If you have had a previous cesarean delivery, you may be wondering if you should attempt a VBAC, or vaginal birth after cesarean. In the past, most doctors recommended repeat cesareans for all women who had them, regardless of the reason. This practice dropped in the 1970s when vaginal birth became preferred for women having more children after a cesarean. This practice dropped again in the 1990s when insurance companies mandated VBACs for all women, even if they were not proper candidates. There was also wide use of induction agents, especially misoprostol, which greatly increases rupture rates.
In 2010, ACOG, the American Congress of Obstetricians and Gynecologists, revised their recommendations so that more hospitals would allow VBAC, thus cutting the high cesarean rate. Most women who have had one or two previous cesarean births with the low transverse incision are able to have a trial of labor after cesarean, or TOLAC. According to ACOG, 60-80% of women who allowed to labor have successful vaginal deliveries. Being pregnant with twins or having a suspected large baby are not grounds for refusing TOLAC.
There are risks and benefits to each mode of delivery. You should consider each side carefully to decide which is best for you. The most-often feared risk of VBAC is uterine rupture at the site of the previous scar. While this may be damaging to mother and baby the risk is small, at about 0.4% during labor. It is also possible to rupture during pregnancy, before labor begins, but this is very rare. The use of pitocin, a medication commonly given to induce labor raises the rate of rupture to 1.1%. While rare, this is sometimes life threatening to both mom and baby. Approximately 6% of uterine ruptures during TOLAC result in the death of the baby.
Other risks of vaginal birth include tearing, which may be severe in some cases, and shoulder dystocia if the baby’s shoulders are too large. This may cause injury to the baby or more tearing to the mother. In some cases, tearing that extend into the anus can cause bowel dysfunction.
The most obvious benefit of VBAC is the quicker healing time. You won’t have to wait a few weeks to pick up and care for your other children. Babies born by VBAC have lower incidence of respiratory distress, since vaginal birth expels excess fluid from the lungs. A VBAC may be best for you if you had your previous cesarean because of problems with the baby or a failed induction.
Cesarean carries different risks than VBAC, but still has them. The pelvic organs may be accidentally damaged during surgery, which happens about 0.5% of the time. Cesarean birth poses an increased risk of hemorrhage, with a risk of 1-6%. Hemorrhage may lead to hysterectomy. There is also an increased risk of infection and blood clots. Some risks affect future pregnancies. Women who have a cesarean are more likely to experience problems with the placenta, such as placenta previa, placental abruption, and placenta accreta. These lead to complications with the pregnancy, and can cause fetal death. Every surgery produces scar tissue, which may cause adhesions, in which the internal organs become stuck to one another or the abdominal wall. This may not cause problems, but in some cases is very painful and may make future abdominal surgeries more difficult and risky. These risks increase with each subsequent cesarean birth, so the number of children you want to have should be a factor in your birth-method decision.
A repeat cesarean may be the best choice for women who had their previous surgery for issues that may repeat, such as health problems or pelvic deformity. Some women are just more comfortable with the risks of cesarean than those of VBAC. Women should discuss all of their options and the benefits and risks of each with their healthcare providers.