Vaginal Delivery After Having A Cesarean Delivery, Is It Right For Me?
In the United States 29% of births are performed by Cesarean delivery, better known as a c-section. Today we will briefly talk about having a vaginal birth after having a prior c-section (VBAC). Some of you reading this may have had a prior c-section and desired to have your next child vaginally….only to find that your doctor did not advise that you do so. Quite often, doctors are averse to undertaking the responsibility of a giving a trial of labor after c-section(TOLAC). Why is this? Well, for starters, there are risk factors involved. The main risk factor that is looked at when dealing with VBAC’s is the uterine incision that was previously made. Even if your abdominal scar is transverse, it does not mean you uterus was cut in the same manner. The majority of uterine incisions however are made in a transverse manner in the lower segment of uterus. This is typically called a low transverse c-section. With this type of scar, the risk that we are always concerned about is uterine rupture. If a patient with a previous c-section is attempting a VBAC, there is a risk that the scar can open up. For patients with one prior low transverse c-section(LTCS), the risk of uterine rupture during labor is 0.7%. If a uterine rupture were to occur, the worst case scenario would be that the baby got outside the uterus and went into the abdomen or the mother could potentially bleed to death. In this scenario the baby could die or suffer severe brain injuries if delivery was not quick enough. Even though the chance of this NOT happening is 99%, many doctors will not take this chance. If you have had 2 c-sections, the risk of uterine rupture is 0.9% in the most recent studies with older studies showing risks as high as 2.4%. Most doctors that I know of do not attempt a VBAC after 2 c-sections. This may sound like a bunch numbers, but in short: If you had 1-2 previous low transverse c-sections and desire a VBAC, your risk of uterine rupture is approximately 1%.
Some women have other types of uterine scars that are not ideal for a TOLAC. An example being what is known as a classical c-section. This is where the uterus was cut in a vertical fashion up to the top of the uterine portion known as the fundus. This type of incision is usually done for preterm c-sections. The risk for uterine rupture in this setting is 10%. In medicine, that is too high of a risk to take. It would be out of the standard of care to give a patient in this scenario a TOLAC. Other uterine surgeries that can carry a risk like this include the removal of fibroids. The majority of doctors who are comfortable with VBAC’s will ask for all operative reports that pertain to the wonderful uterus. In short: A history of a classical c-section, removal of fibroids from the uterus and invasive uterine surgery are a contraindication to attempting a VBAC.
Reasons for not be given a chance to a TOLAC also depend on the hospital itself. If that hospital does not have an anesthesiologist in house along with capabilities of performing a c-section quickly, then it is generally will be a no go on the TOLAC.
The chances of success vary from patient to patient. Factors that play a role in the success of a VBAC attempt include the reason for the c-section. Was the reason due to the position of the baby, was it due to the baby being stressed in labor or was the baby “too big?” These are some questions that you should be prepared to answer if your desire is for a VBAC. Overall, the success rate of VBAC lies between 65%-75%.
What are the benefits of VBAC? It’s a quicker recovery. A c-section is a major surgery! It involves cutting the skin, stretching out muscles and cutting the uterus. To say it can be painful is an understatement! Compared to a c-section, a vaginal birth is less painful and easier to recover from. If you can avoid a c-section, you also avoid the potential risks of bleeding too much during surgery, infection, damage to the bowel, bladder and other organs and worst case scenario death! The risks may be relatively small, but they exist nonetheless. Medicine is not an exact science and there are risks in everything we do. My job as an OBGYN is to weigh the risk verse benefits with my patients in accordance to the standard of care and work with my patients for the care plan that is best for them. Be it a TOLAC or another c-section, discuss with your provider the pros and cons of each and decide what you as the patient are most comfortable with. If you have additional questions, please feel free to blog.
Additional info may be found at http://www.acog.org/Womens-Health/Vaginal-Birth-After-Cesarean-VBAC
Best Regards, Dr. Marc Jean-Gilles