Vaginal Birth After Cesarean Delivery

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Medical Author:

Harish M Sehdev, MD

Medical Editor:

Bryan D Cowan, MD

Medical Editor:

Mary L Windle, PharmD

Medical Editor:

Lee P Shulman, MD

Medical Editor:

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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• Vaginal Birth After Cesarean Delivery Introduction
• Predicting Successful Vaginal Birth after Cesarean Delivery
• Types of Uterine Incisions
• Risk of Uterine Rupture
• Conclusion
• For More Information
• Web Links
• Synonyms and Keywords
• Authors and Editors
• Read more on Vaginal Birth After Cesarean Delivery from Healthwise

Vaginal Birth After Cesarean Delivery Introduction

In 1916, one doctor, EB Cragin, advised the New York Association of Obstetricians and Gynecologists, "Once a cesarean, always a cesarean." For the next 60 years, most obstetricians advised their patients accordingly. This was believed to be the safest management for women who had previously had a cesarean delivery.

Cesarean delivery, also known as cesarean section, is major abdominal surgery involving two incisions (cuts): One is an incision through the skin and abdominal wall and the second is an incision opening the uterus to deliver the baby. While at times necessary, especially in emergencies or for the safety of the mother or the baby, cesarean childbirth is not a procedure to be undertaken lightly by the doctor or the expectant mother. Many women who have had cesarean deliveries wish to deliver their next baby vaginally if possible. Vaginal childbirth occurs when the baby is delivered through the birth canal and vagina.

By 1988, 25% of all babies were delivered by cesarean. Only 3% of babies were delivered vaginally if the mother had undergone a cesarean delivery before. To curb the increasing rate of cesarean birth, both the US National Institutes of Health (NIH) and the American College of Obstetricians and Gynecologists (ACOG) encouraged doctors to allow a woman to try to deliver her baby vaginally if she had undergone a prior cesarean delivery.

Now it is accepted practice that a woman would attempt what is called "a trial of labor" to deliver naturally with her next delivery, under certain conditions, after having had a baby through cesarean childbirth. Many women now have a successful vaginal birth after cesarean delivery (known as VBAC). If the trial of labor is unsuccessful, the woman then undergoes a cesarean birth. About 70% of women who wish to try will successfully deliver vaginally after a cesarean birth.

Yet, the number of cesarean deliveries continues to increase, with latest numbers indicating that 27.6% of all births in the United States are by cesarean—the highest percentage ever reported. However, the rate of VBAC decreased to 10.6% in 2003. Among women with a previous cesarean delivery, the likelihood that subsequent deliveries would be cesarean was about 90% in 2003.

Factors affecting whether a woman may be offered an attempt at VBAC include the following:

• If a doctor has experienced complications with other women undergoing trials of labor after cesarean deliveries, the doctor may be less likely to allow additional women patients to try VBAC. For women who want a trial of labor, this factor may be a consideration in their choice of doctor.
• ACOG guidelines require the presence of an obstetrician, anesthesiologist, and staff capable of performing an emergency cesarean delivery during a woman's entire active phase of labor. Academic centers and larger community hospitals typically have these staff available, but this requirement is more difficult to comply with in smaller hospitals, where staff, especially anesthesiologists, may not be in the hospital at all times. For women who want a trial of labor, this factor may be a consideration in their choice of hospital.
• The reason for the previous cesarean delivery. A prior cesarean delivery for a breech presentation will have a higher chance of success than if the cesarean was done for cephalo-pelvic disproportion (large baby).
• Some women may not be a candidate for a vaginal birth after a prior cesarean delivery if the uterine incision was not a low-transverse incision. In situations where the uterine incision included the upper muscular component of the uterus, attempting a vaginal delivery is associated with a greater risk for uterine scar separation.

Women should be counseled about the risks of a trial of labor, such as rupture of the uterus. Uterine rupture can occur in up to 1% of cases (in which the uterine incision was a low-transverse incision).

With uterine rupture, other complications can occur:

• Brain injury to the fetus caused by lack of oxygen (hypoxic-ischemic encephalopathy)
• Inflammation of the lining of the uterus (endometritis )
• Blood transfusions required because of severe blood loss
• Hysterectomy (surgical removal of the uterus) required
• Rare-stillborn baby or death of mother

Women attempting VBAC are closely monitored during labor. Signs of uterine rupture can be difficult to detect, and at times, a rapid change in the fetal heart rate or loss of contractions on the monitor can be a sign of uterine scar separation.

The decision to undergo a trial of labor after cesarean delivery should be carefully made between the woman and her doctor. The doctor will review the medical information on the woman's previous deliveries (both vaginal and cesarean) and estimate her risk for uterine rupture with her current pregnancy.

If possible, the doctor will avoid inducing labor with prostaglandin agents (used for cervical ripening) as these have been associated with an increase in the risk of uterine scar separation. Inducing labor when the cervix is dilated or with oxytocin (Pitocin) does not appear to increase the risk of uterine scar separation.