following VBACs gets less and less:
- During the first VBAC the risk for rupture is: 0.87%
- Second VBAC: 0.45%
- Third VBAC: 0.38%
- Fourth VBAC: 0.54%
- Fifth VBAC: 0.52
[Source: Journal of Obstetrics and Gynecology]
What is a Uterine Rupture?
Risks of Cesarean Section
What is Cesarean Section from ACOG
Vaginal Delivery Recommended over Maternal-Request Cesarean from ACOG
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