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Considering the Safety of a Vaginal Birth After Cesarean Section
The number of Cesarean sections performed in the United States has grown over the past 20 years. Now, nearly 25% of all deliveries are performed surgically. The increase can be traced to a variety of causes, including: larger babies, more twins and triplets, a decline in the number of doctors performing breech vaginal births, and the fear of litigation. With more first-time cesarean sections come more opportunities to do repeat Cesarean sections.

There was a big push to have patients undergo “VBAC” (vaginal birth after Cesarean) in the late 1980s. Perhaps it was born from a desire to give women a “natural” birth experience, reduce their risk of surgery or cut the cost of maternity care. Regardless of the reasons, we offered appropriate candidates the option of trying labor, with a success rate of nearly 70%.

Today, the climate has changed markedly. With some recent medical articles highlighting the hazards of “VBAC”—including uterine rupture and its serious complications—many of my patients are electing to have a repeat Cesarean section. In the most dramatic article, they noted a ten-fold increase in the uterus tearing open (rupture) if medication was used to prepare the cervix prior to labor.

For those who desire a VBAC and go into spontaneous labor, there is a 1% risk of uterine rupture. I have cared for two patients who experienced this complication. In each case, I was at the bedside when the problem occurred and took prompt action, which prevented serious complications for the mother or child. However, it has given me a great respect for the potential risks associated with VBAC.

I have several important suggestions for those of you who wish to have a VBAC:

1. Speak with your doctor about your first Cesarean section and the prospects of a successful vaginal delivery with this pregnancy. If your first baby was five pounds and it didn’t fit, you are much more likely to fail in this attempt. However, if you had a breech baby the first time, you have a very good chance of delivering vaginally.

2. Speak with your doctor about the hospital where you’ll deliver and their personal experience with VBAC. Specifically, the hospital must have adequate anesthesia availability (see my article on this web site titled Where Will Your Baby Be Delivered?) and a surgical assistant to perform a Cesarean section urgently, if needed. Also, make sure your doctor is comfortable with your desire to have a VBAC.

3. Deliver at a hospital with an obstetrician. Home birth and midwife-directed medical management are ill advised.

4. Be flexible. Even the best-laid plans can go awry. Remember, the most important issue here is not how you deliver but that you have a safe delivery!
Craig L. Bissinger M.D.