Otherwise known as the Dictum of Cragin, the century-old philosophy of “once a caesarean, always a caesarean” has come into question since the 1980s. Based on the increased risk of uterine rupture if a vaginal delivery followed a previous caesarean section (C-section), this advice led to a dramatic increase in the number of C-sections being performed throughout the 20th century. Medical professionals have been revising this advice to better reflect modern medical capabilities, and now new research also highlights the perspectives of women facing the decision of whether or not to repeat a C-section and how they can be better supported in making this decision.
By Stefania Triunfo
The delivery preferences of pregnant women have been changing over the years, with rising numbers of ceasarean sections (C-sections) worldwide. One major factor contributing to this development is that many women who have already had a C-section decide to repeat the procedure in a subsequent pregnancy, thus endorsing the “once a cesarean, always a cesarean” philosophy.
More recently, the pendulum has swung in favour of trial of labor for attempting a vaginal delivery, moving away from a planned repeated C-section. There may be several reasons for this, including changes in policy statements from national medical organizations. However, change comes slowly in medical practice and, despite new recommendations, a vaginal birth after caesarian remains unobtainable for far too many women.
A group of Italian researchers and midwives wanted to find out which factors are most important for women deciding between trial of labor after a previous C-section and an elective repeat caesarean. They used a tailored questionnaire to collect epidemiological, socio-cultural and obstetric data at two Italian hospitals with differing rates of repeated C-sections. More precisely, they collected information about maternal age, education level, information received after the previous C-section, participation in antenatal courses as well as maternal self-determination in attempting a vaginal birth.
Their findings, recently published in the Journal of Perinatal Medicine, confirm the general tendency of health professionals to support women in attempting a vaginal birth. The comparison between the two hospitals identified prenatal counselling, one-to-one assistance in the delivery room and a strong personal motivation as major determinants in choosing a vaginal birth after a previous C-section. On the other hand, women with only limited experience in prenatal care courses tended to choose a repeated cesarian section. Interestingly, the same applied for women with a higher education level. The researchers presume that in this complex and challenging decision process, a repeated C-section might seem like the “safe solution”, making women feel more in control of the birth experience.
In order to mitigate the current rates of repeated C-sections, the researchers conclude that a focus on maternal individual needs, support from family members and other women with experience as well as general management of fear and prejudices is essential. They believe that new strategies and protocols need to be established to better assist women from as early as the postpartum period after their first C-section so that they are able to make an informed and confident decision in their next pregnancy.
Read the original article here:
Stefania Triunfo, Claudia Minciotti, Barbara Burlon, Franca Giovannangeli, Michelangela Danza, Saverio Tateo, Antonio Lanzone: Socio-cultural and clinician determinants in the maternal decision-making process to choice trial of labor vs. elective repeated cesarean section: a questionnaire comparison between Italian settings, 18.06.2019.