I've Had a Cesarean; Is a VBAC an Option For Me?

What is a VBAC (Vaginal Birth After Cesarean)?

It was once thought that if a woman has one cesarean delivery, all other babies she had should be born the same way. Today, it is known, that many women can undergo a trial of labor after cesarean delivery (called TOLAC). After a successful TOLAC, many women will be able to give birth through the vagina (called a vaginal birth after cesarean delivery, or VBAC). TOLAC is a good choice for many women, remembering that each situation is unique and TOLAC may not be appropriate for all women. First let’s look at some stats:

• The Center for Disease Control (CDC) published that of all deliveries in the United States, 32% or 1 in 3 women have a cesarean (2017 data).

• In Minnesota, the cesarean delivery rate is 27.4% (2017 data). Individual hospital statistics may differ.

• The World Health Organization (WHO) recommends the ideal cesarean rate should be between 10-15% and a most recent study shows 19%.

• Health Foundations Birth Center cesarean rate is 2-3%.

• 90% of women who have had a cesarean are candidates for TOLAC.

• 60-80%, roughly 3 to 4 of every 5 women who have had previously had a cesarean can successfully give birth vaginally.

Research also shows, the biggest risk factor of having a cesarean is the facility you walk into in labor. That is right. The facility you walk into in labor. This is why researching the facility and provider group you are planning to deliver with is important. Ask questions. Ask what your hospital or freestanding birth center cesarean rate is. What is your provider groups cesarean rate?

What I find disheartening is that many women do not know that a TOLAC and VBAC are an option. They are told the opposite and filled with a lot of fear. Many providers say that it is an option but make it feel unattainable.

A woman who has had a previous cesarean delivery has the following choices when planning how to give birth again:

• Chose to undergo a trial of labor and give birth vaginally (VBAC).

• Chose an elective repeat cesarean section.

Reasons to consider a TOLAC:

There are many reasons why a woman may want to consider TOLAC. Compared with an elective repeat cesarean section, a VBAC after successful TOLAC is associated with the following benefits:

• No abdominal surgery or risks associated with surgery

• Less postpartum discomfort & shorter recovery period

• Lower risk of infection

• Less blood loss & decreased chance of blood transfusion

• Greater chance of having a vaginal birth in subsequent pregnancies

• Increased feeling of control in the decision-making process

• Increased maternal satisfaction

For women planning to have more children, a VBAC may help them avoid problems linked to multiple cesarean deliveries. These problems include hysterectomy, bowel or bladder injury, and certain problems with the placenta.

What are the risks of a VBAC?

With TOLAC, the greatest concern for women who have had a previous cesarean is the risk of a uterine rupture during a vaginal birth. According to the American College of Obstetricians and Gynecologists (ACOG), if you had a previous cesarean with a low transverse incision, the risk of uterine rupture in a vaginal delivery is approximately 1 in 500 (0.2 to 1.5%). Ninety percent of uterine ruptures happen at the site of a scar from a previous cesarean section. Most studies show that for women who have had one prior C-section with a low-transverse (horizontal) incision, the risk of uterine rupture is less than 1%. Ruptures are more likely to occur during labor because a scar is more likely to give way under the stress of contractions.  A uterine rupture can be very serious and may harm both mother and baby and may lead to death.

During a cesarean delivery, one incision is made in the abdomen and another incision is made in the uterus.  Low transverse incisions carry the least chance of uterine rupture. They also are the most common type of incision used in cesarean deliveries. The risk of uterine rupture with one low, transverse incision scar when the labor starts on its own is about 5 out of 1,000 women (0.5%). Women who have had one previous cesarean delivery with low transverse incisions are candidates for TOLAC at Health Foundations.  It is not possible to tell what kind of incision was made in the uterus by looking at the scar on the skin. Medical records from the previous delivery can include this information.

Risks to the baby if there is a uterine rupture are brain damage and death.  About 10% of the time or 5 to 10 babies out of every 10,000 VBAC attempts will suffer brain damage or death (0.05% to 0.1%) when there is a uterine rupture.

What are the risks of an elective repeat cesarean?

• Increased risk of infection (There is a greater risk of infection, with having a cesarean delivery after TOLAC than having a planned cesarean delivery.)

• Increased blood loss or blood clots

• Decreased bowel function

• Respiratory complications

• Longer hospital stay and recovery time. Three to five days in the hospital is the common length of stay.

• Reactions to anesthesia

• Risk of additional surgeries. For example, hysterectomy, bladder repair, etc.

• Risk of adhesions

• Risk of uterine rupture

• Risk to future fertility and babies

• Increased risk of placenta previa or other placental issues in future pregnancies

• Risk that all future births may be surgical

• Maternal death (very rare). (6 in 100,000 for a scheduled cesarean delivery)

According to research, 60% to 80% of women who attempt a TOLAC end up having a successful vaginal delivery. By laboring for a VBAC, a mother can reduce her risk for major complications related to multiple repeat cesareans.

Although it is not possible to predict whether TOLAC and a VBAC will be successful, several factors have been shown to increase or decrease the likelihood of success. Below are some factors that have been consistently identified as bring strong predictors of VBAC success:

• Prior vaginal delivery

• Spontaneous labor (not induced or augmented)

• One or more prior successful VBAC(s)

• Non-recurrent reason for the prior cesarean (ex: breech presentation, multiple gestation or placenta previa)

• Favorable cervical factors

• Strong maternal desire for a vaginal birth

Because of the additional risk involved, Health Foundations has established research based guidelines for an out-of-hospital TOLAC and VBAC. At Health Foundations a woman is not eligible for a birth center birth who (this list is not all inclusive):

• Had had a prior vertical (classical) cesarean incision

• Has a baby in a non-vertex presentation

• Has a multiple pregnancy

• Has had more than one prior cesarean

• Has any condition of pregnancy where she would no longer be considered low-risk

• Has an inter-delivery interval less than 18 months.

One cesarean with a low transverse incision is the most ideal scenario for a TOLAC and VBAC. However, if you are planning a hospital birth TOLAC, ACOG (The American College of Obstetricians and Gynecologists) has recently changed their guidelines to consider candidates that have had two previous cesareans with a low transverse incision, an unknown type of uterine scar and twins. Thankfully, because research shows the benefits of a non-surgical birth, most women do receive a low transverse incision to make a future vaginal birth more likely to be successful.

Health Foundations Birth Center + Women’s Health Clinic does offer VBACs to women that meet our clinic’s criteria. Please call or go to our website to schedule a consultation with a midwife!

References:

utswmed.org

ACOG.org