Vaginal Birth after Caesarean Delivery

When a woman who has had a Caesarean delivery in the past conceives again or is planning to conceive, the first question that pops up in her mind is, whether she will be able to deliver her baby vaginally this time. Here we attempt to clarify all the doubts and related facts to make you aware and updated on VBAC.

What Is VBAC?

The term VBAC stands for Vaginal Birth After a Caesarean. It means delivering your next baby vaginally after having a baby through a caesarian delivery.

If the mother and the doctor are convinced that the conditions are suited for a VBAC birth, then the mother will have to go through “trial of labour after Caesarean” or TOLAC. To describe TOLAC further, it means that the mother is planning to go into labour with an intention to deliver the baby vaginally. TOLAC does not guarantee a vaginal birth. In case there are any complications or the labour does not progress as planned, the mother may still have to go for a C-section delivery. As per most of the studies, 40 to 60% of mothers who go through TOLAC, ultimately get their C-section delivery done.

Another important question is, whether the trial of labour after Caesarean is safe. Having a VBAC birth is quite safe for most women, but depends on several other factors including why the woman had a Caesarean delivery in the previous case and how many Caesarean deliveries she has already had. The doctor can give specific advice depending on every individual case, and help a mother decide whether she should go for TOLAC and VBAC or not.

Are There Any Chances of Normal Delivery After the C-section?

Women can have a normal delivery after C-section. If you were required to have a C-section delivery with your first child, it does not necessarily mean that you will need it again. Studies indicate that around 60-80% of the women who have previously had a C-section can give birth vaginally if they try.

A VBAC is more likely to be successful in the following cases:

• If your previous C-section was not done due to difficult labour, delayed or stuck labour
• You are not experiencing the same medical condition (such as pre-eclampsia) as the last delivery which led to the C-section
• You have already had a VBAC before
• You go into labour on your own
• If your age is less than 35
• If you are not obese
• If your foetus is not very large or is less than 4 kgs
• If your pregnancy is less than 40 weeks
• Your previous pregnancy happened more than 1.5 years earlier. An ideal gap is 3 years but can be attempted as early as 18 months if all other factors are favourable.
• Your baby is in the head-down position

Am I Fit for Vaginal Birth After Caesarean?

For most women, a VBAC is safe. However, depending on certain medical conditions it can also pose serious complications for the mother and the baby. Hence, your doctor who is fully aware of your medical history and has all the necessary details related to your previous C-section delivery is the best guide for you. Based on your history and present condition, your doctor can weigh the risk factors and help you take a call on whether to opt for VBAC or not.

One of the concerns for women who have had a Caesarean previously is the risk of “uterine rupture” during VBAC. As per the American College of Obstetricians and Gynecologists (ACOG), for women who have had an earlier Caesarean delivery where a low transverse incision (a horizontal cut into the uterus) was made, the risk of uterine rupture during a natural VBAC is around 0.2 to 1.5%.

• Also, in the case of Dystocia, which is a lengthy and difficult labour because of slow cervical dilation or a small pelvis or a big baby, VBAC is not recommended. If you had genital herpes or foetal distress in the previous delivery, then most likely your doctor will schedule a C-section for you. But if you do not have a major medical issue, the baby is normal in size with his/her head down; then you may be a good candidate for VBAC.
  

  Comparing VBAC to Repeat C-section Delivery

  Repeat C-section	VBAC
  Surgical procedure	Normal delivery
  Risks only related to usual surgery	Risks like uterine rupture, hysterectomy, bladder infection, blood clot, etc. (Though such cases are only 1%)
  4-5 days of hospitalization	Two days of hospitalisation
  Discomfort or ongoing pain due to incision	Temporary pain
  Infection may develop during surgery	The risk of infection is double if TOLAC is attempted but is unsuccessful, resulting in a C-section
  Risks like bladder injury or bowel injury	Risk like episiotomy, a surgical procedure wherein an incision is made in the perineum to enlarge the opening through which the baby is delivered
  Surgery may lead to blood clots in the pelvic area	No such risk
  The baby may have a respiratory problem	No such risk in vaginal delivery unless the baby went into distress
  For mothers who are planning more children, having multiple C-sections is riskier as they may cause scarring which is associated with the risk of placental problems	No such risk

  Advantages and Disadvantages of Having VBAC

  There are many advantages and disadvantages of VBAC. The advantages are:

  • Having another surgery means having more incision scars, difficulty and discomfort of surgery which can be avoided in the case of a VBAC delivery.
  • There is less pain after a VBAC delivery. You’ll only experience vaginal pain which is temporary and will disappear with time.
  • Fewer days of hospitalisation as compared to the C-section delivery. This also means lower expenses.
  • The risk of infection related to the surgical process, like excessive bleeding which can cause blood transfusion or hysterectomy, is eliminated. The risk of developing other infections and organ damage is also associated with a surgical procedure.
  • In case you are planning more children, every repeated C-section increases the risk and complications for future pregnancies.

The disadvantages of a VBAC are mentioned below:

• Uterine rupture is one of the main VBAC complications. You may keep yourself in the pain of labour hoping for a VBAC which may end up in an unplanned C-section. An unscheduled C-section may cause you more trouble and complications like excessive bleeding, uterus infection, hysterectomy, etc.
• The baby may suffer neurological disorder or even death in extreme cases after an unsuccessful VBAC.
• Bruises around your vagina or pelvic floor weakening.
• Baby prolapsing, a condition in which the womb slips into the vagina.

Other Risks of Having Vaginal Birth after Caesarean

20% to 40% of women end up having a C-section delivery after attempting for VBAC. There is always some uncertainty associated with VBAC, and you may be among 2-4 women out of 10 who may need an emergency C-section. This may happen when the labour slows down or if the doctor is worried about the well-being of the baby.

In the case of an emergency C-section, the risk and complications are even higher as compared to the planned C-section. With an unplanned C-section, there is always a doubt of surgical complications like the development of blood clots, more bleeding than normal which may need a blood transfusion or even a hysterectomy.

Such risks are more common when VBAC is unsuccessful as opposed to a successful vaginal delivery or a scheduled C-section.

Why Is VBAC Done?

Till the 20th century, most people thought that once a woman goes through a Caesarean delivery, she would have to opt for Caesarean delivery for the rest of the pregnancies. However, recent studies have debunked this theory and proved that it does not hold true.

VBAC is mostly done and preferred because it is a hassle-free process that eliminates the complications associated with the Caesarean delivery. It is the most natural way of delivering the baby. Also, there are negligible post-delivery troubles in the case of VBAC. Like in a Caesarean delivery, you will need to be in the hospital for more days as compared to the normal delivery as the surgery requires more healing hours.

One positive is that postpartum troubles in the case of VBAC are less as compared to Caesarean delivery. The wound and incision may take longer to heal in the case of Caesarean delivery and there may be some ongoing troubles. Also, for the baby, the chances of respiratory infection are relatively higher. This is primarily because respiration is triggered in babies by the contractions of labour, and when amniotic fluid is expelled from the lungs as the baby passes through the birth canal, processes that do not take place in caesarean delivery. In the case of VBAC, the baby passes well through the birth canal which results in lesser neonatal breathing problems.

Hence, along with the American College of Obstetricians and Gynecologists, the National Institutes of Health also recommends VBAC for women who have a low transverse uterine incision and no medical problem. Technologies like the fetal monitor help track the progress of labour and increase the success rate of VBAC. They also eliminate the complication of fetal distress. The process of VABC may involve the administration of medications to induce labour or improve contractions.

How Shall I Prepare for It?

You may be a little hesitant towards opting for a VBAC but rest assured that most women who have had a C-section can successfully deliver vaginally. After a thorough discussion with your doctor, you may take your time to get prepared for VBAC in the following suggested ways:

1. Speak to Your Doctor and Discuss Your Case

The doctor is the best person to find out whether you should go for it or not. Don’t shy away from voicing any concerns you may have and getting any doubts clarified

2. Get Updated about VBAC

You may read a lot on the internet and through journals and related studies. The more aware you are, the more confident you will be

3. Know Your Options

There are medicines available to stimulate labour and also epidurals and medication to manage labour pains. You must know that epidurals do not affect the chances of a successful VBAC. However, be aware that some medical studies have documented increased uterine rupture rates in women who undergo labour induction. Thus, you should discuss any possible complications of induction with your doctor.

4. Be Prepared

You can take classes on childbirth especially relating to VBAC. They may guide you on the exercises to prepare for VBAC.

What Is the VBAC Success Rate?

The VBAC success rate depends largely on factors including the following:

1. The Reason for Your Earlier C-Section

If you had a Caesarian delivery earlier because of a complicated reason like a uterine abnormality, then you may have to go for a Caesarian delivery again. But if your previous C-section was done because of a non-recurring and less severe issue like a low-lying placenta, etc., you can successfully opt for VBAC.

2. If You Have Had a Previous Vaginal Birth

If you have ever had a vaginal birth in any of your previous deliveries the chances of a successful VBAC increase. The chances are very bright and almost up to 80% if you’ve had one or more vaginal delivery in the past or especially if it was VBAC.

3. If Your Pregnancy is Not Complicated

if you already have problems in your ongoing pregnancy, then you may be prescribed to go for a Caesarean delivery by your doctor, but in the absence of any complications, the success rates of VBAC are high.

The chances of successful VBAC are low if you have given birth only by C-section delivery, or you had your BMI of more than 30 at the start of the pregnancy. In these cases, the chance of a successful VBAC drops down below 40%.

For other specifications pertaining to your unique case, it is best to get in touch with your doctor to find out the expected VBAC success rate in your case.

Can I Have VBAC after 2 C-Sections?

VBAC can be successful for women who had one, two, or three C-sections in the past. The chances of VBAC after two C-sections are brighter if:

• If the head of the baby is positioned down
• The baby is not too large
• If you have ever had a successful VBAC in the past
• No serious medical problem in this pregnancy
• Low transverse uterine incision
• Labour beginning naturally
• The due date has not already passed
• No vertical incision
• No history of uterine rupture

In any other case of complication, there are always increased VBAC risks after 2 C-sections, and your doctor may prescribe another Caesarean delivery for you.

How to Increase the Chances of VBAC?

You can always try to deliver your next baby naturally after one or more previous C-sections. Some suggested ways are:

• Make sure that you conceive at such a time so that the delivery time is at least after 18 months of the previous C-section delivery
• You must reduce your weight if you are already obese (before conception itself)
• Keep your BP within a recommended range. High BP can affect the success of the VBAC
• Low-stress levels help. You must perform some relaxation or breathing exercises to prepare for VBAC.
• You need to keep yourself patient and cheerful.

Is It Possible to Have VBAC at Home?

Yes, you can have a VBAC delivery at your home in the presence of a midwife or a doctor. In fact, in some cases, it may be a better option as it keeps the stress level low and gives better care. In addition, there is a lesser risk of emotional dystocia, a condition where blood circulation in the placenta reduces as a result of a rise in catecholamines due to the mother’s emotional stress during labour.

But having a baby in the hospital has its own advantages and may have lesser VBAC complications due to the provision of continuous Electronic Fetal Monitoring (EFM), immediate scar treatment, etc. in the hospital.

It is best to get in touch with the doctor or an expert midwife to explore the chances of natural VBAC at home. They will be able to tell you if you are a good candidate for VBAC.