Vaginal birth after caesarean

Vaginal birth after caesarean (VBAC) refers to the practice of delivering a baby vaginally (naturally) after a previous baby has been delivered through caesarean section (surgically).^[1] According to the American Pregnancy Association, 90% of women who have undergone cesarean deliveries are candidates for VBAC.^[2] From 60-80% of women opting for VBAC will successfully give birth vaginally.^[2][3]

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Drawbacks and benefits

Obstetricians and other caregivers differ on the relative merits of vaginal and caesarean birth following a caesarean birth. Some still recommend a caesarean routinely, others do not; still others respect the wishes of the expectant mother.

Risks include a higher chance of re-hospitalization after birth, infertility, and uterine rupture in the next birth.^{[citation needed]} The risk of uterine rupture in a VBAC is 0.2% to 1.5%.^[2] Because of the risks involved, many health insurance companies will not support VBAC. Today only about 10% of eligible women in the United States try VBAC.^[3]

The risk of infection doubles if vaginal delivery is attempted but results in another cesarean.^[2]

For women with one or more previous caesareans, as an alternative to major abdominal surgery, VBAC remains the safer option.^[3][4] VBAC allows for less risk of infection, shorter recovery time, and less medical expenses.^[3]

Eligibility

There are several common methods of determining eligibility, though the real determination must be made with a doctor or other qualified health care practitioner. Some common factors include:^[3]

• If the previous caesarean(s) involved a low transverse incision there is less risk of uterine rupture that if there was a low vertical incision, classical incision, T-shaped, inverted T-shaped or J-shaped incision.

• A previous successful vaginal delivery (before or after the caesarean section) increases the chances of a successful VBAC.

• The reason for the previous caesarean section should not be present in the current pregnancy.

• The more caesarean sections that a woman has had, the less likely she will be eligible for VBAC.

• The presence of twins will decrease the likelihood of VBAC. Some doctors will still allow VBAC if the twins are positioned properly for birth.

• VBAC may be ruled out if there are other medical complications (such as diabetes), if the mother is over 40, if she is past her due date, if the baby is in the wrong position, etc.

For women planning to have many children, VBAC may be a better option because repeat caesarean sections get more complicated each time.

History

VBAC is not uncommon today. The medical practice until the late 1970s was "once a caesarean, always a caesarean" but a consumer-driven movement supporting VBAC changed the medical practice. Rates of VBAC in the 80s and early 90s soared, but more recently the rates of VBAC have dramatically dropped due to medico-legal restrictions.

In the past, caesarean sections used a vertical incision which cut the uterine muscle fibers. Modern caesareans typically involve a horizontal incision along the muscle fibers. The uterus then better maintains its integrity and can tolerate the strong contractions of future childbirth. Cosmetically the scar for modern caesareans is below the "bikini line."

Twenty years of medical research on VBAC, support a woman's choice to have a vaginal birth after caesarean. Because of the consequences of caesareans, preventing the first caesarean remains the priority.

References