Vaginal Birth After Cesarean Delivery

What is Vaginal Birth After Cesarean Delivery?

Vaginal birth after cesarean section (VBAC) refers to a situation where a woman delivers a baby vaginally after previously having a cesarean section (also known as a C-section, which is surgery to deliver a baby through the mother’s abdomen). If a patient wishes to try for a VBAC, they will undergo a trial of labor (TOL) or, more specifically, a trial of labor after cesarean section (TOLAC). This means they will attempt to deliver vaginally and see how it goes.

Although this practice is generally safe, it’s important to know that it does come with risks, like a potential rupture (break) in the uterus or a split along the previous C-section scar – a condition known as dehiscence. Both of these scenarios can lead to health issues for the mother and/or the baby.

That’s why it’s crucial for healthcare providers to be well-informed so they can explain to their patients the possible risks and benefits of TOL. They should also consider the factors that might influence the chances of a successful vaginal delivery. Lastly, they should have knowledge to manage the delivery process for patients attempting TOLAC.

What Causes Vaginal Birth After Cesarean Delivery?

As the number of C-sections (cesarean deliveries) has increased, so too has the number of women getting pregnant again after previously having a C-section. After having a C-section, some women may have a vaginal birth with their next baby. This can either be planned in advance or happen unexpectedly due to early labor.

Risk Factors and Frequency for Vaginal Birth After Cesarean Delivery

The rate of cesarean delivery, or c-sections, has significantly increased since 1970, going from 5% then to 30% in 2005, peaking at 32.9% in 2009. As recent as 2016, the rate was reported to be 31.9%. In the early 1970s, when the c-section rate began climbing, medical providers generally believed that if a woman had one cesarean delivery, all her future deliveries should also be by cesarean.

However, this belief was questioned by healthcare professionals, and the number of women choosing to deliver vaginally after a previous cesarean (VBAC) began to increase. This switch was particularly noticeable from the mid-1980s to the mid-1990s, with the VBAC rate increasing over 20% and a corresponding decrease in the c-section rate. However, as VBAC became more common, so did the number of severe complications and associated lawsuits, leading to a decrease in VBAC.

While complications can occur with VBAC, if the patients are well-selected, they can benefit from attempting a vaginal delivery. Successful VBAC is associated with lower health risks for the mother and less risk of future pregnancy complications. Plus, women who have a successful VBAC avoid the rigors of surgical recovery in the post-birth period. A higher VBAC rate also helps to decrease the overall c-section rate.

One important aspect to consider is that the risk of severe pregnancy complications increases with every additional c-section a woman undergoes. These risks include severe post-birth bleeding, placenta conditions like placenta previa, and other placental disorders. Avoiding multiple c-sections, therefore, provides significant benefits, particularly for women planning large families.

Signs and Symptoms of Vaginal Birth After Cesarean Delivery

When a pregnant woman goes for her first prenatal check-up or is admitted for labor and delivery, it’s important for healthcare providers to obtain a detailed history and perform a physical exam. Things to cover in her medical history include previous pregnancies (including when they occurred and how they ended), weight and the age of the baby at birth, and any complications from past pregnancies. It might even be necessary to look at medical records from past prenatal care givers or hospitals where she gave birth before.

Delivery method is another important factor. Was the baby born naturally or via a cesarean section? If the mother had an operative delivery, meaning either forceps/vacuum extraction or a c-section, it’s important to know why that decision was made. Ideally, the detailed reports from these procedures should be available in the patient’s file.

A physical exam, particularly a pelvic exam, should be conducted especially if the woman had a previous c-section. This exam can help predict the likelihood of a vaginal birth, but its results shouldn’t be the only deciding factor for a woman to try labor, as this method isn’t always very accurate in predicting successful vaginal birth after cesarean (VBAC).

In the lead-up to delivery, a pelvic exam can offer insight into whether the woman is likely to go into labor on her own. Signs to look for include a softening and thinning of the cervix and the baby’s head sitting low. There should be an attempt to estimate the baby’s weight close to the due date, either by physical exam or ultrasound. However, these estimations should not be the only factor in deciding to attempt labor, because neither method is entirely accurate.

Testing for Vaginal Birth After Cesarean Delivery

Some women might not be suitable for TOLAC, which stands for “trial of labor after cesarean.” This process allows women who had previously delivered through a cesarean section to try a vaginal delivery for their next child. If you’ve had a previous classical cesarean section or an incision into the muscular part of the uterus, there is a higher chance of uterine rupture (when the wall of the uterus tears during pregnancy). Therefore, it’s usually recommended to have another planned cesarean section.

It’s a good idea for your doctor to review any prior surgery reports to understand the type of uterine incision. If this can’t be done, like when the previous surgery was performed in another country, then it may be hard to determine the type of previous incision. This is known as an “unknown scar.” Most cesarean sections involve a low, horizontal cut on the uterus which is considered safe for TOLAC. If there’s no indication of a vertical incision, it may be okay to proceed with TOLAC. The risk of uterine rupture in these cases has been found to be similar to having one low, horizontal cesarean section.

The risk of uterine rupture increases with the number of previous cesarean sections. With one prior cesarean, the risk is less than 1%, and it’s slightly higher with two prior cesarean sections (1% to 2%). Patients with up to two prior cesarean deliveries might still be suitable for TOLAC, which is also supported by the American College of Obstetrics and Gynecology.

Anyone with conditions involving cuts in the muscular part of the uterus is usually not suitable for TOLAC due to a high risk of uterine rupture. This can include certain types of incisions made during cesarean deliveries (“T” or “J” type) or surgeries to remove fibroids or perform open fetal surgery. Women who have experienced a uterine rupture before also have a high risk of it happening again, so a planned cesarean delivery is usually recommended.

Hospitals that offer TOLAC should be able to perform an emergency cesarean section if needed. However, this requirement may limit options for some women, particularly those in rural areas. The latest practice bulletin from ACOG suggests referring such patients to places that can provide TOLAC when appropriate. Some patients may still decide to try TOLAC, even in areas with limited resources.

When deciding between TOLAC and a planned repeat cesarean delivery, it can be helpful to know the likelihood of successful vaginal delivery. Generally, 60% to 80% of women with a previous cesarean section successfully deliver vaginally the next time. The chances might be higher if the reason for the previous cesarean is not likely to happen again, like a breech presentation (when the baby’s feet or buttocks are facing down rather than the head). If you’ve delivered vaginally before, you also have a higher chance of a successful vaginal delivery after a cesarean. There are even special calculators available to help estimate your success rate.

Lastly, starting labor naturally can increase the success rate compared to inducing labor.

Treatment Options for Vaginal Birth After Cesarean Delivery

Patients who have had a previous cesarean section, but want to attempt a natural birth with their next child need regular prenatal care just like any other pregnancy. Along with this, they should also receive extra advice and information about the choice of trying for a natural birth (known as Trial of Labor After Cesarean, or TOLAC) versus having a planned repeat cesarean delivery (PRCD). An early ultrasound can be useful in confirming how far along the pregnancy is in case a cesarean section is scheduled.

When it’s time for the birth, it’s generally better if labor starts naturally. This is because a natural start to labor is more likely to result in a successful vaginal delivery and has a lower chance of the scar from the previous cesarean section tearing open (known as uterine rupture). However, if there’s a medical reason to induce labor, doctors have safe ways to do so without using drugs that soften the cervix (prostaglandins), which can increase the risk of uterine rupture. In some medical centers, doctors use a combination of low-dose oxytocin (a hormone that can trigger labor) and/or a mechanical device that helps to gently open the cervix. Research on these methods, particularly for TOLAC, has shown a mix of results.

An epidural (a type of anesthesia that reduces pain in the lower part of the body), while not mandatory, might help make patients more comfortable. Additionally, it provides a quick way to provide anesthesia should a cesarean section become necessary.

During labor, it’s important to regularly check the baby’s heartbeat and observe the progress of labor. Doctors strongly recommend continuous monitoring of the baby’s heartbeat. If they suspect complications like a uterine rupture, they will perform a cesarean section quickly. Often, the first sign of a uterine rupture is a change in the baby’s heart rate, which happens in about 70% of cases. Other signs can include changes in uterine contractions, severe abdominal pain, a sudden drop in the baby’s position, or blood in the urine. Despite careful monitoring, a uterine rupture can happen suddenly and unexpectedly, sometimes leading to serious outcomes for the baby.

After a successful vaginal birth, the care woman receives will be similar to any other birthing woman, such as delivery of the placenta and usual post-birth care. Occasionally, doctors might find a small tear in the scar from the previous cesarean after the placenta is delivered. This would usually only need repair if there’s ongoing bleeding. If a woman experiences low blood pressure or other signs of inadequate blood volume (hypovolemia) after delivery, doctors would promptly check for potential complications including a possible uterine rupture.

When considering issues related to pregnancy and childbirth, some might include:

Amnionitis (inflammation of the innermost layer of the placenta)
Face and Brow Presentation (when the baby’s face or forehead, rather than the top of head, is leading the way in the birth canal)
False labour (contractions that seem like real labour but don’t lead to childbirth)
Malpresentation (when the baby is not positioned correctly for childbirth)
Obstruction (something blocking the path of the baby’s delivery)
Pregnancy and Delivery (general concerns about progressing through a normal pregnancy and delivery)
Uterine anomaly (an unusual structure or feature of the uterus)

Possible Complications When Diagnosed with Vaginal Birth After Cesarean Delivery

In patients trying for Trial of Labour After Cesarean (TOLAC), the most serious risk is uterine rupture. This happens when the surgical scar from a previous cesarean section tears. Uterine rupture is a medical emergency requiring immediate surgery to deliver the baby and address any additional issues. Uterine rupture can disrupt the baby’s supply of blood and oxygen, leading to complications such as fetal acidosis, a need for neonatal intensive care, and potentially even death. While the risk of infant mortality is low with TOLAC, it is slightly higher than for babies born to mothers having a planned repeat cesarean (0.13% versus 0.05%).

Uterine rupture can also endanger the mother’s life. Patients may have significant bleeding and may require a blood transfusion or even a hysterectomy to control the bleeding.

Another complication known as uterine dehiscence is also possible. This is not as severe as a uterine rupture and involves the underlying muscle layers of the uterus opening up while the outer layer stays intact. This can be seen as a “uterine window.” Often, patients with uterine dehiscence have no symptoms and the severe complications associated with uterine rupture don’t usually occur. The academic texts often confuse uterine rupture and dehiscence which makes understanding research conclusions challenging.

Lastly, some patients attempting TOLAC may end up needing a cesarean delivery. If this happens after labor starts, the risks of post-birth infection, uterine atony (weak uterine muscles leading to heavy bleeding), and wound separation increase compared to planned repeat cesarean sections.

Main Risks:

Uterine rupture
Emergency surgery for baby’s delivery
Fetal complications
Potential infant mortality
Maternal hemorrhage
Potential need for blood transfusion or hysterectomy
Uterine dehiscence
Emergency cesarean delivery
Post-birth infection, uterine atony, and wound separation

Frequently asked questions

The prognosis for Vaginal Birth After Cesarean Delivery (VBAC) is generally positive if patients are well-selected. Successful VBAC is associated with lower health risks for the mother and less risk of future pregnancy complications. Women who have a successful VBAC also avoid the rigors of surgical recovery in the post-birth period.

Vaginal Birth After Cesarean Delivery (VBAC) can either be planned in advance or happen unexpectedly due to early labor.

The signs and symptoms of Vaginal Birth After Cesarean (VBAC) delivery can vary, but there are a few key indicators that healthcare providers look for. These signs and symptoms include: 1. Softening and thinning of the cervix: This is known as cervical ripening and is an important step in preparing for labor. It indicates that the cervix is becoming more favorable for a vaginal birth. 2. Baby's head sitting low: The position of the baby's head can also be a sign that a VBAC may be possible. If the baby's head is engaged and sitting low in the pelvis, it suggests that the baby is in a good position for a vaginal birth. It's important to note that while these signs and symptoms can be helpful in predicting the likelihood of a successful VBAC, they are not definitive. Other factors, such as the reason for the previous cesarean section and the overall health of the mother and baby, also play a role in determining whether a VBAC is a safe option. Ultimately, the decision to attempt a VBAC should be made in consultation with a healthcare provider who can assess the individual circumstances and provide personalized guidance.

There are no specific tests mentioned in the text that are needed for Vaginal Birth After Cesarean Delivery (VBAC). However, the text does mention the importance of reviewing prior surgery reports to understand the type of uterine incision, especially if the previous surgery was performed in another country. Additionally, regular prenatal care and monitoring of the baby's heartbeat during labor are recommended. In case of suspected complications like uterine rupture, a cesarean section may be performed.

The doctor needs to rule out the following conditions when diagnosing Vaginal Birth After Cesarean Delivery: - Amnionitis (inflammation of the innermost layer of the placenta) - Face and Brow Presentation (when the baby's face or forehead, rather than the top of head, is leading the way in the birth canal) - False labour (contractions that seem like real labour but don't lead to childbirth) - Malpresentation (when the baby is not positioned correctly for childbirth) - Obstruction (something blocking the path of the baby's delivery) - Pregnancy and Delivery (general concerns about progressing through a normal pregnancy and delivery) - Uterine anomaly (an unusual structure or feature of the uterus)

The side effects when treating Vaginal Birth After Cesarean Delivery (VBAC) can include the following: - Uterine rupture: This is when the surgical scar from a previous cesarean section tears, which can disrupt the baby's supply of blood and oxygen and lead to complications such as fetal acidosis, the need for neonatal intensive care, and potentially even death. - Emergency surgery for baby's delivery: In the case of uterine rupture or other complications, immediate surgery may be necessary to deliver the baby and address any additional issues. - Fetal complications: Uterine rupture can endanger the baby's life and lead to complications such as fetal acidosis. - Potential infant mortality: While the risk of infant mortality is low with VBAC, it is slightly higher than for babies born to mothers having a planned repeat cesarean. - Maternal hemorrhage: Uterine rupture can cause significant bleeding, and patients may require a blood transfusion or even a hysterectomy to control the bleeding. - Uterine dehiscence: This is a less severe complication where the underlying muscle layers of the uterus open up while the outer layer stays intact. It is not as severe as a uterine rupture and often does not lead to severe complications. - Emergency cesarean delivery: Some patients attempting VBAC may end up needing a cesarean delivery, which can increase the risks of post-birth infection, uterine atony (weak uterine muscles leading to heavy bleeding), and wound separation.

An obstetrician or gynecologist.

Vaginal Birth After Cesarean Delivery became more common from the mid-1980s to the mid-1990s, but decreased afterwards.

Vaginal Birth After Cesarean Delivery (VBAC) is treated by providing regular prenatal care, extra advice, and information about the choice of attempting a natural birth versus having a planned repeat cesarean delivery. An early ultrasound can be used to confirm the progress of the pregnancy. During labor, it is important to regularly check the baby's heartbeat and observe the progress of labor. Continuous monitoring of the baby's heartbeat is strongly recommended. If complications like a uterine rupture are suspected, a cesarean section will be performed quickly. After a successful vaginal birth, the woman will receive similar care to any other birthing woman, including delivery of the placenta and usual post-birth care.

Vaginal birth after cesarean section (VBAC) refers to a situation where a woman delivers a baby vaginally after previously having a cesarean section.

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