Roger Harms, M.D., Mayo Clinic specialist in obstetrics-gynecology

"Once a Caesarean, always a Caesarean," was a statement made by a prominent physician (Dr. Edwin Cragin) in the first decade of the 20th century. It was well founded. The chances of someone having a Caesarean delivery at that time were less than 3 percent of all pregnancies, and it was done always of the most grievous of indications. Why? A patient at that time had a substantial chance of dying if she had a Caesarean delivery, so it was not done lightly. And almost anything that can be done to succeed in a vaginal delivery in 1910 was accomplished to avoid a Caesarean. So if you did not succeed in delivering vaginally in 1910, the chances were very good that it was a repetitive reason.

The second issue was that, in that era, rupture of the uterus with the result in blood loss was often not within the capabilities of medicine at the time to save a woman's life. So that was another powerful reason to make the statement. And finally, Caesarean sections at that time were always done with a vertical incision on the uterus, which was substantially more likely to give out in a future labor. So the actual chance of having that disaster of uterine rupture and the inability to deal with it on part of the physician was increased. So this doctor's statement of dogma had such a great ring to it that it carried forward for the next 65 years without anybody arguing whatsoever.

In the early 1970s, Caesarean deliveries were starting to be accomplished almost exclusively through transverse incisions in the lower part of the uterus. For some technical and anatomical reasons, that kind of scar is substantially stronger when stressed by a subsequent labor. That major change, plus the ability of physicians and hospitals to respond to bleeding and to respond rapidly with anesthesia with abdominal delivery as necessary, gave physicians the courage to try once again to question that dogma. And the success rate was really encouraging. So that's when the pendulum started swinging toward vaginal birth after Caesarean, and I think it was a definite progress in our care of patients, that we no longer adhere to that dogma.

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