After a cesarean, most women have two choices for future births: a vaginal birth after cesarean (VBAC) or a repeat cesarean section (RCS). There is a lot of misinformation about these two options. Let’s review some quick facts.
Per the American College of Obstetricians and Gynecologists, VBAC is a reasonable and appropriate choice for most women with one prior cesarean and for “some women” with two prior cesareans (1). Being pregnant with twins, going over 40 weeks, having an unknown or low vertical scar, or suspecting a “big baby” should not prevent a woman from planning a VBAC (1).
VBAC is successful 75% of the time (4-8). Successful VBACs have lower maternal complication rates than planned repeat cesareans which have lower rates than VBACs that end in a cesarean (6), otherwise known as cesarean birth after cesarean or CBAC.
Uterine rupture is the major concern in terms of VBAC and while it can be catastrophic, it is rare (9). As the National Institutes of Health asserts, “VBAC is a reasonable and safe choice for the majority of women with prior cesarean. Moreover, there is emerging evidence of serious harms relating to multiple cesareans… The majority of women who have TOL [trial of labor] will have a VBAC, and they and their infants will be healthy. However, there is a minority of women who will suffer serious adverse consequences of both TOL and ERCS” (10).
Permitting labor to begin naturally after one prior low transverse (“bikini cut”) cesarean carries a 0.4% risk of rupture which can increase upon labor augmentation or induction (6). These rates are similar to other serious obstetrical emergencies such as placental abruption, cord prolapse, and shoulder dystocia.
Cesarean risks, including placenta accreta, hysterectomy, blood transfusion, and ICU admission, increase with each surgery (11); whereas after a successful VBAC, the future risk of uterine rupture, uterine dehiscence, and other labor related complications significantly decrease (12).
With each option, the risk of maternal death is very low: ERCD at 13.4 per 100,000 versus 3.8 per 100,000 for TOL (10). The evidence quality on perinatal mortality (infant death within 28 days of birth) is low due to the wide range of rates reported by various studies (11).
45% of American women are interested in the option of VBAC (14), yet 92% have a RCS (15). Some women chose their RCS or it was medically necessary. Others felt like they didn’t have much of a choice for numerous reasons including hospital VBAC bans (16); immense social pressure; or the misrepresentation of VBAC risks (17).
Our repeat cesarean rate feeds America’s rising total cesarean rate, currently at 32% (18). Declercq (2009) links our high cesarean rate with our high maternal mortality rate relative to other developed countries (19).
Throughout America, hospital and doctor attended VBACs are legal (20). In some states, it is legal for a midwife to attend an out-of-hospital VBAC. However, of the women interested in VBAC, 57% are unable to find a supportive care provider or hospital (14). This is due primarily to the 1999 ACOG recommendation that a doctor be “immediately available” to perform a cesarean, yet they provided no clear definition or standard for where the obstetrician and/or anesthesiologist should be or what they could be doing (1).
As a result, hospitals developed their own definitions producing differing VBAC protocols and requirements. The most severe variety was the institution of formal VBAC bans in 28% of all American hospitals and de facto bans in an additional 21% (21), disproportionally affecting women living in rural areas. The 2010 ACOG guidelines addressed these bans and confirmed: “restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will” (1). Hopefully VBAC will become a viable option to the many women who desire it (22).
Ready to learn more? Check out the list of articles and categories to your left.
Want more information on planning a VBAC? Go here.
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1. American College of Obstetricians and Gynecologists. (2010). ACOG Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Washington DC.
2. Kmom. (2009, February 12). Ultrasound Measurement of Cesarean Scar Thickness. Retrieved from Well Rounded Mama: http://wellroundedmama.blogspot.com/2009/02/ultrasound-measurement-of-cesarean-scar.html
3. Humphries, G. (2004, June 14). The Suture Debate. Retrieved October 1, 2009, from International Cesarean Awareness Network: http://www.ican-online.org/vbac/the-suture-debate
4. Coassolo, K. M., Stamilio, D. M., Pare, E., Peipert, J. F., Stevens, E., Nelson, D., et al. (2005). Safety and Efficacy of Vaginal Birth After Cesarean Attempts at or Beyond 40 Weeks Gestation. Obstetrics & Gynecology, 106, 700-6.
5. Huang, W. H., Nakashima, D. K., Rumney, P. J., Keegan, K. A., & Chan, K. (2002). Interdelivery Interval and the Success of Vaginal Birth After Cesarean Delivery. Obstetrics & Gynecology, 99, 41-44.
6. Landon, M. B., Hauth, J. C., & Leveno, K. J. (2004). Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery. The New England Journal of Medicine, 351, 2581-2589.
7. Landon, M. B., Spong, C. Y., & Tom, E. (2006). Risk of Uterine Rupture With a Trial of Labor in Women with Multiple and Single Prior Cesarean Delivery. Obstetrics & Gynecology, 108, 12-20.
8. Macones, G. A., Cahill, A., Pare, E., Stamilio, D. M., Ratcliffe, S., Stevens, E., et al. (2005). Obstetric outcomes in women with two prior cesarean deliveries: Is vaginal birth after cesarean delivery a viable option? American Journal of Obstetrics and Gynecology, 192, 1223-9.
9. National Institutes of Health. (2010, June). Final Statement. Retrieved from NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights: http://consensus.nih.gov/2010/vbacstatement.htm
10. Guise, J.-M., Eden, K., Emeis, C., Denman, M., Marshall, N., Fu, R., . . . McDonagh, M. (2010). Vaginal Birth After Cesarean: New Insights. Rockville (MD): Agency for Healthcare Research and Quality (US). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK44571/
11. Kamel, J. (2012, Apr 3). Confusing fact: Only 6% of uterine rutpures are catastrophic. Retrieved from VBAC Facts: http://vbacfacts.com/2012/04/03/confusing-fact-only-6-of-uterine-ruptures-are-catastrophic/
12. Silver, R. M., Landon, M. B., Rouse, D. J., & Leveno, K. J. (2006). Maternal Morbidity Associated with Multiple Repeat Cesarean Deliveries. Obstetrics & Gynecology, 107, 1226-32.
13. Mercer, B. M., Gilbert, S., Landon, M. B., & Spong, C. Y. (2008). Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Obstetrics & Gynecology, 11, 285-91.
14. Declercq, E. R., & Sakala, C. (2006). Listening to Mothers II: Reports of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection. Retrieved from Childbirth Connection: http://www.childbirthconnection.org/article.asp?ck=10068
15. Osterman, M. J., Martin, J. A., Mathews, T. J., & Hamilton, B. E. (2011, July 27). Expanded Data From the New Birth Certificate, 2008. Retrieved from CDC: National Vital Statistics Reports: http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_07.pdf
16. Kamel, J. (2010, July 22). VBAC ban rationale is irrational. Retrieved from VBAC Facts: http://vbacfacts.com/2010/07/22/vbac-ban-rationale-is-irrational/
17. Kamel, J. (n.d.). Scare tactics. Retrieved from VBAC Facts: http://vbacfacts.com/category/vbac/scare-tactics/
18. Menacker, F., & Hamilton, B. E. (2010, March). Recent Trends in Cesarean Delivery in the United States. Retrieved from Center for Disease Control and Prevention: http://www.cdc.gov/nchs/data/databriefs/db35.htm
19. Declercq, E. R. (September, 2009). Birth by the numbers. Retrieved from Orgasmic Birth: http://www.orgasmicbirth.com/birth-by-the-numbers
20. Kamel, J. (2009, February 28). Is VBAC illegal? Is homebirth illegal? Retrieved from VBAC Facts: http://vbacfacts.com/2009/02/28/is-vbac-illegal/
21. International Cesarean Awareness Network. (2009, February 20). New Survey Shows Shrinking Options for Women with Prior Cesarean. Retrieved from ICAN: http://www.ican-online.org/ican-in-the-news/trouble-repeat-cesareans
22. Kamel, J. (2010, March 9). American women speak about VBAC. Retrieved from VBAC Facts: http://vbacfacts.com/2010/03/09/american-women-speak-about-vbac/
Last revised: 11/11/12
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