By Julie Revelant, ,
Published October 23, 2016
If you’ve had a previous cesarean delivery, chances are you’re hoping to have a vaginal delivery the next time around.
The American College of Obstetricians and Gynecologists (ACOG) say that vaginal birth after cesarean (VBAC) is safe, but some physicians and even women themselves are not always in favor of it.
Here’s what you should know before you deliver.
The history of VBAC
In the U.S., more than one in five pregnant women give birth to their first baby by C-section, according to Childbirth Connection, a program of the National Partnership for Women & Families.
Years ago, it was a common practice for women to have repeat C-sections with subsequent deliveries.
The type of incision used at that time was prone to open up during labor so it was considered unsafe for women to have a trial of labor after cesarean (TOLAC), Dr. James Bernasko, an OB-GYN in the division of maternal-fetal medicine at Stony Brook University Hospital said.
The practice continued until the 1980s when experts realized that many women were going into labor and delivering vaginally before their scheduled C-sections, without any complications. As a result, doctors became more aggressive about encouraging women to try for a VBAC.
Yet there were some major problems with this new way of thinking.
For starters, some women’s incisions were still opening up, leaving them at risk for hemorrhage and a hysterectomy. Some babies also suffered oxygen deprivation and ended up with brain injuries.
As a result of the costly lawsuits that ensued, it became clear that VBAC shouldn’t be an option for all women.
“Physicians swung all the way back in the other direction and did not want to give anyone a trial of labor,” Bernasko said.
An individualized approach to VBAC
Today, doctors typically use a low-transverse incision, which is less likely to open during labor.
The risk of uterine rupture during trial of labor— when a VBAC is attempted— is between 0.5 percent and 0.9 percent and between 60 and 80 percent of women will have a successful VBAC.
ACOG’s guidelines state that a trial of labor is safe if the cause for the initial C-section is unlikely to reoccur, such as having a second breeched baby.
However, if the cesarean was done because the baby was large, and the next baby measures large as well, it may make sense to repeat the cesarean.
Because of the risk of uterine rupture, ACOG also recommends that women undergo the procedure in a hospital where an emergency cesarean can be done within 30 minutes.
Some physicians don’t want to take a chance
According to a 2013 survey by Childbirth Connection, 14 percent of women who had a previous cesarean had a subsequent vaginal birth, while the remaining 86 percent had a repeat cesarean. The same survey showed that although 48 percent of the women wanted to have a VBAC, 46 percent were denied the option.
Experts say instead of offering individualized care, some doctors will offer a repeat cesarean as the only option.
Some doctors may not want to wait for labor to progress, they may not be comfortable with the risks associated with VBAC or they’re nervous about being sued should something go wrong.
“There’s no question that litigation is on the minds of a lot of physicians,” said Dr. Daniel Roshan, board-certified maternal fetal medicine doctor and OB-GYN in New York City.
Some women too, may opt for a cesarean since it’s easier to plan for or for another personal reason.
Weighing the benefits and risks
Women who have VBACs have an easier recovery and a lower risk of infection and hemorrhage.
VBAC may also help ward off the potential for future risks that come with multiple cesareans such as hysterectomy, bowel and bladder injury, transfusion, placenta previa and placenta accreta.
Women who have VBACs also have a lower rate of complications than those who have scheduled C-sections, according to a report by the Centers for Disease Control and Prevention (CDC).
What’s more, a successful VBAC has fewer complications than an elective repeat cesarean, while a failed trial of labor has more complications than an elective repeat cesarean, according to ACOG.
If women have an unsuccessful trial of labor, they have a higher risk for infection, hysterectomy and a blood transfusion. There’s also a small risk that the baby will have oxygen deprivation.
Yet some studies show that VBAC could carry more risks. A study in the journal PLoS Medicine found that less than 1 percent of mothers who have a repeat cesarean have severe bleeding, while 2.3 percent of those who give birth vaginally do.
Placenta previa, placenta accreta, a breech baby or signs of fetal distress are all legitimate indications for a cesarean regardless of the previous deliveries, Bernasko said. Also, women with a previous vertical incision are not candidates for VBAC.
Experts say women who want to try for a VBAC should not be induced. Induction medications can increase the risk for uterine rupture and if the cervix is not ready, more medications may be given.
“Natural labor after C-section is always more likely to be successful than induced labor after C-section,” Bernasko said.
How to have a successful VBAC
If you’re a good candidate for VBAC, there are some things you can do to increase your chances of success.
For starters, try not to gain more than the recommended amount of weight during pregnancy. Studies show that pregnancy weight gain is associated with having a large baby, which could lead to a C-section, Roshan said.
If you have a normal body mass index (BMI) before pregnancy, gaining between 25 and 35 pounds is ideal. If you’re overweight, aim for 15 to 25 pounds and between 11 and 20 if you’re obese.
Other things than can help include evening primrose oil, which has been shown to thin and soften the cervix; red raspberry leaf tea, which may shorten labor; and acupuncture, which can increase spontaneous contractions, Roshan said.
Although you may want to have a vaginal birth, you should also be flexible since birth is always unpredictable.
You should also choose your provider wisely and never assume that your doctor shares your philosophy.
“This is a discussion that should be brought up early so that the patient and the provider are on the same page in terms of what is the appropriate thing to do,” Bernasko said.