If you’ve had a previous cesarean delivery, you may be wondering whether a vaginal birth is possible the next time around.
Years ago, it was a common practice for women to have repeat C-sections with subsequent deliveries. But the old saying, “Once a cesarean, always a cesarean” is no longer true. A Vaginal Birth After Cesarean, or VBAC, is widely discussed as cesarean deliveries are growing more common. In fact, C-sections now account for one in three births in the United States.
Having a baby vaginally after a C-section is associated with a number of benefits, including a decrease in maternal illness, elimination of abdominal surgery, lower risk of infection and a decrease in complications in future pregnancies.
With my first child, I had a primary C-section after pushing for more than three hours with no success. With my second, I elected for a Trial of Labor After Cesarean Section (TOLAC), which is a planned attempt to labor and delivery vaginally after a previous cesarean delivery. With TOLAC, the most common concern is the possible rupture of the cesarean scar on the uterus or rupture of the uterus itself. Although a rupture of the uterus is uncommon, it is very serious and may harm both you and your baby. Thankfully, my delivery resulted in a successful VBAC. I am able to relate to my patients and let them know about my experiences of a C-section, natural childbirth and a vaginal delivery with an epidural.
Although there are a number of benefits of VBACs, there is still much to consider. It is important to discuss your options with your provider to see what the best method is for you and your baby. Most of all, I want my patients to be safe, keep their uterus and have a healthy baby with the understanding that staying out of the operating room is our second goal.
For those wondering if they may be a candidate for a VBAC, here are seven elements to consider:
- Comfort and Experience of your Provider
If a woman wants to have a VBAC, she should ask her provider if they routinely allow a TOLAC. We usually quote a woman a 60 to 80 percent chance of VBAC if she is a good candidate.
- Type of Uterine Scar
The type of uterine scar is the most important consideration. Women with a low transverse uterine scar from the prior C-section are considered good candidates for TOLAC. If a woman’s uterus was incised vertically, if she had previous removal of fibroids or previous rupture, there is a significant risk of uterine rupture and these women are not considered candidates for a TOLAC. That is why it is important for your doctor to have a copy of the previous operative reports to confirm the incision was a low transverse incision on the uterus.
- Previous Vaginal Deliveries
Women who have previously had vaginal deliveries and then had a C-section for reasons such as breech presentation, fetal distress, or placenta previa have an excellent chance of having a VBAC.
- Previous Number of Cesareans
The issue of TOLAC after two cesareans is controversial. The risk of uterine rupture after two C-sections is thought to be just under two percent, however, it is not universally accepted to allow TOLAC after two C-sections. The major concern is the condition of the uterus and the health of the mother.
- Health History of the Mother
A woman who’s first C-section was for arrest of labor, for failure to progress, or for “dystocia” (baby not fitting) are less likely to have a successful VBAC. Other risks factors for a successful VBAC include advanced maternal age, a high BMI (body mass index), a big baby (8.5 to 9 pounds) and advanced gestational age at delivery.
- Risks and Benefits of Both Options
Consider the risks when deciding if you are a good candidate for a VBAC, including uterine rupture, which could have significant implications on the baby’s well-being if not delivered immediately. The risk of uterine rupture is thought to be about 1 percent. However, risks for having a repeat C-section include progressively worsening scar tissue, which increases the risk of injuring the bowel or bladder, and increased blood loss. You may also be at risk for the placenta attaching itself to the uterine wall too deeply and not separating from the uterus after birth, which is a very serious condition and is increasing with more repeat C-sections. There are also risks inherent to surgery: developing a blood clot, developing wound infection and having a slower recovery than a vaginal birth.
- Bigger Picture
When contemplating a VBAC, remember to keep the big picture in mind. I am particularly sensitive when patients need a C-section, whether it is their first or a repeat, as I recall the disappointment and fear I felt. I truly understand the desire of wanting to have a vaginal delivery, but sometimes it’s not in the cards. I really want patients to make decisions for themselves, but I hope to help make their expectations realistic.
For a referral to an OB/GYN on the medical staff at Andrews Women’s Hospital on the campus of Baylor Scott & White All Saints Medical Center – Fort Worth, call 1.800.4.BAYLOR or visit BSWHealth.com/FortWorthWomen
Beatrice Kutzler, MD, is a board-certified OB/GYN in Fort Worth, Texas, and is on the medical staff at Andrews Women’s Hospital on the campus of Baylor Scott & White All Saints Medical Center – Fort Worth. She received her medical degree from University of Texas Medical School and completed her residency in obstetrics and gynecology at University of Texas Health Science Center. She has been in practice for more than 25 years and still loves what she does. Even after all this time, she says she rarely wakes up and doesn’t want to go to work!