If you've already had a baby by cesarean section, it doesn't rule out the possibility of vaginal birth for your next delivery. Many women have a vaginal birth after cesarean (VBAC) without incident. “A VBAC is a very safe option for many women who have had one previous C-section and who have been identified as low risk—and that is the majority of women,” says Nancy Petit, M.D., chief of the division of obstetrics at St. Francis Hospital in Wilmington, Del. But along with the benefits of vaginal birth after cesarean, there are also a handful of risks. Thirty to 45 percent of Ob-Gyns no longer offer VBACs, and some hospitals offer it only with strict stipulations, such as going into labor spontaneously before your due date. (A VBAC should never be attempted if labor has been induced.) Read these important facts, and discuss your concerns and wishes with your obstetrician.
There are several reasons why you might want to try VBAC. Some women simply want to the experience of vaginal birth. There are also medical reasons why VBAC appeals to women and their health-care providers instead of a repeat cesarean:
Elimination of the need for abdominal surgery, which has inherent risks like infection, hemorrhage, and anesthesia-related complications
Reduction of the risk for possible blood transfusions, which also lowers the risk of blood-borne disease
Decreased length of hospital stay
Shorter recovery time
Fear of litigation drives much of the reluctance to allow VBACs. “Lots of providers and hospitals refuse to offer women the option because they fear getting sued if something goes wrong,” says Amy Romano, C.N.M., a nurse-midwife in Connecticut and author of Lamaze International’s Science & Sensibility blog (scienceandsensibility.org). Even some midwives have stopped offering VBACs because of liability issues.
That’s because a VBAC can lead to uterine rupture, a dangerous tearing of the uterine muscle or past C-section scar. “Uterine rupture can be catastrophic for the baby and may be life-threatening to the mother,” says Marilynn Frederiksen, M.D., an associate professor of clinical obstetrics and gynecology at the Feinberg Medical School of Northwestern University and a member of s panel of childbirth experts convened by the National Institutes of Health (NIH).
However, the incidence of uterine rupture is low—less than 1 percent—and it’s more of a risk if you need to be induced. What’s more, the NIH panel found that repeat C-sections expose women to greater risk of death than VBACs. “VBAC is a safe and reasonable option for most women and is in fact safer than repeat Cesarean for many,” Frederiksen says. Repeat C-sections also pose risks to mothers and babies in future pregnancies, when the likelihood of such serious conditions as placenta previa and placenta accreta increases.
The ACOG reports there's a greater risk of infection for mother and baby in cases of attempted vaginal birth after cesarean. Nevertheless, if you're going to have a VBAC, you should give birth in a facility that's equipped to do emergency cesareans, should the need for one arise.
VBAC tends to be safest for women who:
Have had at least one vaginal delivery
Have had only one previous C-section (The risk of uterine rupture increases with each cesarean performed)
Had a low-transverse incision (a horizontal cut low in the uterus) during their previous C-section. If you had a high vertical or "classical" cesarean, made by cutting vertically in the upper uterus, your risk of uterine rupture is greater.
Have a history of low-risk pregnancies
Are delivering only one baby who is a reasonable size
Do not have certain health conditions, including high blood pressure, diabetes (pre-existing or gestational) or active genital herpes
Have no history of uterine surgery or other uterine problems
Conceived longer than nine months after C-section, since your body will have had more time to recover
Don’t have placenta previa (low-lying placenta) or abruptio placenta (placental separation)
When determining if you’re a candidate for VBAC, your doctor will also consider the size of the baby relative to the size of your pelvis. If the baby can't fit, your uterus may be subject to prolonged stress in a delivery that won't progress properly.
Also, there may be factors that could signal possible complications during the baby's delivery (for example, breech presentation), which, coupled with the other risk factors of prior cesarean, might make VBAC too risky. Ultimately, most of these factors can be identified prior to the delivery. So you should be able to discuss your options and wishes at length with your health-care provider.
If you think the VBAC debate doesn’t affect you because you’re pregnant for the first time, think again. As the number of medically unnecessary C-sections rises, so do your chances of going under the knife for delivery No. 1 and having to deal with the VBAC question for delivery No. 2.
The best advice? If at all possible, avoid that first C-section. Certified nurse-midwife Amy Romano, C.N.M., says some women decide to be “conservative” during their first pregnancy and agree to interventions that may not be necessary, including C-sections. “Then in their next pregnancy, those women face risks they would not have faced if their first baby had been born vaginally,” she says.
Moms with Subsequent Pregnancies:
If you’re not a first-timer, would like to try for a VBAC and are a good candidate, start researching your options early in pregnancy. If your doctor or hospital doesn’t allow VBACs, consider other providers. For example, a major medical center with a level-3 NICU (neonatal intensive-care unit) and round-the-clock staffing by anesthesiologists is more likely to offer the option than a small community hospital is.
Support and information can come from childbirth educators, doulas, midwives and women online and in other communities who have had a VBAC. “Making a choice that is not considered mainstream, even when research supports its safety, can be very difficult,” Romano says. “So the more support a woman has, the better.”