Is Vaginal Birth Possible after a Caesarean Delivery?

What Is a Vaginal Birth After Cesarean (VBAC)?

Vaginal birth after Cesarean stresses that vaginal delivery is possible even after having a C-section. In Cesarean section, the baby is delivered by making an incision or surgical cut in the belly, which reaches the uterus. The success rate is around 60 to 80% in VBAC. However, few factors decide the success of a vaginal birth following a Cesarean delivery (C-section).

What Is a Trial of Labor After Cesarean (TOLAC)?

A trial of labor is an attempt to deliver vaginally after a C-section. Vaginal birth is tried, and if successful, it results in vaginal birth after delivery. Else, a repeat C-section is done.

Why Is a Trial of Labor After Cesarean Recommended?

1. Future Pregnancies: Suppose there is a plan for future pregnancies. In that case, a trial of labor is suggested to prevent multiple Cesarean deliveries and their complications like placenta accreta and placenta previa.
2. Short Recovery Period: After a vaginal delivery, the period of stay in the hospital is comparably reduced. Also, resuming day-to-day activities can happen a lot sooner. Therefore, for better recovery, trials of labor are carried out to optimize the chance of vaginal birth.
3. Reduce Surgical Complications: A VBAC reduces the chance of complications like a hysterectomy or surgical removal of the uterus and injury to abdominal organs like the bladder and bowel. Also, the risk of developing an infection, excessive bleeding, and deep vein thrombosis is very much reduced after a successful VBAC.
4. Opportunity for Vaginal Birth: A VBAC gives the women a chance to experience a vaginal birth.

How Is VBAC Different From Normal Vaginal Delivery?

Vaginal delivery after C-section is similar to that of normal vaginal delivery, except that in VBAC, continuous monitoring of the baby's heart rate is done to opt for an emergency repeat C-section if needed.

What Factors Determine the Chances of Vaginal Birth After Cesarean?

1. Type of Uterine Incision: VBAC is not usually recommended in women with a prior high vertical incision or classical incision due to the risk of uterine rupture. On the other hand, women with low vertical or low transverse incision C-sections are good candidates for VBAC.
2. Time of Previous Delivery: The risk of uterine rupture is high in people who have had a previous C-section within 18 months.
3. Previous Vaginal Deliveries: History of vaginal delivery at least once before or after a C-section increases the chance of VBAC.
4. Number of C-Sections: VBAC is not suggested in people who have had more than two C-sections before.
5. Uterine Rupture: History of uterine rupture also determines the possibility of VBAC.
6. Place of Delivery: VBAC should not be planned for home delivery, but it should be scheduled for a center with a facility to go for emergency C-sections if needed.
7. Induced Labor: A successful VBAC is not possible if there is no spontaneous pain and the labor has to be induced.
8. Uterine Surgeries: VBAC is not suggested in women with a history of uterine surgeries like surgery for fibroid removal.
9. Other Health Concerns: Placental problems or having triplets or higher-order multiples contradicts vaginal birth after C-section.

Of all the above, having had a vaginal delivery after a C-section is an essential indicator that you are eligible for vaginal birth.

Why Is the Type of Incision a Crucial Deciding Factor for VBAC?

A C-section leaves a scar on the abdomen and uterus, which makes the uterus prone to rupture when a vaginal delivery is tried after a C-section. Therefore, the type of incision plays a vital role in deciding the possibility of VBAC.

1. In a low transverse incision, a horizontal cut is made on the lower and thinner part of the uterus. It has a much-reduced risk of uterine rupture and is most preferred.

2. Low vertical incisions are made vertically on the thinner part of the uterus. They carry a comparatively increased risk than low transverse incisions.

3. On the other hand, high vertical incisions are indicated for preterm Cesarean deliveries and carry the highest risk of uterine rupture. Therefore, VBAC is almost contraindicated after these types of C-sections.

When Can I Have a Vaginal Birth After Cesarean?

Your chances for a normal delivery after C-section are good if:

• You have already had only one C-section.

• You are pregnant with one baby and had previous one to two low transverse C-sections.

• You are pregnant with one baby and had a prior C-section of any type other than the high vertical or classical uterine incision.

• You have had a normal delivery after a C-section.

• You are pregnant with twins and had a previous C-section of low transverse type.

• Yours is an uncomplicated pregnancy with a normal healthy baby.

• You have spontaneous onset of labor pain.

• You have no history of uterine ruptures.

• The reasons for which you had a C-section are not repeating this time.

When Are My Chances of VBAC Reduced?

Your chances for normal delivery are less if you have the following:

• If the interval between your C-section and subsequent pregnancy is less than three years, it is improbable that you will be offered normal delivery.

• If you have already had more than one C-section, with no normal deliveries in between.

• If the baby is unusually large.

• If you have crossed your due date or pregnancy lasts for more than 40 weeks.

• If your age is more than 40.

When Is a Vaginal Birth After C-Section Contraindicated?

VBAC (Vaginal Birth After Cesarean) is contraindicated in the following situations:

• If you have had a classical C-section, you have a vertical incision on your uterus.

• If you have had more than two C-sections with no normal deliveries in between.

• If you have had uterine rupture before.

• If you have had uterine myomectomy (surgical removal of myomas in the uterine cavity).

• If you have had prior hysterotomy (a form of abortion in which the fetus is surgically removed just like in a C-section through an abdominal incision).

• If you have had a complicated pregnancy like placenta previa (a pregnancy problem in which the placenta covers the opening of the cervix).

• If the body mass index is high.

• If there is preeclampsia.

• If there is stalled labor which is a period of no or minimal contractions after a good amount of contraction.

What Are the Benefits of VBAC?

A vaginal birth following a C-section opens the door for you for future normal deliveries, especially when you plan to have a big family.

• Shorter hospital stay.

• Early mobilization - In a few hours, you are ready to move.

• Less postoperative pain.

• No anesthetic complications.

• No major surgical complication.

• Less respiratory complications for your baby.

• Increases chances for you to have normal deliveries in future.

What Are the Risks of VBAC?

• Repeat C-Section - Many a time, labor needs to be terminated in a C-section. The reason could range from impending rupture of the uterus, fetal distress, and shoulder dystocia (a condition in which one of the baby's shoulders gets stuck behind the pubic bone during labor).

• Increased Chances of Infection - A trial of labor that ends up in a C-section increases the risk of infection to your uterus as well as the abdominal wall.

• Increased Chances of Surgical Complication - Injury to nearby organs.

• Uterine Rupture - Your uterus might open up along the line where your previous incision was done. If this happens during or before labor, you need to have an emergency C-section.

• Hysterectomy - Rarely, you might end up having a hysterectomy (surgical removal of the uterus) if there is any complication or when you have a uterine rupture.

How Should I Prepare for a Successful VBAC?

• Make yourself well prepared by learning about VBAC.

• Gather as much information about it as you can.

• Talk to your doctor. Understand your chances.

• Take good care of yourself and your baby.

• Choose a well-equipped hospital.

• Prepare yourself mentally for a C-section if an emergency arises.

Where Should VBAC Be Done?

VBAC must be tried in a center with:

• Neonatal ICU.

• 24x7 emergency operation theatre.

• Adult ICU.

• Blood bank.

Conclusion:

Vaginal delivery is possible after a Cesarean section, but the possibility depends on several factors. Know about the factors contributing to VBAC and stick to the advice of your healthcare professional at all means. However, do not be bothered about the type of delivery. Your ultimate aim is to have a healthy baby and a healthy you, needless of the path you take to get there.