Doc Talk: Should you have another C-section?

07/01/2014 12:00 AM

08/08/2014 10:25 AM

For various reasons, nearly one-third of women who give birth in the United States have a cesarean section. In the past, women who had a C-section were destined to have a C-section with every subsequent pregnancy. It was believed that a vaginal delivery would put too much stress on the uterine scar and cause a rupture of the uterus.

In the 1970s, many women and their doctors wanted to try vaginal birth after a cesarean (VBAC), and did so with positive outcomes. The rate of VBAC increased from just over 5 percent in 1985 to 28 percent in 1996, then began a steady decline. By 2006, the VBAC rate fell to 8.5 percent, due to restrictions by some hospitals and insurers as well as decisions by patients when presented with the risks and benefits.

Which is better?

Here are some of the facts:

• About one or two in every 100 attempts at VBAC results in uterine rupture. Although this is a low risk and ruptures are often not serious, some ruptures can be catastrophic for both mother and baby.
• Approximately 60 to 80 percent of appropriate candidates who attempt VBAC are successful. However, if the VBAC fails and an emergency C-section is required, complications are more likely to occur than if a scheduled C-section is performed.
• Many hospitals, especially small ones, did not allow attempts at VBAC because they did not meet criteria set by the American Congress of Obstetricians and Gynecologists (ACOG). These criteria require that medical staff always be available in the hospital to perform emergency C-sections if needed. These requirements have been lessened over the past few years, but many smaller hospitals still do not allow VBAC.
• A VBAC avoids major abdominal surgery, lowers a woman’s risk of hemorrhage and infection, and shortens recovery. It may also help women avoid potential future consequences of multiple cesarean deliveries such as hysterectomy and bowel or bladder injury.

How to decide

The decision whether to attempt VBAC is based on a number of factors, such as the mother’s health and history and on patient preference.

Some women prefer to avoid the risk of a uterine rupture, no matter how small that risk may be, and also prefer the convenience of a scheduled C-section. Other women, especially those who have had both a vaginal delivery and a C-section, prefer the faster recovery of a VBAC.

Generally, women who have had successful vaginal births are better candidates for VBAC than women who often experienced complications in the past. If the situation that led to the C-section is likely to occur again, then attempting a VBAC is not advisable. Several other factors also need to be considered, such as the type of incision used in the C-section, the health of the mother and child during pregnancy, and the size of the child.

The latest ACOG guidelines state that attempting a VBAC is a safe and appropriate choice for most women, including for some women who have had two previous cesareans. Ultimately, the decision is very individualized. It’s important for the pregnant woman and her physician to thoroughly discuss the options, benefits and risk factors before agreeing on a course of action.

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