Does the Maxim “Once a Caesarean, Always a Caesarean” Still Hold True?

E dwin Cragin's century-old opinion, " once a Caesarean, always a Caesarean, " is correct if placed in proper context [1]. Cragin was predicting the near certainty of repeat Caesarean section in a self-selected group of women (1%–2%) who failed to deliver vaginally after several days in active labour. At that time, rickets and pelvic deformity were prevalent even in industrialised countries, syntocinon for augmentation of slow labour was unknown, and surgery was crude and dangerous. The primary Caesarean section was undertaken to save the life of an exhausted, dehydrated, ketotic, often pyrexial and delirious, moribund mother. In those days, fetal compromise was not an indication for Caesarean section; indeed there was no such thing as fetal monitoring (either antepartum or intrapartum). Cragin recognised that women who survived one Caesarean section were not candidates for vaginal delivery in subsequent pregnancies. Within the last three decades, Caesarean section rates in many countries have risen 5-fold to10-fold. For example, in England and Wales the rate rose from 4% in 1970 to a current 22% [2]. In the United States it rose The rising rate has been driven at least in part by our reliance on electronic fetal monitoring, pressure from health consumers to salvage small babies even at the very margins of viability, fear of litigation, decreasing expertise in operative vaginal deliveries and, in the West, lifestyle choices. The current Caesarean section rate of about 50% in some countries [4] is too high and unsustainable, and according to the World Health Organization, is not associated with any further improvement in perinatal outcome compared to outcomes at a Caesarean section rate of 10%–15% [5]. Can we halt and reverse this trend, reduce the morbidity and drain on health care budgets associated with it, and, above all, balance maternal choice issues? In contrast to Edwin Cragin's patients, women today are healthier (rickets is rare now, even in nonindustrialised countries), and in the rich world at least, oxytocin, blood transfusion, antibiotics, and thromboprophylaxis are available, while surgery and anaesthesia are safe. Therefore, some obstetricians have enthusiastically and nonselectively promoted vaginal birth after Caesarean section. However, the consequences in inappropriate cases can be disastrous. Labour/vaginal birth after Caesarean section is associated with increased risks of uterine rupture and feto-maternal morbidity and mortality. These risks and costs of care rise further if the attempt fails [6]. Available evidence suggests that the complication rates are lowest in women …