Deciding between a VBAC and a Repeat C-section

If you’ve had a cesarean birth and get pregnant again, one question is going to come up - should you plan for another c-section, or should you try to give birth vaginally?

This is not always an easy decision to make, and there are several factors to take into account. This is also a very personal decision, one that should be made in partnership with your ob-gyn based on your own needs and health history. Here are some important questions to ask when considering the options:

1. What type of incision did you have?

During a c-section, the doctor cuts through your skin, muscles, and the wall of the uterus. These cuts, or incisions, can be done in different ways. They can be transverse (side-to-side) or vertical (up-and-down). The type of incision on your uterus can have a big impact on future births.

Most cesarean incisions these days are low transverse—that is, side-to-side across the lowest, thinnest part of the uterus. The scar from this type of incision carries the smallest risk for uterine rupture, which means trying a vaginal birth after cesarean (VBAC) could be safe.

But with a vertical incision, your scar is on the part of the uterus that contracts during labor. This means the risk for uterine rupture is higher. There are two types of vertical incisions:

• Low vertical—An up-and-down cut is made in the lower part of the uterus. The risk of rupture is higher than a low transverse incision, but you can still consider trying a VBAC.

• High vertical (also called classical)—An up-and-down cut is made in the upper part of the uterus. The risk of rupture is highest with this type of cut, and trying a VBAC is not recommended.

If you’re not sure what type of incision you had on your uterus, try asking your doctor or checking your medical records. Unfortunately, the type of uterine incision done at the time of a prior cesarean delivery cannot always be confirmed. And the incision on your skin may be different than the one on your uterus, so you can’t tell by looking at the scar on your skin.

2. What circumstances led to your previous cesarean birth?

Cesarean births are done for many reasons. Some reasons are a matter of chance, while others are more likely to happen again. The history behind your previous cesarean can provide clues for what to do for later births.

Let’s say your first baby was breech and you didn’t have a chance to labor. There’s no reason to think you couldn’t have a safe vaginal birth if your fetus is head-down this time. But if you required a cesarean delivery after hours of prolonged or stalled labor (often when the cervix stops opening), there’s a higher chance that this can happen again. That might guide us toward planning a repeat cesarean.

3. Do you have any health conditions that could make a VBAC risky?

Some health conditions are known to lower your chances of a successful VBAC, including obesity and preeclampsia. If your fetus is measuring larger than average or your pregnancy has gone past 40 weeks, that too could make a VBAC more difficult. The same is true if it has been less than 19 months since your cesarean birth. In all these cases, it may be better to choose a repeat cesarean over a VBAC.

Also, a vaginal birth is generally not recommended for anyone who has a condition affecting the placenta, like placenta previa. This calls for a planned cesarean birth, regardless of your birth history.

4. Do you need to be induced?

VBACs are sometimes done with labor induction, but this may increase the risk for uterine rupture. So if your labor needs to be induced, it may be safer to plan a repeat cesarean.

That said, if you go into labor before your scheduled cesarean, it may be best to try a VBAC. You and your fetus will be closely monitored for any signs that a cesarean may be necessary.

5. How big of a family do you want?

When deciding whether to attempt a VBAC, it also helps to think about how many more children you want to have. That’s because the risks for complications increase with each repeat cesarean. We want to try to minimize your total number of cesarean births.

So if you are pregnant with your second child and are sure it’s your last, it would be OK to schedule a repeat cesarean if that’s what you would prefer. But if you envision a larger family with three or more children, that could be a reason to consider trying for a VBAC.

6. What resources are available at your hospital?

VBACs have become more common in recent decades, as research has continued to show they are safe under the right conditions. But not all hospitals are equipped to handle them, especially in the event of an emergency like uterine rupture.

If you want to try for a VBAC, you should choose a hospital with enough resources to handle any potential emergency. These resources include 24/7 anesthesia in the hospital, access to a blood bank for blood transfusions, an intensive care unit (ICU), and a neonatal intensive care unit (NICU). These types of hospitals are most common in larger cities.

7. What are you comfortable with?

Last but not least, your personal values have a place in this decision-making process too. I’ve met many women who feel strongly about having a vaginal birth experience, which leads them to try for a VBAC. Others are more comfortable with a repeat cesarean birth.

A previous traumatic birth experience can also have an impact on future pregnancies and deliveries. If you had a long labor that ended with a cesarean birth, for example, you might not be so eager to try a vaginal birth the next time around.

All these positions are valid and should be respected. My hope is that everyone feels empowered to express their preferences for giving birth.

A note on VBAC calculators

These are just a few of the factors that come into play when determining whether you should attempt a VBAC. Which brings me to VBAC calculators, something you may encounter if you search about this topic online. A VBAC calculator is one of many tools that can offer information about possible VBAC success.

VBAC calculators are not perfect. They only offer an estimate of your chances of success of having a VBAC, and the estimates can be wrong. If your doctor uses a VBAC calculator, it should be just one piece of the decision-making puzzle.

The most widely used VBAC calculator asks for your age, height, weight, prepregnancy weight, birth history, and whether you are being treated for chronic high blood pressure.

One size does not fit all

If you’re pregnant and have had a previous cesarean birth, talk through all these questions with your ob-gyn. Weigh the risks and benefits of each birth option, like you would with any important health care decision. Think of this as an ongoing conversation with your ob-gyn that starts early in your pregnancy and evolves over time. Your feelings may change, and your risk factors could change too.

There is no one-size-fits-all answer when it comes to choosing between trying for a VBAC and a repeat cesarean birth. What matters is that you are comfortable with your decision, and that you feel supported throughout your pregnancy and birth.

Resource: American College of Obstetrics and Gynecology, Experts and Stories, "Expert View" Dr. Angelica Glover www.acog.org

Author

R Ellen Eye, MD, FACOG Rita Ellen Eye, MD is a board-certified OB/GYN physician who joined Premier OB-Gyn in 2014. Dr. Eye is originally from Potosi, Missouri, a small town near St. Louis (and she remains a loyal fan of the St. Louis Cardinals!). She graduated from her high school as Valedictorian. She attended Missouri University of Science and Technology, earning her Biological Sciences degree while graduating with Magna Cum Laude honors. She received her doctoral degree from the University of Missouri-Columbia in 2006. Dr. Eye went on to complete her residency in Obstetrics and Gynecology and was honored by being elected Chief Resident at the University of Oklahoma in Tulsa. She began her successful private practice in Texas where she lived and worked for four years before moving to Florida. She is married to husband Chet and a proud mom to a sweet daughter named Faith. Dr. Eye is board certified by the American Board of Obstetrics and Gynecology.