Considering Vaginal Birth after C-Section
The Risks and Benefits of VBAC Compared to Repeat Cesarean Section
As of 2009, 28% of babies each year in the United States are born by Cesarean section, according to the National Center for Health Statistics (NCHS) (data downloaded on September 18, 2009). These data also show that the percentage of women giving birth surgically has steadily increased from 1990 to 2004 (see graph below, "Percent of Vaginal and Cesarean births in the U.S.").
Many of these Cesareans are medically necessary to increase the likelihood of a positive outcome in cases of breech births, multiples, placenta previa, and other conditions. Thus, these c-sections are usually planned in advance.
In contrast, unplanned Cesareans are often prompted by a "failure to progress" during labor. "Failure to progress" means that labor has slowed to the point that the doctor thinks the baby will not successfully emerge without help. Reasons for a failure to progress range from a very large baby to a nonreassuring fetal heart rate, as described by Tina Cassidy in her 2006 book Birth: The Surprising History of How We Are Born (Atlantic Monthly Press).
An increasing number of first-time mothers are having their babies surgically (National Center for Health Statistics), as can be seen in the graph below ("Percent of Vaginal and Cesarean births in the U.S."). For whatever reason a c-section is performed, many women would like to deliver their next child vaginally. This is called a vaginal birth after cesarean section, or VBAC. But, what are the chances of a successful vaginal birth after a c-section? What are the risks and benefits of choosing a VBAC over a repeat cesarean? Are VBACs even an option in all hospitals or birthing centers?
What are the Odds of a Natural Birth after a Cesarean?
Women that choose a trial of labor, after delivering their first child by c-section, give birth naturally in 60-80% of cases, according to the American College of Obstetricians and Gynecologists (ACOG website, viewed on September 20, 2009). In spite of these encouraging numbers, fewer and fewer women are attempting VBACs. Instead, these women are choosing to have their babies by repeat c-section (data downloaded from the National Center for Health Statistics).
In fact, VBAC rates increased through the early 1990s, following a 1988 recommendation encouraging vaginal birth after cesarean from the ACOG (Cassidy, 2006), but peaked in 1997 and have fallen by 50% since that time. These trends can be seen in the graph below ("Repeat C-Section and VBAC Rates in the U.S."), which was generated using data from the National Center for Health Statistics.
What is the cause of this downward trend in VBACs in the United States? Examining the risks, benefits, and availability of VBAC sheds light on this issue.
Risks of Vaginal Birth after C-Section
According to the American College of Obstetricians and Gynecologists, vaginal birth after a cesarean involves the following potential complications:
- Uterine rupture. During labor, the uterus can split open along the old c-section scar, causing copious bleeding. Uterine rupture can be life-threatening for the baby and the mother. The risk of uterine rupture depends greatly on the shape of the mother's previous cesarean scar. The most common cesarean scar -- a low transverse incision, called a "bikini incision" -- is associated with a 0.2%-1.5% chance of uterine rupture, according to the Mayo Clinic Guide to a Healthy Pregnancy (Mayo Clinic Foundation for Medical Education and Research, 2004). Low vertical incisions, which are used much more rarely, rupture in 1%-7% of cases. The rarest c-section incision, called a classical incision, has the highest risk of rupture -- 4%-9%. Pregnant women exploring VBAC should note that the shape of the scar on their skin is not the same as the scar on their uterus, so they should determine what type of uterine scar they have from their medical records.
- Failing to deliver vaginally, resulting in a second cesarean. Such women suffer a higher risk of infection after delivery (ACOG website, viewed on September 20, 2009).
Benefits of Vaginal Birth after a Cesarean
The American College of Obstetricians and Gynecologists lists the following benefits of giving birth naturally after a prior cesarean:
- Avoiding abdominal surgery (repeat c-section). This is especially important for women who want to have more children in the future. The risk of complications during a cesarean is much greater when women have had a previous cesarean (or other abdominal surgery).
- Lower risk of infection, because no abdominal incision is made.
- Shorter recovery time and less pain during recovery.
- Less blood loss (about 50% less) and hence a smaller likelihood of needing a blood transfusion.
- Mother can hold baby and breastfeed almost immediately after birth (depending on the hospital).
In addition to these physical benefits, some women may feel more psychologically positive about having a vaginal delivery versus a cesarean.
Hospital Support for Vaginal Birth after Cesarean Section
The ACOG recommends that VBAC only be attempted in hospitals that can perform emergency cesareans. This means that the hospital must be equipped to deliver a baby by c-section within 30 minutes of the pregnant patient entering the hospital. Many smaller hospitals do not have sufficient staff to guarantee that emergency cesareans are possible (Cassidy, 2006).
For this reason, all (non-hospital) birthing centers in the United States do not allow their patients to attempt VBAC (Cassidy, 2006).
Choosing Between Repeat Cesarean and Natural Birth
Hospitals and OB/GYNs are increasingly risk-adverse and may not permit a pregnant woman to attempt a VBAC (Cassidy, 2006), even if she meets the medical criteria stated by the American College of Obstetricians and Gynecologists. However, women interested in VBAC should know the potential benefits of avoiding another cesarean, and consult with their doctors to make the most appropriate choice for them.
Sleeping Baby Luke
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Percent of Vaginal and Cesarean births in the U.S.
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Repeat C-Section and VBAC Rates in the U.S.
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