International Cesarean Awareness Network

by D. Ashley Hill, MD,

OBGYN.net Editorial Advisor,

Associate Director - Department of Obstetrics and Gynecology,

Florida Hospital Family Practice Residency, Orlando, Florida

Vaginal Birth After Cesarean (VBAC)

 

About 25% of all babies in the United States are born by cesarean
delivery, creating a situation where many women have to choose whether
or not to have a repeat c/section, or to undergo an attempt at vaginal
delivery for their next pregnancy. In medical terminology this is
called a"vaginal birth after cesarean," or VBAC, and is pronounced
"V-BACK." Scientific investigation has led to considerable information
about this process, and by reviewing this information, and discussing
this issue with a physician or midwife, patients can determine if they
wish to have another c/section or to try for a vaginal delivery. VBAC’s
are successful on average 60-80% of the time and are considered by most
to be a valid way to reduce the overall c/section rate.

 

Before discussing the pros and cons of either a repeat c/section or
an attempt at vaginal delivery, it is helpful to discuss what occurs
during a c/section. Basically, an Ob/Gyn doctor makes an incision into
the skin of the abdomen, usually via a "bikini cut" but sometimes via
an up-anddown cut called a vertical skin incision. He or she then cuts
through each layer of tissue until reaching the uterus, which is
essentially a large muscle. The area closest to the bladder, called the
"lower uterine segment," heals better than the upper part of the
uterus, so doctors make an incision in this lower area 90% of the time.
The doctor makes a sideways cut, (going the same direction as the
bikini cut), into this area, then reaches in, cups the baby in her or
his hand, and delivers the baby through the incision. This sideways cut
on the uterus is called a low transverse c/section, or LTCS for short.
The uterine incision is sutured closed and heals over the next 2-6
weeks.

 

In unusual cases the doctor may need to make an up-and-down
(vertical) cut into the muscle of the uterus, which is called a
"classical c/section" to deliver the baby. Since this cut is through
muscle, it may not heal well, and can come apart during the next
pregnancy or delivery. This is called a scar breakdown, scar
dehiscence, or a uterine rupture, depending on the extent of breakdown.
When this happens the baby, umbilical cord, or placenta (afterbirth)
may pop through the opening in the uterine muscle and into the
abdominal cavity, causing bleeding, fetal distress, and, in some cases,
even brain damage or death. If the uterus actually ruptures (which is
thankfully rare), the mother can hemorrhage, leading to an emergency
hysterectomy. This is much more common with classical c/sections than
low transverse c/sections. As frightening as this sounds, we know
through medical research that uterine scar breakdowns (and especially
uterine ruptures) are relatively uncommon events, occurring in 5-12% of
classical incisions and 1/2 of 1% of low-transverse incisions.

 

There are pros and cons to both repeat c/sections and an attempt at
vaginal delivery, so patients should be well-versed on both so that
they can make an informed decision regarding their health care. While
an attempt at vaginal deliver after a low-transverse c/section is
usually quite safe, current medical standards clearly show that women
who have had a classical c/section should *not* undergo an attempt at
vaginal delivery, since the chance of uterine rupture is too high to
risk. These women should undergo a repeat c/section for every
subsequent pregnancy. Therefore, this paper will focus on women who
have had a low transverse c/section, since they may safely undergo an
attempt at vaginal delivery if they wish. Please note that the
important incision is on the uterus, and that the type of *skin*
incision is irrelevant. There are many benefits of vaginal delivery,
for both mother and baby. During a vaginal delivery the amniotic fluid
is squeezed from the baby’s lungs, making it easier for him or her to
breathe. This does not happen as much during c/section.

 

Furthermore, it is a misconception that c/section is always safer for babies than vaginal delivery. Scalpel injuries and trauma to babies during c/section, although rare, can certainly occur. In most cases vaginal deliveries are safer for mothers than c/sections, with some medical studies indicating that the chance of death for a mother is 7 times higher when delivered by c/section versus vaginally. Contrary to popular belief, a c/section is a *major* operation, not unlike a hysterectomy in it’s complexity and potential complications! These complications may include infection, hemorrhage, scar tissue formation (which may produce lifelong abdominal or pelvic pain), anesthesia complications, opening of the skin incision leading to a very large scar, damage to the bladder or intestines, and the formation of blood clots within blood vessels or the lungs.

 

These complications are usually much more common with c/sections than vaginal deliveries, although as with all medical issues the patient’s individual situation will dictate which complications are more, or less, likely. An unfortunate side effect of our legal system is that many women are led to believe by malpractice lawyers that a c/section will prevent any and all problems for their baby. This is simply untrue and is a very unsophisticated way of looking at this major operation and pregnancy in general.

 

There are certain risks that are more likely when a patient has had
a prior c/section. These include scar tissue formation around the
uterus that may make another c/section technically difficult, and the
development of placenta accreta, where the placenta grows into the
prior uterine scar, sometimes leading to hemorrhage and emergency
hysterectomy. The most uncommon, but most significant, risk is uterine
rupture. This occurs in about 1/2 of 1 percent (about 0.5%) of patients
who have had a prior low-transverse c/section. As discussed, this may
result in hemorrhage or harm to the baby, but both of these are
actually uncommon. Uterine ruptures usually cause significant pain, so
close observation by a patient’s doctor and nurse, and perhaps the use
of fetal monitoring, will often diagnose this condition.

 

Since we know that vaginal deliveries are almost always safer for
the mother, and usually as safe for the baby, and that VBAC attempts
are successful in about 80% of cases, why do some women still choose to
have a repeat c/section rather than try for a vaginal delivery? In some
cases it is fear of pain during labor (although many patients report
that the pain from recuperation from a c/section is worse than labor
pain), in others it is a "fear of the unknown," while for some women
there is a convenience in scheduling the exact date of their baby’s
birth. Some patients desire a tubal ligation and believe that it is
safer to undergo a c/section and tubal ligation rather than a vaginal
delivery with subsequent tubal ligation, although medical research has
shown this to be untrue. Finally, a number of women do not wish to take
the risk, no matter how rare, of uterine rupture. No matter what the
reason, since there is a small risk with an attempt at vaginal delivery
and a risk with repeat c/section, patients should make the best choice
for themselves, based on their specific medical history, doctor’s
advice, and individual situation.

 

D. Ashley Hill, M.D.

Associate Director

Department of Obstetrics and Gynecology

Florida Hospital Family Practice Residency

Orlando, Florida

 

Comment from ICAN:

Ashley  Hill, MD is an Obstetrician in Florida who will not take mothers  pursuing VBACs due to malpractice concerns. While we sympathize with  all OB/GYN’s in the litigation predicament, ICAN cannot ethically  condone obstetricians claiming and promoting the belief that VBAC is  both safe and a reasonable expectation for most mothers while  increasing the risks to women and babies through coerced repeat  cesareans in order to protect doctors from litigation.

 

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