There should be no automatic repeat Caesarean sections. In every case the need for this type of delivery should be assessed individually and in relation to the particular baby. The chances of having a vaginal birth following a Caesarean birth are good, although it will usually be described as a ‘trial’ of labor.
Such a birth is normally expected to take place in a consultant unit with facilities available for an emergency Caesarean section if necessary; this is because of the fear that your uterine scar may not stand up to the pressure of labor, and separate or rupture as a consequence. This happens only rarely — once in every 500 cases where the incision is of the lower-segment ‘bikini line’ kind. It is more common, 1-3 per cent, with classical up-and-down scar. In both cases it is more likely to occur when labor is artificially accelerated with Syntocinon.
If a scar does rupture, it is likely to do so at the end of pregnancy or in labor and it usually goes slowly. You might suspect it if you feel pain over the area of the scar which persists in between contractions, or have bleeding from the vagina. It might also be indicated by shock, swelling over the scar, a uterus which becomes rigid and does not contract, a rise in pulse rate or temperature or a fall in blood pressure. Clearly you should be admitted to hospital immediately in these circumstances. However, in most cases, separation is ‘silent’ so that neither the mother nor her attendants realise it until her uterus is checked following delivery, and it is then surgically repaired.
You are likely to face considerable opposition if you want to have a baby at home after a Caesarean section, although that experience may make you particularly keen to avoid a repetition. It has to be a confident and experienced midwife who will book you willingly, but it certainly has been done, even when there has not been a normal delivery in between. The general reluctance is a reflection of the obstetric practice in this country. In less developed countries home birth following Caesarean section is considered the norm, and it is generally trouble free if there is no evidence of gross disproportion of the pelvis.
In assessing whether the original reason for the operation is likely to be repeated, you need to bear in mind that although there will always appear to have been a convincing reason for operating, some operations are performed for reasons other than the health of mother or baby. These could include fear of litigation, lack of patience, theoretical but undemonstrated risk, and inexperience. Briefly, the reasons given could include:
— Fetal distress. This is particular to that baby and should not recur. If your baby had an initial Apgar score of 7 or above, he or she was not truly in distress. (The Apgar score is a means of rating a baby’s condition at birth; it ranges from 1 to 10 and is done at one minute and again at five minute intervals until the baby scores 9.)
— Failure to progress. If your cervix does not dilate fully, the baby cannot be born and forceps cannot be used to help it out. This is a problem considered by many midwives to be associated with unhappiness in your surroundings, although it can also be mechanical, when the baby is too big for your pelvis. A home birth could be recommended if you remember feeling uneasy in hospital. If the reason was thought to be that the baby was too big for your pelvis, you should ask to have pelvimetry (an X-ray of your pelvis in various positions to assess its diameters) while you are not pregnant. This should give you a guide, although it is only a forecast. No one can be certain whether a baby will fit through a pelvis or not until labor. The baby has to be small if the transverse diameter at the outlet is 10 cm or less, but it is still not impossible. However if the same problem were to occur again at home, transfer would ultimately be inevitable.
— Breech and other malpositions and malpresentations. This would only be relevant if another baby was to adopt the same position, which can happen, although it need not.
— Contracted pelvis. This would remain the same. Again, it is worth having pelvimetry before you become pregnant again.
— Herpes. Some consultants consider this an automatic indication for Caesarean section. Others consider vaginal delivery is reasonable if there is no outbreak during the last four weeks of pregnancy, but this is controversial.
— Failed ventouse or forceps. You would have to know exactly why instrumental delivery failed. Forceps should not have been used unless the baby’s head was engaged in the pelvis and you were fully dilated. Pelvimetry might help here too. Remember that squatting can make all the difference between a normal or an operative delivery.
— Pre-eclampsia. This is much less likely in a subsequent pregnancy (4 per cent as opposed to 12 per cent), although if it does develop again and becomes severe, a repeat Caesarean section may well be necessary.
— Placenta praevia. This should not recur, but it would be useful to have a scan during late pregnancy to make sure.
— Fibroids. If untreated since the last pregnancy, fibroids might well be an indication for a repeat section if they obstruct the baby’s way out, but they can degenerate without any treatment after pregnancy.