Vaginal delivery after caesarean section – right to choose
What are my options for vaginal delivery after a C-section? VBAC
More than one in five women (20%) in England today give birth by caesarean section (a surgical procedure where an incision is made in your abdomen and your baby is born through this incision). Many women have a history of more than one caesarean section.
If you've had one or more C-sections, you may be thinking about how you're going to give birth next time.
Whether you choose to have a normal birth (VBAC) or a C-section again in a future pregnancy, your choice is safe with different risks and benefits.
Overall, both are safe options with very little risk.
When discussing your options, your gynecologist will ask you about your medical history in your previous pregnancies.
To properly advise you about your chances of a vaginal birth after a caesarean section, (VBAC) we need to know:
- the reason for the caesarean section. What happened – was it necessary?
- the type of incision made in your uterus (vertical or transverse)
- how you felt about your previous birth. Do you have any concerns - questions?
- whether your current pregnancy is low-risk. Have there been any problems or complications?
You, along with your obstetrician and midwife, will consider what your chances are for a successful vaginal birth after a caesarean section (VBAC), taking into account your personal wishes and your future fertility plans in the process of making the decision about whether to try for a vaginal birth or a caesarean section.
What is a VBAC?
VBAC stands for “vaginal birth after caesarean section”.
It is the term used when a woman gives birth naturally after having a caesarean section in the past.
Vaginal birth can involve birth assisted by "cupping" or "spooning".
What is an elective repeat cesarean?
Elective caesarean means planned caesarean.
The date is usually planned in advance during your pregnancy monitoring.
A caesarean section usually happens in the last seven days before your expected due date, unless there is a reason why you or your baby needs to be born earlier.
What are the benefits of a successful VBAC?
Benefits of a successful VBAC include:
- a vaginal birth (may include assisted labour); Increases the chance of normal delivery in future pregnancies.
- shorter recovery and shorter hospital stay.
- less abdominal pain after birth.
- avoid caesarean section.
When a woman tries for a VBAC, what is the chance of success?
Overall, about three out of four women (75%) with a normal, uncomplicated pregnancy who will go into labor on their own give birth naturally after a caesarean section.
Of women who have given birth vaginally, either before or after a caesarean section, about nine out of ten women (85-90%) can give birth normally.
Most women with two previous C-sections will give birth again by C-section.
However, women who go into labor spontaneously (on their own) have a slightly lower chance of a successful vaginal delivery (between 70% and 75%).
What are the chances of a successful VBAC?
A number of factors (risk factors) make the likelihood of a successful vaginal birth less likely. These are when:
- the woman had never given birth vaginally
- labor must be induced
- there was no progress in the progress of labor and a caesarean section was required (usually because of the position of the baby)
- are overweight – body mass index (BMI) over 30 at the first trimester pregnancy appointment.
What are the disadvantages of VBAC?
Disadvantages of VBAC include:
- Emergency caesarean section
There is a chance that you may need to have an emergency C-section during your labor.
This occurs in 25 out of 100 women (25%).
This probability is only slightly higher than in women giving birth for the first time, when the probability of an emergency caesarean section is about 20 in 100 women (20%).
The usual reasons for an emergency caesarean section are to slow down the progress of labor or if there is concern for the baby's well-being.
- Blood transfusion and infection in the uterus
Women who choose a VBAC have a one in 100 (1%) greater chance of needing a blood transfusion or having an infection in the uterus compared to women who choose a planned C-section.
- Scar weakening or scar rupture
There is a chance that the scar on your uterus will weaken and open.
If the scar breaks open completely (scar tear) this can have serious consequences for you and your baby.
This occurs in only two to eight women in 1000 (about 0.5%).
Inducing labor increases the chance of this happening.
If there is any indication that any of the above is happening your baby will need to be delivered by emergency caesarean section.
- The risks to your baby
The risk of your baby dying or being brain damaged if you attempt a VBAC is very small (two in 1000 women or 0.2%). This risk will not be higher than if you were giving birth for the first time, but it is higher than if you were giving birth by elective – repeat caesarean section (one in 1000 or 0.1%). However, this must be weighed against the risks to you if you have a repeat C-section (read below). These disadvantages are more likely to occur in women who attempt a VBAC and it does not work.
When is VBAC not recommended?
There are very few times when a VBAC is not indicated and a repeat C-section is a safer option.
These are when:
- you have had three or more previous caesareans;
- the uterus has ruptured during a previous birth;
- you have a high uterine incision (classic caesarean section)
- you have other pregnancy complications that require a caesarean section.
What are the advantages of repeat caesarean section?
Advantages of a repeat cesarean include:
- there is no risk of rupture of the uterine scar
- avoids the risks of childbirth and especially the risk of possible brain damage or stillbirth from lack of oxygen during labor (one in 1000 or 0.1%).
However, since a C-section is scheduled for seven days before your expected due date, there is a chance that you will go into labor before your scheduled C-section date.
One in ten women (10%) go into labor before this date.
What are the disadvantages of repeat C-sections?
The disadvantages of repeat cesarean sections
include:
- A longer and perhaps more difficult operation. A repeat C-section usually takes longer than the first surgery because of the scar tissue that has formed. Adhesions can also make surgery more difficult and can lead to bowel or bladder damage. There are rare reports of accidentally cutting the baby in a caesarean section.
- Chance of a blood clot (thrombosis). A blood clot that occurs in the lung is called a pulmonary embolism. Pulmonary embolism can be life-threatening (death occurs in less than 1 in 1000 C-sections).
- There is a longer recovery period. You may need extra help at home and you will be able to drive about six weeks after giving birth.
- Breathing problems for your baby. Breathing problems are quite common after a C-section but luckily, they usually don't last long. Occasionally, the baby will need to be hospitalized in the special neonatal care unit. Three to four in 100 babies (3-4%) born by a planned C-section experience breathing problems compared to two to three in 100 (2-3%) after VBAC. Waiting until seven days before the expected due date minimizes this problem.
- The need for elective caesarean section in future pregnancies. More scar tissue is created with each C-section. This increases the chance of the placenta growing over the scar and making it difficult to remove in a subsequent caesarean section (placenta placentae). This can lead to bleeding and may require an obstetric hysterectomy. All serious risks increase with each C-section you have.
What happens if you go into labor with a planned VBAC?
You should tell your gynecologist and midwife immediately and go to the maternity ward so that an emergency caesarean section can be performed if necessary.
Contact the maternity hospital as soon as you think you are in labor or if your waters have 'broken'.
Once you are in labor, you and your baby's heartbeat will need to be monitored constantly. You can have epidural anesthesia if you want.
What if you don't go into labor when planning a VBAC?
If labor does not start until 40 weeks, you will discuss the various options with your obstetrician.
These are:
- you will continue to wait to go into labor automatically
- labor will be induced. This increases the risk of weakening the scar and decreases the chance of a successful VBAC
- you will have a successful VBAC
- you will repeat an elective caesarean section.
In 1916, Cragin used the expression "Once a cesarean, always a cesarean" to refer to the dangers of caesarean section as a surgery and to convince that caesarean sections should be avoided, aiming to reduce risks from future surgeries.
In 1960, repeat cesarean after a previous cesarean became accepted practice in the United States of America.
Advances in surgical techniques and advances in anesthesia have boosted the rate of caesarean sections performed, which jumped from 5% in the early 1970s to 27% in 1988.
This rapid increase was accompanied by an increase in maternal morbidity, a lengthening of hospitalization time, and an increase in the cost of hospitalization.
Consequences that led the United States to a national effort to reduce cesarean section rates in the 1980s.
C-sections due to a previous C-section constituted 1/3 of all operations, and natural delivery after C-section appeared as a strategy to reduce the C-section rate.
Many decades ago, doctors almost always recommended a new C-section because they were concerned that the pain would cause the uterus to rupture at the site of the scar.
But in 1980, medical experts concluded that many mothers can safely give birth by vaginal delivery next time, based on evidence that the risk of uterine rupture is less than 1%.
However, in the last decade the scale began to tip again towards "lifetime" C-sections: in 2006, in 19 US states, 92% of women had a C-section again in their next pregnancy.
And in 1999, the American College of Obstetricians and Gynecologists issued guidelines recommending that VBAC (Vaginal Birth after Cesarean Section) should only be attempted in hospitals equipped for extremely urgent surgery.
However, VBAC remains a safe practice for the right candidates, and when these women follow it, a 60-75% rate actually succeeds in delivering vaginally.
The expert group argues that the doctor should impartially present the pros and cons to women so that they can make up their own minds.
But what is the success rate?
In research, when reviewing the international literature, the success rate of a vaginal delivery after caesarean section ranges from 60% to 75%.
Knowing the factors associated with increased success rates helps us predict which women deserve and can enter this procedure.
Which women are suitable for vaginal delivery after caesarean section?
According to the NIH expert panel, further study is needed on which women are the best candidates for VBAC.
Generally, however, VBAC is performed on women who have had a previous caesarean with a "transverse" section - the one most common today.
Otherwise, women should be low-risk:
- not to conceive twins or triplets
- the baby is not too big
- not to be obese
- not have high blood pressure or diabetes.
Short height, increased weight as well as old age of the mother are associated with increased failure rates.
A newborn weight of more than four kilograms also reduces the chances of success.
Women in whom the interval between pregnancies was longer than 18 months, that is, the caesarean section was performed more than 18 months ago, have higher success rates.
Cervical dilatation of more than five centimeters in a previous delivery that developed into a caesarean section is also a positive prognostic factor.
Uterine rupture is the most important, in terms of consequences, complication of vaginal delivery after caesarean section.
The reported probability of uterine rupture in various studies ranges from 0.2% to 1.5%.
Its consequences include death or neurological damage to the newborn in 30% of cases, total hysterectomy, bleeding, injury to other organs such as the bladder, and even the death of the woman.
The first, perhaps, indication of uterine rupture is the fetal distress which is reflected in the pathological cardiotocogram.
Other signs are heavy vaginal bleeding, a sudden change in the woman's vital signs and level of consciousness, and severe pain in the area of the old incision.
In the event that a vertical incision has been made in the first caesarean section, the rate of uterine rupture is 3.7%.
Uterine surgeries such as removal of fibroids increase the risk of rupture.
Extended administration of oxytocin in women preparing for vaginal delivery after cesarean section increases the risk, and in studies the rate of uterine rupture is 2.3% to 2.7% of cases. In the case of the use of prostaglandins, this percentage is higher.
In a 2005 multicenter study, Landon et al looked at data on 17,898 women who chose VBAC and 15,801 women who chose planned cesarean delivery.
The results showed that the risk of neonatal encephalopathy increases slightly but there is a significant difference in the rate of uterine rupture in the 2 groups of course with higher rates in the 1st group
Finally, the American College of Obstetricians and Gynecologists included in the guidelines issued in 1999, an instruction according to which a team of surgeons, anesthesiologists and neonatologists, as well as an operating room, must be on hand whenever a vaginal delivery is performed on a woman with a history of caesarean section.
Vaginal delivery after caesarean section is possible and although it has been left behind it can be done in selected cases and obstetric clinics such as the REA Obstetrics and Gynecology Clinic which have an intensive care unit for both newborns and post-partum patients.
The rates of successful such births in other countries should encourage us, and knowledge of the true dimensions of the risks, as offered by research, should be our guide.
Finally, we should point out that the alternative of a second caesarean section does not eliminate the risks.
With price
Ioannis Kalogirou
Obstetrician gynecologist
