Vaginal birth after cesarean section

Description
A cesarean section (C-section) is the delivery of a baby through an incision in the mother's abdomen and uterus. The notion "once a cesarean, always a cesarean" once dominated obstetrics. During the past 30 years, however, this concept has gradually changed. If you've had a C-section and your incision was made horizontally in the lower part of your uterus, you may be able to deliver vaginally with your next pregnancy. This is known as vaginal birth after a C-section, or VBAC.

Purpose
For some women, VBAC is recommended as a safe option that may make the birth and postpartum experience less complicated and more satisfying than a subsequent C-section. About 50 to 60 percent of women who are candidates for VBAC attempt a vaginal delivery, and as many as 60 to 80 percent are successful.

Indications
It's not possible to predict with certainty whether a trial of labor will be successful. Unrelated medical or obstetrical complications, such as multiple births, a baby in breech position (feet first), high blood pressure, diabetes, heart disease, an active herpes infection or other problems, may make a subsequent C-section necessary.
According to the American College of Obstetricians and Gynecologists (ACOG), the following criteria can help identify women who are best suited for VBAC:

You've had only one or two previous C-section deliveries, with a horizontal incision in the uterus. This type of incision, made in the lower part of the uterus, forms a stronger scar and is less likely to open during the stress of labor than an incision in the upper part of the uterus. (The incision in your skin may not be in the same location as the incision in your uterus. Your doctor will need to check your hospital records to verify which type of incision was made in your uterus.)
Controversy remains regarding the safety of VBAC for women whose uterine scars are vertical and only in the lower part of the uterus. Experts at the ACOG have recommended further study of this particular situation. Any scar that's in or extends into the upper part of the uterus is considered to be a high risk for uterine rupture and not suitable for VBAC. The risk of uterine rupture during VBAC also increases with each C-section that is done.


You have no other uterine scars or previous uterine ruptures.

Your pelvic structure is large enough to allow the baby to pass through the birth canal. VBAC may not be possible if your pelvic structure is too small or the baby is too large (as may happen if you have a very large baby due to diabetes, a condition known as macrosomia). Your doctor may need to do specialized X-ray or ultrasound exams to verify that your pelvic structure is adequate for a vaginal birth.

You can deliver in a hospital setting where a doctor and surgical, anesthesia and blood bank personnel are readily available around the clock throughout labor in case a C-section becomes necessary. (This is not the case in all hospitals.)

Patient preparation
As with any pregnancy, it's important to take good care of yourself. Seek regular prenatal care, eat healthfully, and get appropriate amounts of exercise, as recommended by your doctor.
Thoroughly discuss the risks and benefits of VBAC with your partner and your doctor. Remember that your personal thoughts, feelings and wishes about VBAC are important elements in the decision. If you decide to attempt a vaginal delivery, it's important to learn about VBAC. You may want to attend a class about VBAC, as well as a traditional prenatal class to help you prepare for vaginal birth. Support groups for VBAC may also be available.

Before you go into labor, ask your doctor when you should go to the hospital. You may be asked to come in as soon as labor begins, or you may be able to remain at home during the early stages of labor.


Procedure
There are three stages of labor. In the first stage, the cervix dilates completely. In the second stage, the baby is born. In the third stage, the placenta is delivered. The stages are the same for routine vaginal deliveries and VBAC. The length of labor for women attempting VBAC is usually comparable to that of women who haven't had previous C-sections.
Most experts recommend continuous electronic fetal monitoring during VBAC to help identify potential complications as early as possible. For example, an abrupt change in the fetal heart rate may be one of the first signs of uterine rupture.

Epidural anesthesia is generally considered safe during VBAC. There was once a concern that this type of anesthesia may mask the symptoms of uterine rupture, but studies have not shown this to be the case. Generally, however, epidural anesthesia has been associated with a higher rate of C-sections when used during vaginal births.

As with other routine vaginal deliveries, labor is sometimes encouraged or induced with a synthetic form of oxytocin (the hormone that causes the uterus to contract). Oxytocin must be used cautiously to avoid overstimulating the uterus, which increases the risk of uterine rupture.


Postprocedure care
After the delivery, your doctor may feel the inside of your uterus for any separation of the previous scar. Repair is not typically necessary for a slight separation that doesn't cause significant blood loss or a complete opening between the uterus and abdominal cavity. You'll also receive routine postpartum care for vaginal deliveries.

Benefits
When successful, VBAC may have several benefits.
Recovery from a vaginal birth is usually quicker and less uncomfortable than recovery from a C-section. This may facilitate easier bonding with the baby.
There is a shorter hospital stay and fewer limits on activity.
Initial attempts at breastfeeding are often easier.
The risk of complications (such as infection, bleeding, fever, injury from anesthesia, and injury to the bowel or urinary tract) is lower.
You may feel a special sense of accomplishment.

Risks
Potential risks of VBAC include uterine rupture and a repeat C-section after going though labor. Uterine rupture, which occurs in less than 1 percent of all VBACs, requires emergency surgical intervention. The bleeding from a ruptured uterus can put your life and your baby's life at risk. Also, according to recent research, more serious complications occur among women who attempt VBAC and end up having a C-section than among those who choose to have a repeat C-section in the first place. (In this situation, there is an increased risk of infection for both you and the baby.)
Recent research indicates that inducing labor (initiating labor with artificial methods before it begins naturally) during VBAC may significantly increase the risk of uterine rupture. When medications such as oxytocin and prostaglandins are used, the uterus can be overstimulated and subsequently rupture. This risk seems to be especially high when prostaglandins are used.


Considerations
Your health and your baby's health are the first considerations when determining if VBAC is appropriate. Discuss the option carefully with your doctor.