Should I have a VBAC trial of labor after a previous cesarean?

Introduction

This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.

Key points in making your decision

In the recent past, a woman who had one baby by cesarean section delivery would have a cesarean for all future deliveries. Today, many women with one cesarean scar, or a past vaginal delivery plus two cesarean scars, can plan to go into labor (trial of labor) to deliver vaginally. This is called vaginal birth after cesarean (VBAC).

Whether you deliver vaginally or by cesarean section, you are unlikely to have serious complications. Overall, a routine vaginal delivery is less risky than a routine cesarean, which is a major surgery. But researchers have found that pregnant women who have a cesarean scar have a slight risk of the scar on the uterus breaking open during labor. This is called a uterine rupture.¹

This information can help as you think about having a trial of labor and vaginal delivery after having had a cesarean delivery. Consider the following when making your decision:

• Even if you are a good candidate for VBAC and you have a trial of labor, it is still possible that you will need a cesarean. About 60% to 80% of women deliver vaginally after a VBAC trial of labor.¹
• If the problem that led to a previous cesarean (such as breech position) doesn't repeat itself in this pregnancy, you are about as likely to have a successful vaginal delivery as women who have not had a previous cesarean.¹
• Delivering a baby vaginally after one cesarean is a safe choice for most women. Whether it is right for you depends on whether you have any other risk factors that could make VBAC unsuccessful or unsafe.
• During VBAC, there is a remote risk of a cesarean scar on the uterus tearing open. This is called uterine rupture. This risk increases with each additional scar and with the use of medicine to start (induce) labor.¹
• If you have had one or two cesareans but have also delivered vaginally before, your uterine rupture risk is much lower than if you had never delivered vaginally.¹
• If you are planning to have more pregnancies, consider that with each additional scar on the uterus, there are more risks in the next pregnancy. Placenta problems are more likely to happen. It's best to try a trial of labor and avoid more scarring if you can.
• Some hospitals and doctors do not offer VBAC.

Medical Information

What is a VBAC?

A vaginal birth after cesarean, or VBAC, is a birthing option for many women who have previously had:¹

• One cesarean delivery.
• One or two cesarean deliveries and a past vaginal delivery.

When you go into labor with the plan to deliver vaginally, it is called a "trial of labor."

Is a VBAC trial of labor a good choice for you?

Delivering a baby vaginally after having one cesarean, or after having a vaginal delivery and two cesarean deliveries, is a safe choice for most women. Whether it is right for you depends on several factors, including:

• Why you had a cesarean previously. If you had a cesarean because of a problem that you now have in this pregnancy (such as a breech baby), a trial of labor is generally not recommended. However, most women have cesarean deliveries because of problems that develop during labor (not before labor), such as stalled labor or signs of fetal distress. Usually there is no reason to expect that the same problem will happen again (although it may).
• How many cesarean deliveries you have had. If you have had one cesarean, a trial of labor is generally safe. If you have had two cesareans, a trial of labor is only considered safe if you've also delivered vaginally before. A trial of labor is not recommended for women who have had more than two cesareans. The more cesarean deliveries you have had, the higher your risk of uterine rupture (though the risk is still low) and problems with the placenta that may cause difficulties during delivery.
• How many future pregnancies you are planning. The risks of complications during pregnancy and surgery increase with the number of cesarean scars you have.
• Your personal preference. If there is no medical reason for a repeat cesarean, the choice is yours. Women in similar situations may make different choices based on their own experiences and concerns.
• The hospital where you will deliver. In order to offer VBAC, a hospital must have the staff and the equipment to do rapid emergency cesarean at any time of the night or day.

What are the risks of VBAC?

Risks of a VBAC trial of labor include:

• Development of a typical labor problem (such as fetal distress) that requires a cesarean delivery to ensure your own or your infant's safety. This occurs in about 20% to 40% of women who are considered good candidates for a VBAC trial of labor.¹
• Separation of the uterine scar (dehiscence). This usually causes no problems and, in some cases, is not even detected. It usually heals on its own.
• Uterine rupture, which can be life-threatening to mother and infant, although it is rare.

Women who have a trial of labor and then deliver by cesarean have a higher risk of infection. This means that infection risk is lower after a vaginal birth, and after a repeat cesarean without labor.¹

No two births are alike, and the labor and delivery process is impossible to fully plan and control. No doctor can guarantee that you will have a successful trial of labor.

What are the risks of a cesarean delivery?

The risks of cesarean delivery include:

• Infections.
• Blood loss that requires a blood transfusion.
• Genital or urinary complications.
• Blood clots (thromboembolism).
• Risks related to anesthesia.
• Fetal injury during the delivery. The injury usually is not serious.
• A longer recovery time.

Future risks. With each surgery on the uterus, more scar tissue forms. If you are planning on a pregnancy after this one, scarring is an important factor to think about. After you have two scars, each additional scar in the uterus raises the risk of placenta problems in a later pregnancy, such as placenta previa or placenta accreta. These problems raise not only the risks for a baby but also your risk of needing a hysterectomy to stop bleeding.²

If you need more information, see the topics Vaginal Birth After Cesarean (VBAC) and Cesarean Section.

Your Information

Your choices are:

• Attempt a trial of labor.
• Plan another cesarean delivery.

This information does not apply to you if you have one or more risk factors for uterine rupture during this pregnancy.

The decision about whether to have a trial of labor takes into account your personal feelings and the medical facts.

These personal stories may help you make your decision.

Wise Health Decision

Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about having a VBAC trial of labor. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

Use the following space to list any other important concerns you have about this decision.

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to have or not have a VBAC trial of labor.

Check the box below that represents your overall impression about your decision.

Return to the topic:

• Cesarean Section
• Vaginal Birth After Cesarean (VBAC)

References

Citations

1. American College of Obstetricians and Gynecologists (2004). Vaginal birth after previous cesarean delivery. ACOG Practice Bulletin No. 54. Obstetrics and Gynecology, 104(1): 203-212.

2. Paré E, et al. (2005). Vaginal birth after caesarean section versus elective repeat caesarean section: Assessment of maternal downstream health outcomes. British Journal of Obstetrics and Gynaecology, 113(1): 75-85.