Pregnancy & Birth

Vaginal Birth After Cesarean (VBAC) or Repeat Cesarean Section?

A substantial proportion of cesarean sections (more than one in three) are repeat procedures.³  If you are pregnant and have had a cesarean section in a previous birth, you will need to decide whether to attempt a vaginal birth after cesarean (VBAC) or have a planned cesarean section. Because both VBACs and cesarean deliveries involve some risks to both mothers and babies, making this decision can be a challenge. There is not a single answer that is right for everyone.

Often the condition that makes a cesarean necessary in one birth will not exist in the next, and many women who have had a cesarean section can go on to have a safe vaginal birth. The majority of women (at least three out of every four) who plan a VBAC with supportive caregivers will go on to have one, instead of needing a cesarean section, although it has become increasingly difficult to find a setting that supports VBACs.⁴  Women who give birth vaginally avoid the known risks of cesarean section. (See “Comparing the Risks of Cesarean Births Versus Vaginal Births,” page 228.)

My first child was delivered via C-section due to breech presentation and advancing PIH [pregnancy- induced hypertension] within me. I had a long recovery and wanted so much to try for a VBAC with my second child. We talked to my OB about all possible aspects of the hospital experience. One thing we discussed and I am glad I followed through on later was asking for a “hep lock” [heparin lock, a catheter that is inserted in your vein like an IV but is capped off instead of being constantly connected to a bag of fluid] instead of the full IV. I was more mobile with the hep lock. We hired a wonderful doula—someone who knew what we wanted from the birth and would be with us at all times during the labor and birth watching for any signs of uterine rupture (our doula was a retired birthing center nurse). With the help of my husband, our doula, and two very supportive delivery room nurses, I delivered my second child vaginally with no pain medication. The VBAC met my goals for a shorter recovery. It was a wonderful experience.

VBAC has its own set of risks. The most serious complication that can occur is a separation of a previous uterine scar (a uterine rupture) that, in rare instances, can result in excessive bleeding, the need for a hysterectomy, and even the death of the baby. However, a large proportion of what have been termed uterine ruptures are asymptomatic—that is, they have no medical consequences. The risk of uterine rupture during an attempt at vaginal birth after one prior cesarean section with a lower uterine horizontal incision is about one in one hundred, and the risk increases with the number of previous cesarean sections.⁵ (Uterine rupture can occur in the absence of scars on the uterus from a previous cesarean. However, the single factor that increases the chance of uterine rupture dramatically is a prior cesarean.)⁶

Women who attempt VBACs and ultimately need cesarean sections may feel that the physical and emotional toll of laboring and then having cesarean surgery was worse than the toll of a planned repeat cesarean would have been.

As you consider whether you want to pursue a VBAC, learn about how different factors in your previous cesarean experience may affect your likelihood of success in giving birth vaginally and your chances of uterine rupture. (For more information, see “What You Need to Know About VBAC,” page 234.)

If you decide to attempt a VBAC, it’s essential to choose a setting with available emergency care, in case you need to undergo a cesarean section. Also, find out the provider’s and hospital’s VBAC rates. To try to get a sense of how comfortable the nurses and physicians are with caring for women having VBACs, ask your provider about her or his feelings about trials of labor, about how the covering obstetricians feel, and about the support that you can expect in the hospital.

Many women as well as some obstetrical providers have become interested in trying to find ways to decrease the rate of cesarean births. In 1982, a large group of concerned parents and professionals founded the International Cesarean Awareness Network, Inc. (ICAN, first called the Cesarean Prevention Movement). It aims to prevent unnecessary cesareans, to provide support for cesarean recovery, and to promote VBAC.

In a practice guideline article published in 1988, the American College of Obstetricians and Gynecologists (ACOG) embraced the position that VBACs are a safe and reasonable alternative to repeat cesareans. They reaffirmed this position in 1991. In 1998 and again in 1999, ACOG added the caution that VBAC should be attempted only in institutions equipped to deal with uterine rupture. The rate of VBAC declined from more than one in four women in 1996 to fewer than one in ten in 2004.⁷  The national Listening to Mothers II survey reported that a majority of women (57 percent) in 2005 who wanted the option of a VBAC were denied that choice, primarily because their provider or hospital was unwilling to do a VBAC.⁸  If you are interested in a VBAC, try to find a hospital where VBACs are allowed and get a list of that hospital’s providers. Childbirth educators, midwives, and doulas in the area may be able to help identify VBAC- friendly caregivers and hospitals.

None of the local hospitals would even let me do a VBAC except for the [hospital-based] birthing center where I had my first baby. They had many stipulations, such as, I couldn’t get in the tub, or the shower, I had to have a hep lock put in my hand as soon as I went into labor should I need a C-section, I had to have constant fetal monitoring, and I couldn’t use a midwife because a doctor had to be on the premises for a VBAC. These stipulations were a combination of the birthing center and my ob-gyn practice. I remember calling my doula and saying, “I feel like not telling them when I go into labor so I can get to the birthing center just in time for pushing to avoid all of these crazy interventions.” My doula responded with the exact answer I needed. She said, “So, you are feeling like you have no power or control in your birthing process.” I said, “Yes,” and she told me that I needed to take back control. I immediately went to work researching VBAC statistics. . . . I wrote a letter to my practice saying that I wanted to be able to labor in the tub or the shower, [that] I did not want constant fetal monitoring unless something in my labor indicated that I needed it, and that I wanted to use the midwife or I was leaving the practice. It took many painful conversations, but they finally agreed to my terms. . . . I was so thrilled and felt so in control again. It was an amazing feeling.

WHAT YOU NEED TO KNOW ABOUT VBAC If you had a cesarean and want a VBAC, it is essential to talk with your health care provider before you go into labor. As you consider whether you want to try to have a VBAC or schedule a repeat cesarean section, you will want to know two very important things: First, what is your individual chance of having a successful VBAC? And second, what is your individual chance of having a uterine rupture? The following factors can affect your chance of having a successful VBAC: 1. The events that occurred during your previous labor and the reason you had the surgery. Was the reason for your previous cesarean a problem such as a breech presentation, which is not likely to happen again, or was it something such as arrest of dilation or fetal descent that is more likely to recur? 2. The previous number of cesareans or uterine surgeries that you have had. 3. Any history of previous vaginal births. 4. Your practitioner’s philosophy regarding VBAC. 5. The birth center’s or hospital’s guidelines and practices regarding VBACs. A growing number of hospitals and providers are refusing to allow women to attempt VBACs, for multiple reasons, including concern about uterine rupture and its complications, fear of lawsuits, and lack of immediately available anesthesia. Hospitals that cannot provide twenty- four-hour in-house anesthesia and obstetrical coverage usually do not allow VBAC attempts. Your chance of having a uterine rupture is increased if you: 1. Have a vertical scar on your uterus. Most of the time, the surgeon will make a horizontal cut into the uterus (low transverse cesarean section). Rarely, if this is not possible or the cesarean is performed in an emergency, a vertical incision will be made in the uterus (low vertical or classical). If you have a horizontal/ transverse scar on your uterus, your chance of uterine rupture is lower and a VBAC is safe to try. If you have a vertical incision, the chance of the uterus rupturing is much higher and a VBAC is not recommended. The visible scar on your belly is not always in the same direction as the scar on the uterus beneath. If you don’t know what kind of incision was made in your cesarean, you can find out by asking for your medical records. In rare cases, a surgeon may make both a horizontal and a vertical cut in the uterus, creating a scar in the shape of an upsidedown T; if this happened in your previous cesarean, it is not safe to give birth vaginally.

End of Excerpt.

Notes:

3. Physicians Committee for Responsible Medicine, “When Is Surgery Unnecessary?” accessed at www.pcrm.org/resources/education/society/society3.html on September 6, 2006.  [back to text]

4. Childbirth Connection, “Options: VBAC or Repeat C-Section,” accessed at www.childbirthconnection.org/article.asp?ck=10211 on July 26, 2006.  [back to text]

5. Julie Welischar, MD, and Gerald Quirk, MD, PhD, “Vaginal Birth After Cesarean Delivery,” UptoDate
Online, updated August 29, 2006; accessed via http://www.utdol.com/ (a subscription- only service) on January 25, 2007.  [back to text]

6. M. Barger, E. Declercq, A. Nannini, J. Weiss, and L. Bartlett, “Uterine Rupture,” American Public
Health Association, October 2001.  [back to text]

7. Brady E. Hamilton, Joyce A. Martin, Stephanie J. Ventura, Paul D. Sutton, and Fay Menacker, “Births: Preliminary Data for 2004,” National Vital Statistics Report, accessed at www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_08.pdf on December 14, 2006.  [back to text]

8. Eugene R. Declercq, Carol Sakala, Maureen P. Corry, and S. Applebaum, Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences (New York: Childbirth Connection, 2006).  [back to text]

Excerpted from Chapter 13: Cesarean Births in Our Bodies, Ourselves: Pregnancy and Birth  © 2008 Boston Women's Health Book Collective.