uterine rupture

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VBAC vs Repeat Cesarean Delivery

Thursday, March 6th, 2014

Not so long ago, a vaginal birth after a cesarean delivery (VBAC) was unheard of. Because the uterus was cut in such a way that weakened it and made it vulnerable to rupture in subsequent pregnancies, women were often scheduled for cesareans before they could even go into labor if they had had a cesarean delivery in the past.

Now, with improved surgical techniques, VBAC is a choice that many women get to make, depending on the reason for the original cesarean. For example, if the first cesarean was performed because of a too-large baby and a too-small pelvis, that reason will in most cases still exist in subsequent pregnancies. On the other hand, if an isolated event such as breech presentation mandated the first cesarean, the event does not reoccur, and the correct surgical procedure was used the first time, then attempting a VBAC is usually safe.

Benefits of VBAC

This is important for a number of reasons. The most important reasons involve the safety of both mother and baby. A vaginal birth is safer than a cesarean delivery. Although the risk of infection or hemorrhage is relatively low with a cesarean, it is still several times greater than with a vaginal delivery. Therefore, a cesarean should be a last resort whenever possible.

Another reason VBAC safety matters is because many women prefer the natural experience of childbirth. This, of course, should not be a reason to put her life or the life of her fetus in jeopardy, but when it’s feasible, childbirth is a nicer experience when it fulfills the mother’s wishes.

Other benefits of VBAC include avoiding an additional scar on your uterus, which is important if a future pregnancy is desired. The more scars on the uterus, the more likely the uterus is to rupture.  Also, the placenta is more likely to be more adherent to the scarred uterus and not separate naturally, causing a life-threatening condition known as placenta accreta and resulting in massive hemorrhaging which may lead to maternal death.

Vaginal birth also comes with an easier recovery period, less pain afterward, a shorter hospital stay, and a more active role for you and your partner in the birth of your baby.

Risks of VBAC

The possibility (however remote) still exists for the uterus to rupture at the site of the previous cesarean scar, and this is one of the main fears when attempting VBAC. If the uterus ruptures, an emergency cesarean and possibly hysterectomy will be required to prevent severe injury to both baby and mother. That is why it is so important to be delivered in a hospital or medical center that has 24-hour anesthesia and in-house obstetrical coverage with a good blood bank.   With that the said, the risk of uterine rupture after a VBAC is 0.2% compared to 0.1% in those patients who had scheduled another cesarean.  Both figures mean that in 99.8% to 99.9% of the cases, a VBAC does not result in uterine rupture.

If you are hoping to have VBAC, you should clearly discuss this with your doctor to see if it is a good fit for your individual situation. In addition, you will need to deliver in a facility that has the equipment and staff capable of handling any emergency that might arise.

If you and your doctor decide that VBAC may be safe for you, you will be able to have a “trial of labor,” or TOLAC (trial of labor after cesarean). This means that you will go into labor naturally with the goal of delivering vaginally. However, there are no guarantees. Some women who attempt VBAC end up with necessary cesareans anyway. A trial of labor is a safe choice as long as the conditions that necessitated the first cesarean no longer exist and the baby is monitored closely for signs of distress. For more information on this and other women’s health issues, see my book, Inside Information for Women.

– Yvonne S. Thornton, M. D., M. P. H.