After a cesarean, most women have two choices for future births: a vaginal birth after cesarean (VBAC) or a repeat cesarean section (RCS). There is a lot of misinformation about these two options. Let’s review some quick facts.
Per the American College of Obstetricians and Gynecologists (ACOG, 2010), VBAC is a “safe and appropriate choice for most women” with one prior cesarean and for “some women” with two prior cesareans. Being pregnant with twins, going over 40 weeks, having an unknown or low vertical scar, or suspecting a “big baby” should not prevent a woman from planning a VBAC (ACOG, 2010).
Research on uterine scar thickness (Kamel, 2009) and single vs. dual layer suturing (Humphries, 2004) are on-going as the studies completed thus far are not strong enough to provide conclusive support for specific actions.
VBAC is successful 75% of the time (Coassolo, 2005; Huang, 2002; Landon, 2004; Landon, 2006; Macones, 2005). Successful VBACs have lower complication rates than planned repeat cesareans which have lower complication rates than “failed” VBACs (Landon, 2004), otherwise known as cesarean birth after cesarean or CBAC.
Uterine rupture is the major concern in terms of VBAC and while it can be catastrophic, it is rare (National Institutes of Health, 2010).
Permitting labor to begin naturally after one prior low transverse (“bikini cut”) cesarean carries a 0.4% risk of rupture which can increase upon labor augmentation or induction (Landon, 2004). These rates are similar to other serious obstetrical emergencies such as placental abruption, cord prolapse, and post partum hemorrhage.
Cesarean risks, including placenta accreta, hysterectomy, blood transfusion, and ICU admission, increase with each surgery (Silver, 2006); whereas after a successful VBAC, the future risk of uterine rupture, uterine dehiscence, and other labor related complications significantly decrease (Mercer, 2008).
With each option, the risk of maternal death is very low: 0.02% VBAC vs. 0.04% RCS (Landon, 2004). Additionally, the risk of adverse infant outcomes during a VBAC is 0.05% which is “quantitatively small but greater than that associated with elective repeat cesarean delivery” (Landon, 2004).
45% of American women are interested in the option of VBAC (Declercq, 2006), yet 92% have a RCS (Martin, 2009). Some women chose their RCS or it was medically necessary. Others felt like they didn’t have much of a choice for numerous reasons including hospital VBAC bans (Kamel, 2010); unsupportive health care providers, friends, and family (Kamel, 2009b & 2010b); or the misrepresentation of VBAC risks (Kamel, 2009b & 2010b).
Our repeat cesarean rate feeds America’s rising total cesarean rate, currently at 32% (Menacker, 2010). The World Health Organization (WHO, 2009) warns against total cesarean rates higher than 15% and indicates that at least half of American cesareans could be unnecessary. Declercq (2009) links our high cesarean rate with our high maternal mortality rate relative to other developed countries.
In all 50 states, hospital and doctor attended VBACs are legal and in some states it is legal for a midwife to attend an OOH (out-of-hospital) VBAC (Kamel, 2009c). However, of the women interested in VBAC, 57% are unable to find a supportive care provider or hospital (Declercq, 2006). This is due primarily to the 1999 ACOG recommendation that a doctor be “immediately available” to perform a cesarean, yet they provided no clear definition or standard for where the obstetrician and/or anesthesiologist should be or what they could be doing.
As a result, hospitals developed their own definitions producing differing VBAC protocols and requirements. The most severe variety was the institution of VBAC bans in one-third of all American hospitals (ICAN, 2009), disproportionally affecting women living in rural areas. As the new ACOG (2010) guidelines retracted this problematic proposal, hopefully VBAC will become a viable option to the many women who desire it (Kamel, 2010c).
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American College of Obstetricians and Gynecologists. (1999). ACOG Practice Bulletin No. 5: Vaginal birth after previous cesarean delivery. Washington DC.
American College of Obstetricians and Gynecologists. (2010, July 21). Ob-Gyns Issue Less Restrictive VBAC Guidelines. Retrieved July 21, 2010, from ACOG: http://www.acog.org/from_home/publications/press_releases/nr07-21-10-1.cfm
American College of Obstetricians and Gynecologists. (2010). ACOG Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Washington DC.
Coassolo, K. M., Stamilio, D. M., Pare, E., Peipert, J. F., Stevens, E., Nelson, D., et al. (2005). Safety and Efficacy of Vaginal Birth After Cesarean Attempts at or Beyond 40 Weeks Gestation. Obstetrics & Gynecology, 106, 700-6.
Declercq, E. R., & Sakala, C. (2006). Listening to Mothers II: Reports of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection. Retrieved from Childbirth Connection: http://www.childbirthconnection.org/article.asp?ck=10068
Declercq, E. R. (September, 2009). Birth by the numbers [video]. Retrieved from Orgasmic Birth: http://www.orgasmicbirth.com/birth-by-the-numbers
Huang, W. H., Nakashima, D. K., Rumney, P. J., Keegan, K. A., & Chan, K. (2002). Interdelivery Interval and the Success of Vaginal Birth After Cesarean Delivery. Obstetrics & Gynecology, 99, 41-44.
Humphries, G. (2004, June 14). The Suture Debate. Retrieved October 1, 2009, from International Cesarean Awareness Network: http://www.ican-online.org/vbac/the-suture-debate
International Cesarean Awareness Network. (2009, February 20). New Survey Shows Shrinking Options for Women with Prior Cesarean. Retrieved from ICAN: http://www.ican-online.org/ican-in-the-news/trouble-repeat-cesareans
Kamel, J. (2009, January 17). Predicting uterine rupture by uterine thickness via sonogram. Retrieved from VBAC Facts: http://vbacfacts.com/2009/01/17/predicting-uterine-rupture-via-sonogram-to-measure-uterine-thickness/
Kamel, J. (2009b, October 19). Response to OB: Scare tactics vs. informed consent aka why I started this website. Retrieved from VBAC Facts: http://vbacfacts.com/2009/10/19/response-to-ob-scare-tactics-vs-informed-consent-aka-why-i-started-this-website/
Kamel, J. (2009c, February 28). Is VBAC illegal? Is homebirth illegal? Retrieved from VBAC Facts: http://vbacfacts.com/2009/02/28/is-vbac-illegal/
Kamel, J. (2010, July 22). VBAC in rural hospitals. Retrieved from VBAC Facts: http://vbacfacts.com/2010/07/22/vbac-in-rural-hospitals/
Kamel, J. (2010b, March 16). Another VBAC consult misinforms. Retrieved from VBAC Facts: http://vbacfacts.com/2010/03/16/another-vbac-consult-misinforms/
Kamel, J. (2010c, March 9). American women speak about VBAC. Retrieved from VBAC Facts: http://vbacfacts.com/2010/03/09/american-women-speak-about-vbac/
Landon, M. B., Hauth, J. C., & Leveno, K. J. (2004). Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery. The New England Journal of Medicine, 351, 2581-2589.
Landon, M. B., Leindecker, S., Spong, C., Hauth, J., Bloom, S., Varner, M., et al. (2005). The MFMU Cesarean Registry: Factors affecting the success of trial of labor after previous cesarean delivery. American Journal of Obstetrics and Gynecology, 193, 1016-1023.
Landon, M. B., Spong, C. Y., & Tom, E. (2006). Risk of Uterine Rupture With a Trial of Labor in Women with Multiple and Single Prior Cesarean Delivery. Obstetrics & Gynecology, 108, 12-20.
Macones, G. A., Cahill, A., Pare, E., Stamilio, D. M., Ratcliffe, S., Stevens, E., et al. (2005). Obstetric outcomes in women with two prior cesarean deliveries: Is vaginal birth after cesarean delivery a viable option? American Journal of Obstetrics and Gynecology, 192, 1223-9.
Martin, J. A., Hamilton, B. E., Sutton, P. D., Ventura, S. J., Menacker, F., & Kirmeyer, S. (2009, January 7). Births: Final Data for 2006. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_07.pdf
Menacker, F., & Hamilton, B. E. (2010, March). Recent Trends in Cesarean Delivery in the United States. Retrieved from Center for Disease Control and Prevention: http://www.cdc.gov/nchs/data/databriefs/db35.htm
Mercer, B. M., Gilbert, S., Landon, M. B., & Spong, C. Y. (2008). Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Obstetrics & Gynecology, 11, 285-91.
National Institutes of Health. (2010, June). Final Statement. Retrieved from NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights: http://consensus.nih.gov/2010/vbacstatement.htm
Silver, R. M., Landon, M. B., Rouse, D. J., & Leveno, K. J. (2006). Maternal Morbidity Associated with Multiple Repeat Cesarean Deliveries. Obstetrics & Gynecology, 107, 1226-32.
World Health Organization, UNFPA, UNICEF and AMDD. (2009). Monitoring emergency obstetric care: A handbook. Retrieved from World Health Organization: http://www.who.int/reproductivehealth/publications/monitoring/9789241547734/en/
Last revised: 7/25/2010