Ask Your Midwife Elizabeth Stein, Certified Nurse Midwife Ask your Midife Articles
Vaginal Birth After Cesarean

By Elizabeth Stein, CNM

Question
My first baby was born by cesarean delivery. Can I have a vaginal delivery this time? Is it safe? Or should I just plan a repeat cesarean?

Answer
Safety and your wishes are both important considerations. Let's review some of the risks and issues.

Why a VBAC?
In the United States, of 4 million births per year, nearly 1 million cesarean deliveries are performed. While many women have had successful VBACs, the pendulum seems to be swinging back toward repeat cesarean deliveries.

In 1916, the dictum "once a cesarean, always a cesarean" came into favor. At that time, the c-section rate was 2 percent. Cesareans were usually performed because of a contracted bony pelvis. The uterine incision was classical -- high up and vertical. This way of doing things remained unchanged and unchallenged until the early 1980s. After many advances in surgery, anesthesia, and the use of the lower-segment transverse uterine incision, women were encouraged to have a trial of labor (TOL) and vaginal birth after cesarean (VBAC). It was hoped that this would lower the cesarean rate, which was approximately 24 percent, of which one-third were repeat cesareans.

If you wish to have a trial of labor and a VBAC, consider the reason for the first cesarean. If it was a nonrepetitive event, there is a good chance for a vaginal delivery this time. For example, if your first baby was breech (buttocks or feet first) but this baby is vertex (head down), or if you had twins and now there is one vertex baby, or if you had placenta previa (the placenta covering the cervix) and this time the placenta is high, you may have a successful VBAC.

But what if you just didn't progress in labor, or your baby was too big to fit through your pelvis? This is known as cephalopelvic disproportion. It's considered a potentially repetitive event. If a careful review of your previous medical records doesn't reveal any complications associated with your previous delivery or postpartum recovery, you may still consider a trial of labor.

It's reasonable for some women to have a trial of labor in a safe setting. You and your partner should understand the potential complications, risks, and benefits for you and for your baby in order to make an informed choice. Your midwife or doctor should discuss the size of this baby in relation to your pelvis, and she should understand your previous delivery experience as well as your expectations, concerns, and fears. All your questions should be thoroughly answered.

Benefits
What are the benefits of a VBAC? There are many. You avoid major abdominal surgery, which carries the risk of infection, hemorrhage, anesthesia-related complications (for both you and baby), surgery-related complications (such as the bladder, the bowel, or the baby being cut), blood clots, and possible need for blood transfusions. Very rare complications of abdominal surgery can include hysterectomy (removal of the uterus) and death. With a VBAC, you get the satisfaction of accomplishing a vaginal delivery. Your hospital stay is shorter and less painful, and you recover more quickly.

Risks
Under certain circumstances, it's not safe to attempt a vaginal delivery. The type of incision that was cut into the uterus during your c-section is very important. If the incision was a classical vertical incision (up and down), it would be unsafe to go through labor because incision site could separate (known as uterine rupture), endangering your baby and yourself. Your midwife or doctor can determine which type of uterine incision you had by reading your previous medical records. Don't look at your skin incision! It is the incision into the uterus that matters, and it may be different from what you see on your skin.

The length of time from your c-section to your current due date is another issue. If less than 12 to 24 months will have passed since your c-section, your health-care provider will question whether there has been sufficient time for healing. Is the scar site strong enough to go through labor without separating? The highest risk for uterine rupture during labor is during the first year after a cesarean delivery. The risk of uterine rupture decreases over the following years. Other factors, such as surgical technique, suture material used, or infection may be involved as well. This issue is controversial and is being studied.

Another factor that is associated with an increased chance of uterine rupture is induction of labor. If labor hasn't started naturally and your midwife or doctor wants to induce you, give very careful consideration to scheduling a repeat cesarean delivery instead. Scheduled repeat cesarean deliveries have the lowest risk of complications. A woman undergoing a trial of labor, who then experiences a long, hard labor, typically suffers more infections and complications -- especially when the membranes are ruptured. If an attempted VBAC labor is long and difficult or if complications arise, a repeat cesarean should be considered while in labor.

Women with a previous cesarean delivery should not labor in an out-of-hospital birthing center or attempt a home delivery. If complications arise, too much precious time is lost during the transfer to the hospital. It's a safer choice to labor and deliver in a hospital with a birthing room. Your midwife may deliver you vaginally, but a physician and facilities should be available immediately if the need for an emergency cesarean delivery arises. An anesthesiologist should be present in the hospital. You may want to consider having an epidural in place. It will provide pain relief during labor or anesthesia for a repeat cesarean delivery. During an emergency c-section, there is no time to place an epidural. If you don't already have an one in place, you'll receive general anesthesia and you would need to be intubated (breathing tube placed in your airway), exposing you and your baby to anesthetic gases as well as additional risks. You would also be asleep and miss seeing you newborn's first moments.

Making the choice
Who chooses which route? A woman who had a long, hard labor, developed an infection, and ended up having a c-section is usually not inclined to go through labor again, with the chance of having another cesarean. She'd tend to want a scheduled repeat cesarean. On the other hand, a woman who had a cesarean because her baby was breech may want to experience labor and a vaginal delivery. She may choose a trial of labor, hoping for a successful VBAC. An unsuccessful VBAC just means you have a repeat cesarean delivery -- it doesn't mean you have failed. The bottom line is a healthy mom holding a healthy baby.

The woman's choice of route of delivery (vaginal or abdominal) should be thought of as her preference or desire. She should be willing to switch plans if the clinical picture changes. Her choice should be respected, and she should feel free to change her mind and the plan of management. If no complications develop, her newborn will be fine by either route of delivery. Women juggle busy lives filled with child care, work, and family responsibilities. Some may want to plan and prefer the idea of a scheduled repeat cesarean. Each woman's preferences, past obstetrical history, and current status are unique and should be individually reviewed.


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