VBAC: Vaginal Birth after Cesarean

If you have undergone a cesarean delivery, you are not alone. In November 2005, the Centers for Disease Control and Prevention reported the national cesarean birth rate was the highest ever at 29.1%. Performing a cesarean section on one out of three women and a repeat cesarean on more than 90% of women with a prior cesarean runs contrary to the US Healthy People 2010 goals. US National objectives to improve maternal, infant, and child health outcomes is to lower the cesarean rate for first time mothers to 15%, and increase the VBAC rate to 63% by the year 2010.

If you desire to try a vaginal delivery this time around, you'll be happy to know that 90% of women who have undergone 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 to 4 out of 5 women who have previously undergone cesarean birth can successfully give birth vaginally. After reading the information below and discussing it with your health care provider, you will be able to make an informed decision on whether VBAC may be an option for you this time around. If you are a good candidate for a VBAC the risks are generally low and the benefits to you and your baby can be great.

If you were given the following reasons for a previous cesarean and are considering a repeat cesarean, you may wish to discuss the following with your health care provider:

· Dystocia (pronounceddis-to'she-a): Dystocia refers to a long and difficult labor due to slow cervical dilation, a small pelvis, or a big baby. Many women who are given this reason for previous cesareans, have a subsequent successful vaginal delivery the next time, and give birth to a bigger baby than the first! I am unaware of any 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 for birth. As part of our pre-labor care, we opening the musculature and joints of your pelvis to restore their normal function, and prepare to deliver a baby of any size. Also, during labor there are certain positions that a woman can use to help open up the pelvis, allowing a larger baby to move through. For example, squatting opens the outlet of the pelvis by 10%.

· Genital Herpes: For many years, 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, the AmericanCollege of Obstetricians and Gynecologists (ACOG) has determined and recommended that unless there is a visible lesion at the time of birth, a vaginal birth is acceptable.

· Fetal Distress: When it comes to the life of the baby, there is no question in a mother's mind of what to do. If the baby is in distress, cesarean deliveries can be life saving. According to the Centers for Disease Control and Prevention, 9% of cesarean deliveries in 1991 were due to fetal distress. Fetal heart rate monitoring can be a routine part of the VBAC procedure, which helps detect fetal distress.

The following are criterion that generally must be met to be considered for VBAC:

  • No more than 2 low transverse cesarean deliveries.
  • No additional uterine scars, anomalies or previous ruptures.
  • Your health care provider should be prepared to monitor labor and perform or refer for a cesarean if necessary.
  • Your birth location should have personnel available on weekends and evenings in case a cesarean is necessary.

These criteria would make you a good candidate for a VBAC:

  • If the original reason for a cesarean delivery is not repeated with this pregnancy
  • You have no major medical problems
  • The baby is average in size
  • The baby is head-down

VBAC is not recommended in the following situations:

  • If you are pregnant with twins
  • If your baby is in a breech presentation
  • If you have diabetes
  • If you have high-blood pressure

Comparing a Repeat Cesarean to a 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 problems3

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.

VBAC and the Risk of Uterine Rupture:

The greatest concern for women who have had a previous cesarean is the risk of a uterine rupture during a vaginal birth. According to the AmericanCollege of Obstetricians and Gynecologists (ACOG), if you had a previous cesarean with a low transverse incision, the risk of uterine rupture in a vaginal delivery is .2 to 1.5%, which is approximately 1 in 5001.

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 health care provider. Recently, ACOG stated that VBAC is safer than repeat cesarean and VBAC with more than one previous cesarean does not pose any increased risk.2

Benefits of a VBAC:

· Breastfeeding - The Centers for Disease Control has identified cesarean section as a risk factor for the initiation of breastfeeding. According to the CDC Guide to Breastfeeding Interventions, medications and procedures administered to the mother during labor affect the infant's behavior at the time of birth, which in turn affects the infant's ability to suckle in an organized and effective manner at the breast. ( It is important to note that mothers who give birth by cesarean can initiate, establish and continue breastfeeding particularly if they are encouraged, educated and supported by breastfeeding specialists.) If you have a VBAC you can usually start to nurse in the birthing room.

· Safety. A successful VBAC is safer than a planned C-section. You're less likely to get an infection, have serious blood loss or experience complications from the anesthesia with a VBAC than with a repeat C-section.

· Shorter recovery time. You'll likely spend one less day in the hospital after a VBAC than you would after a repeat C-section. Your energy and stamina will return more quickly as well.

· More participation in the birth. For some women, VBAC is more emotionally satisfying than a repeat C-section.

· Earlier bonding with your baby. If you have a successful VBAC, you may get to hold your baby sooner than you would after a repeat C-section.

· Cost. A successful VBAC costs less than a planned repeat C-section.

Resources:

1. ACOG Practice Bulletin, No. 5, July 1999

2. ACOG, Midwifery Today, Winter No 36, page 47.

3. International Cesarean Awareness Network

4. Levine EM, Ghai V, Barton JJ, Strom CM. Mode of delivery and risk of respiratory diseases in newborns. Obstet Gynecol 2001;97(3):439-42.

5. Mayo Clinic

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