Mayo Clinic Guide to a Healthy Pregnancy: From Doctors Who Are Parents, Too!

CHAPTER 25. Vaginal birth after a cesarean birth

Your first child was delivered by cesarean birth (C-section), but you would really like to experience a vaginal delivery. Now, in your second pregnancy, can you have a vaginal birth? The answer is, maybe. It used to be that once you had a C-section, all of your subsequent deliveries would be by cesarean as well. Today, a vaginal birth after cesarean birth (VBAC) is possible in many cases.

However, VBAC is not without risk. Several factors must be considered before you and your care provider decide to try VBAC.

Women who choose VBAC go through labor and delivery in the same manner as any woman who experiences a vaginal birth. You wait for the first signs of labor and then head to the hospital. If you’re attempting a VBAC, it’s not recommended that you have a home delivery.

At the hospital, it’s important that a doctor and hospital staff closely monitor your active labor. They can be ready to perform a C-section if it’s needed. Most women who plan to have a vaginal birth after cesarean delivery are able to do so. Sometimes, though, a repeat cesarean birth is necessary.

BENEFITS VS. RISKS

Success rates of VBAC depend on many factors, including the reason surrounding your previous C-section.

Benefits of VBAC An advantage to having a vaginal birth is that it’s generally safer than a C-section because it doesn’t involve major surgery. Other advantages of a vaginal birth include:

 Lower risk of blood transfusions

 Lower risk of infection

 Shorter hospital stay, generally one to two days instead of three or more days

 More energy after childbirth

 A faster return to normal activities

In addition, you may feel more involved in the delivery process during a vaginal birth because of your efforts to push the baby out. Your labor coach and others also may be able to play a greater role in a vaginal delivery.

Risks of VBAC The possible risks of vaginal birth after a C-section include:

Failure to deliver vaginally A repeat C-section after an unsuccessful attempt at vaginal delivery may increase your risk of complications, which may include the need for a blood transfusion, the formation of blood clots and infection. You may also feel emotionally and physically drained after going through labor and being unable to deliver your child vaginally. A small number of women feel that they have failed, even though the events that transpired were beyond their control.

Tearing of the scar from your previous cesarean birth (uterine rupture) The risk of this happening is typically low in women who choose VBAC. However, uterine rupture may be life-threatening to you and your baby. Uterine rupture also increases the chances you’ll need a hysterectomy after delivery of your baby. There are several factors that increase the risk of uterine rupture, which you should discuss with your care provider. If you’re at high risk of a uterine rupture, your care provider will likely recommend that you have a repeat cesarean delivery.

ISSUES TO CONSIDER

Are you a good candidate for a vaginal birth after a cesarean delivery? It depends mainly on the type of uterine incision used during your initial cesarean birth and the reasons you had a cesarean delivery.

Previous incision During a C-section, your care provider creates an incision in the abdominal wall and in your uterus. The incision in your abdominal wall goes through skin, fat and muscles. From this opening, your surgeon makes an incision in your uterus. The incision in your uterus is different from the incision in your abdomen. The types of uterine incisions are as follows:

A low transverse incision This is the most common type. It’s made horizontally across the lower portion of the uterus. It usually bleeds less than an incision made higher on the uterus. It also tends to form a stronger scar and presents less danger of rupture during subsequent labors. If you have had one or even two of these incisions, you may be a candidate for VBAC.

A low vertical incision This incision is made low on the uterus, where the uterine wall is thinner. It may be used to deliver a baby in an awkward position or when the doctor thinks that the incision may need to be extended. At this time, there’s no consistent data indicating that this type of incision increases the risk of uterine rupture. Therefore, if you’ve had this type of incision, you may still be a candidate for VBAC. Unfortunately, not many low vertical incisions are confined to the lower part of the uterus.

A classical incision This type of incision is made higher up on the uterus, on the portion of the uterus that contracts during labor. It was once used for all cesarean births but is now rarely used because a classical incision is associated with the highest risk of bleeding and of subsequent rupture of the uterus. It’s generally used only in emergency situations when doctors need to deliver the baby quickly. VBAC is not recommended for women who have had a classical uterine incision.

Unknown type of incision For some women, it’s difficult to determine the type of incision used during a previous C-section. Studies haven’t shown an increased risk of rupture in this situation because the vast majority have been low transverse uterine incisions. Unless your doctor has concern that your previous incision was a classical one, women with an unknown type of incision may be a candidate for VBAC.

Reason for previous C-section The reasons surrounding your first cesarean birth often influence the type of delivery you have in the next pregnancy:

 If your first cesarean was performed for a reason that may not necessarily recur, your chance of having a successful vaginal delivery is almost the same as that of a woman who has never had a cesarean birth. Examples include breech presentation, an infection, pregnancy-induced high blood pressure (preeclampsia), placental problems and fetal distress.

 If you’ve had at least one vaginal delivery either before or after your cesarean birth, you’re more likely to have a successful VBAC than issomeone who hasn’t had a vaginal delivery.

 If you previously had a difficult labor because of the size of your child or the small size of your pelvis (dystocia), you may still have a successful VBAC. However, the chances are somewhat lower than if you had a cesarean birth for a nonrecurring condition.

 If you have a chronic medical condition, such as a specific heart condition, where problems may arise again during labor and delivery, you and your care provider may decide on a repeat cesarean.

Who might not be a candidate In some cases, a repeat cesarean birth is a better option than VBAC. According to the American Congress of Obstetricians and Gynecologists, labor should not be attempted in the following situations:

 You have a prior classical or T-shaped incision or another similar type of uterine surgery

 Your pelvic opening is too narrow to allow a baby’s head to pass through

 You have a medical or obstetric problem that precludes vaginal delivery

 You’re at a facility that can’t perform emergency cesarean birth

Medical experts disagree on whether to attempt labor in these circumstances:

 You’ve had two or more previous cesarean births and no vaginal deliveries. However, the American Congress of Obstetrics and Gynecology states that women with two previous C-sections may be offered VBAC.

 You have an unknown uterine scar or have experienced a prior low vertical incision

 You are beyond your due date

 Your care provider suspects that your baby is larger than normal

In these situations, your best bet is to discuss with your health care team the potential risks and benefits associated with your particular case.

TIPS FOR PLANNING A VBAC

Most women who’ve undergone a cesarean are candidates for a vaginal birth in their subsequent pregnancies. Yet most choose not to have a vaginal delivery following a previous cesarean. Why don’t more women choose VBAC? Part of the reason may be the fear of a possible long, protracted delivery that ends in surgery. Another possible reason is that not all women have access to facilities that are prepared to handle VBACs.

If you and your care provider think that VBAC is right for you, don’t be afraid to try it. Although it’s impossible to guarantee that a VBAC will be successful, you can increase your chances of a positive experience. Try these suggestions:

 Discuss your fears and expectations. Your care provider can help you better understand the process and how you may be affected. If you have a new care provider, make sure he or she has your complete medical history, including records of your initial C-section.

 Take a class on VBAC with your labor coach. These classes often help you work through concerns you may have about VBAC.

 Have your VBAC at a well-equipped hospital. Look for a hospital that has continuous fetal monitoring, a surgical team that can be assembled quickly, and the ability to administer anesthetics and blood transfusions 24 hours a day.

 Discuss use of medications. For women undergoing VBAC, certain medicines should be avoided because they may increase risk of uterine rupture.

 Make sure a qualified care provider is available. Constant monitoring by your labor and delivery team can decrease the risk of complications. Make sure your labor and delivery team is aware of your obstetrical history.

 Think of yourself as an athlete preparing for an event. Thinking positively, a healthy diet, regular exercise and plenty of rest will provide your best chance of a vaginal labor and delivery.

 Keep your ultimate goal in mind. You want both you and baby to have a healthy outcome, regardless of how you get there.