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Vaginal Birth After Cesarean Delivery (cont.)

Factors Affecting Whether a Woman May Be Offered an Attempt at VBAC

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.

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