Baby #2: VBAC or Repeat Cesarean?  

From November, 2007 Newsletter

Written by Carol Peterson, ICCE, CD(DONA)

Perhaps you've had a cesarean and you're now considering a vaginal birth, or you've been told "once a cesarean, always a cesarean".  If so, read on to discover your options, and plan to attend the upcoming ICAN meeting where you'll hear inspiring stories from women who have succeeded at achieving a VBAC.

What is a VBAC?

VBAC stands for vaginal birth after cesarean.

I’ve been told by my OB/midwife that I should just schedule a repeat cesarean.   Can’t I try to have a vaginal birth?

Well, it depends.  If your prior cesarean involved a “classical” (vertical), T-shaped or J-shaped incision, then yes, you will need to have another cesarean.  The risk of uterine rupture is simply too high.  Lower uterine incisions, or “bikini” incisions, do not carry the same risks as a classical incision.  There are other indications for a repeat cesarean, some of which include:

My last surgery went well.  Why would I even consider attempting a VBAC?

The majority of research shows that any elective cesarean, whether repeat or primary, does not improve the health of mom and baby.  Despite many claims, most research shows that moms are safer with a VBAC than a repeat surgery.  Just because a primary cesarean went well does not mean that a subsequent surgery will be risk-free.  While advances in medical technology, blood transfusions, and better anesthesia techniques have improved the safety of cesarean, there are still risks associated with the surgery, some of which include (1):

What are the benefits of a VBAC?

For a lot of women, the single biggest benefit is the satisfaction that comes with achieving the vaginal birth that they wanted with their prior birth(s).  Beyond this, and beyond avoiding the risk of surgery, benefits include shortened recovery times, feeling better physically and emotionally after the birth, being more mobile after delivery, easier time with initial breastfeeding, and finding it easier to care for a newborn.  As said previously, shortened recovery time becomes important when one is also mothering a busy toddler or pre-schooler.

Are there risks associated with attempting a VBAC?

The most common concern is uterine rupture.  According to the article "Midwives and Uterine Rupture: What We Have to Offer" (2), the overall incidence of uterine rupture is 5.2 per 1000 births, or 0.5%.  The incident increases when labor is induced with prostaglandins, at 24.5 per 1000 births (2.45%), and 7.7 per 1000 births (0.77%) when labor is induced without prostaglandins (i.e. Pitocin).   

The article When Research is Flawed: The Safety of Planned Vaginal Birth After Cesarean[3], shows the majority of problems associated with VBAC are due to care provider medical intervention, and not the fact that there was an attempted VBAC.  

What are my chances of succeeding with a VBAC?

According to ICEA (1), studies of literature indicate that approximately 60-80% of trials of labor after a cesarean result in a vaginal delivery.  Success rates are slightly improved when the original surgery was due to breech baby or fetal distress.  Success rates are slightly lower when the initial cesarean was performed for failure to progress, dystocia, or cephalopelvic disproportion (baby poor fit for pelvis), but the success rate among these candidates is still approximately 50-70%.

My OB/midwife told me that I could attempt a VBAC with future pregnancies, but now he/she is telling me that I will need a cesarean.  What should I do?

While most OBs will tell women that they have options, their policies do not support VBAC.  Some hospitals will not allow an attempted VBAC, simply because if the fear of litigation.  These policies can put unneeded fear into a woman considering a VBAC, as she thinks, "If it so risky that my hospital won’t allow it, then I am really better off with another surgery."  In many cases, women need to stick up for their rights to attempt a VBAC.  In short, find a practice that will support your decision to VBAC. 

What are some things that I can do to improve my chances of a VBAC?

One of the most important aspect is to find a care giver that supports your decision and sees birth as normal, is slow to induce, and is patient enough to allow nature to take its course.  If you felt unprepared with your first birth, find a childbirth class that is more in-depth to help you prepare as much as possible.  Read books on VBAC and begin visualizing yourself having a vaginal delivery.  Hiring a doula to help you with your labor may also reduce the risk of a repeat cesarean.  Because many care givers require continuous fetal monitoring for a VBAC, select a hospital with wireless telemetry monitors so that you can remain mobile during labor.  During labor, alternate periods of rest with more active comfort measures, such as walking, using the birth ball, or spending time in the shower.  In addition, more tips can be found in ICAN’s white paper, Vaginal Birth After Cesarean Checklist.    

I hope that this information gives you confidence to consider VBAC as an option, and remember, every birth is different, and the circumstances surrounding your first cesarean usually will not be present in subsequent births.  For more information on VBAC, ICAN offers a number of white papers on the subject (www.ican-online.org).

Happy Birthing!  

[1] ICEA Position Statement and Review: Cesarean Birth and VBAC, July 2002

[2] Midwives and Uterine Rupture: What We Have to Offer, Kristin Eggleston, Midwifery Today, August 2007

[3] When Research is Flawed: The Safety of Planned Vaginal Birth and Cesarean, Henci Goer, www.lamaze.org