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Vaginal Birth after Cesarean (VBAC)

If you had submitted yourself to a cesarean delivery before, you are not the only one. In June of 2003, the US Centers for Disease Control reported that the national cesarean birth rate was the highest ever at 26.1%, which is over a quarter of all deliveries. But if you are considering trying a vaginal delivery this time, you’ll be happy to know that 90% of women who have suffered cesarean deliveries are candidates for VBAC. Quite interestingly, the highest rate of VBAC is in women who have experienced both vaginal and cesarean births and given the choice, decide to deliver vaginally. In most published studies, 60-80% or 3 out of 5 women who have previously undergone cesarean birth can successfully give birth vaginally.

One of the greatest concerns for women who have had a cesarean before is the risk of a uterine rupture during a vaginal birth. According to the American College of Obstetricians and Gynecologists (ACOG), if you had a previous cesarean with a low transverse incision, the risk for uterine rupture in a vaginal delivery is .2 to 1.5%, which is approximately One in 500. Some studies have documented increased rates of uterine rupture in women who undergo labor induction or augmentation. You will want to discuss the possible complications of induction with your physician. Recently, ACOG stated that VBAC is safer than repeat cesarean and VBAC with more than one previous cesarean does not pose any increased risk.

If you had the following reasons for a previous cesarean and are considering repeat the procedure, you may wish to discuss the following topics with your care provider:

Dystocia: refers to a long and difficult labor due to slow cervical dilation, a small pelvis, or a big baby. Many women given this reason for previous cesareans, deliver vaginally the next time, and give birth to bigger babies than the first! ACOG states that the effects [or difficulties] of labor with a baby more than 8 ¾ lbs have not been substantiated. There is no evidence that a big baby necessitates a cesarean. The pelvis and the baby's head are not rigid structures and both mold and change shape to allow the birth to occur. During labor there are certain positions that a woman can use to help open up the pelvis, allowing for a larger baby to move through. For example, squatting opens the outlet of the pelvis by 10%.

Genital Herpes: women with a history of herpes almost always delivered by cesarean, due to the risk of passing herpes to the baby during delivery. Physicians would do cultures in the last weeks of pregnancy and if the virus were active, a cesarean would be scheduled. Now ACOG has determined and recommended that unless there is a visible lesion at the time of birth, a vaginal birth is acceptable.

Fetal Distress: if the baby is in distress, cesarean deliveries can be life saving. According to the Centers for Disease Control, 9% of cesarean deliveries in 1991 were due to fetal distress. Fetal heart rate monitoring is usually a routine part of the VBAC procedure, which helps detect fetal distress. You may want to discuss the possibility of fetal oxygen monitoring with your physician. Fetal oxygen monitoring is another type of monitoring that is thought to be a more accurate indicator of fetal distress than fetal heart rate monitoring.

There are some criterions that a woman should meet while considering VBAC such as, not have had more than 2 low transverse cesarean deliveries, no additional uterine scars, anomalies or previous ruptures. Moreover, your physician must be prepared to monitor labor and perform an emergency cesarean if necessary during active labor, and your hospital must have anesthesia and personnel available on weekends and evenings in case an emergency cesarean is necessary.

You can also be a good candidate for a VBAC if the original cause for a cesarean delivery is not repeated with this pregnancy, if you have no major medical problems, or if the baby is a normal size and head-down.

VBAC would only not be recommended if you are pregnant with twins, if you have diabetes or high-blood pressure.

Repeat Cesarean vs. VBAC:

Repeat Cesarean	VBAC
Usual risks of a surgical procedure	Less than 1% chance of uterine rupture. If uterine rupture occurs you have risks of blood loss, hysterectomy, damage to bladder, infection, & blood clots
Hospital stay of approximately 4 days	Hospital stay of approximately 2 days
Development of an infection in the uterus, bladder, or skin incision	Risk of infection doubles if vaginal delivery is attempted but results in cesarean
Injury to the bladder, bowel, or adjacent organs	Possibility of tearing or episiotomy
Development of blood clots in the legs or pelvis after the operation
On-going pain & discomfort around incision	Temporary pain and discomfort around vagina
Small chance that the baby will have respiratory problems	The baby’s lungs will clear as baby passes through birth canal
If you plan for many more children, take into account that the more surgeries a woman has had the greater the risk of surgical complications. A fourth or fifth cesarean has more risk than the first or second.