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Once a cesarean, always a cesarean.

Cragin, 1916

Once a cesarean, always a trial of labor?

Pauerstein, 1966

Once a cesarean, always a controversy.

Flamm, 1997


Few issues in modern obstetrics have been as controversial as the management of the woman who has undergone a prior cesarean delivery. As we approach the 100th anniversary of the oft-quoted remark by Cragin, the issue remains unsettled.


100 Years of Controversy


Management of the woman who has undergone a previous cesarean delivery has been—for good reasons—a controversial topic for more than 100 years. By the beginning of the 20th century, cesarean delivery had become relatively safe. But, as women survived the first operation and conceived again, they were now at risk for uterine rupture. This was because of the prevailing use of vertical hysterotomy—and especially the classical incision (Williams, 1903). The inherent dangers of uterine rupture led to the dictum above by Edwin B. Cragin (1916). It was not until later that Kerr (1921) described use of a transverse low-segment uterine incision that was predicted to be less likely to rupture with subsequent labor.


Perhaps contrary to popular belief, these events did not result in strict adherence to repeat cesarean delivery. In the 10th edition of Williams Obstetrics, Eastman (1950) stated a preference for vaginal delivery in these women and described a 30-percent vaginal delivery rate at Johns Hopkins Hospital. But while only 2 percent of women who labored had a uterine rupture, they had a 10-percent maternal mortality rate. Subsequent observational studies from the 1960s also suggested that vaginal delivery was a reasonable option (Pauerstein 1966, 1969). Germane to this is that through the 1960s, the overall cesarean delivery rate was only approximately 5 percent. Beginning then, however, well-intentioned efforts to improve perinatal outcomes were accompanied by a rapidly escalating cesarean delivery rate that exceeded 20 percent by 1985 (Chap. 30, Cesarean Delivery in the United States). In addition, the concept of cesarean delivery on maternal request has increased the primary operation rate (American College of Obstetricians and Gynecologists, 2013b). And as expected, as the primary cesarean rate increased, the rate for repeat operations followed (Rosenstein, 2013).


To address this, a National Institutes of Health (NIH) Consensus Development Conference (1981) was convened, and it questioned the necessity of routine repeat cesarean delivery. With support and encouragement from the American College of Obstetricians and Gynecologists (1988, 1994), enthusiastic attempts were begun to increase the use of vaginal birth after cesarean—VBAC. These attempts were highly successful, and VBAC rates increased from 3.4 percent in 1980 to a peak of 28.3 percent in 1996. These rates, along with a concomitant decline in total cesarean delivery rates for the United States, are shown in Figure 31-1.

Figure 31-1

Total and primary cesarean ...

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