New Updated Guidelines on Vaginal Birth After Cesarean

by Dr. Michele Brown OB/GYN

Cesarean Section Delivery

delivery by cesarean

The American College of Obstetrics and Gynecology in August 2010 has just issued brand new guidelines for allowing women with previous cesarean sections to undergo a trial of labor for a vaginal delivery. These "hot off the press" new recommendations were created in an effort to reduce the escalating cesarean section rate that has been plaguing American hospitals recently. Rates have spiraled from 5% in 1970 to 31% in 2007. Along with this statistic, it was found that VBAC rates have plummeted from 28.3% in 1996 to 8.5% in in 2006.

Of particular interest is the finding that although cesareans have increased in all states, there are large differences between the states. The lowest rates were found in Alaska, Idaho, New Mexico, and Utah. The highest rates were noted in Florida, Louisiana, Mississippi, New Jersey, and West Virginia.

What are some of the reasons behind this trend?

  • Fear of liability on the part of the physician
  • Electronic fetal monitoring with recording of minute to minute fetal heart activity
  • Decreased training and use of forceps on the part of physicians
  • Refusal to do vaginal breech deliveries
  • Refusal of obstetricians to attempt turning babies to head down positions from other non deliverable positions (called external cephalic version)
  • Hospitals refusing to allow doctors to allow a vaginal birth after cesarean section

Risks of Attempting a VBAC

The biggest reported risk of vaginal birth after a cesarean is separation of the previous scar on the uterus (dehiscence) or complete rupture of the uterus which causes significant risk to both mother and fetus. The incidence of this is between .5 to .9%. Risks with rupture include maternal hemorrhage, need for transfusion, potential hysterectomy, and severe consequences for the newborn including possible death.

Risks of a Repeat Cesarean Section

The risks of a cesarean are similar to the risks of any abdominal surgery. This includes:

  • Hemorrhage
  • Infection
  • Operative injury to other organs (bowel or bladder).
  • Blood clots
  • Transfusion
  • Hysterectomy
  • Multiple incisions in the uterus can result in a placental problem in future pregnancies if the placenta attaches to the previous scar.
  • How does one choose which women are more likely to be successful candidates for a vaginal birth after a cesarean?

Considering a VBAC

The chance of success for a vaginal birth after a cesarean in a well chosen patient can be as high as 60%–80%. Patient and physicians should consider the following important questions when making a decision.

  • What were the original indications for the cesarean?
  • Women that had a cesarean for an inability of a baby to fit through the pelvis (dystocia) are more likely to be unsuccessful compared to a woman that had a cesarean for a non-repeatable cause such as breech, or abruption (separation of the placenta).
  • The physical characteristics of the woman
  • Women who are older, heavier and with large babies (4000 to 4500 grams) that are overdue are less likely to be successful.
  • Did the woman have a vaginal birth in the past?
  • Women that had a previous vaginal birth but underwent a more recent cesarean are more likely to be successful.
  • The number of cesarean sections or previous uterine surgeries a woman has had in the past.

There is increased risk in a woman who has had more than one previous cesarean, extensive surgery in the uterus such as a large fibroid removal, or a large uterine scar that travels longitudinal in the muscle of the uterus rather than a thin lower uterine horizontal scar. There is no increased risk with a previous low vertical uterine scar. Previous history of a uterine rupture should preclude a woman from a vaginal delivery in the future because of the high rate of recurrence.

  • Does the facility or hospital have the ability to do an emergency cesarean section should it be necessary?
  • The ability to provide emergency cesarean delivery should a crises occur is essential when contemplating an option of vaginal birth after a cesarean section.
  • Will there be more pregnancies in the future with a clear advantage of having a vaginal delivery and avoiding future cesareans or, will she be having abdominal surgery anyway for a tubal ligation after this current delivery?

New Recommendations

After careful counseling between patient and health care provider, early in prenatal care, more patients can now be considered potential candidates for trial of labor.

New recommendations by the American College of Obstetricians and Gynecologists include allowing a trial of labor in:

• Women with 2 previous cesarean section scars.
• Women with a previous cesarean that now have twin birth.
• Women that have an unknown previous uterine scar.

Women can have the option of taking on added risk associated with a trial of labor, even if they will be delivering in an institute without the capability of emergency cesarean if they are fully informed and well counseled.

Use of certain inducing agents, such as misoprostol (a type of prostaglandin) should not be used to induce labor in women with a previous cesarean because of the increased risk of rupture.

Dr. Brown, founder of Beauté de Maman, is a board-certified member of the American College of Obstetrics and Gynecology, a member of the American Medical Association, the Fairfield County Medical Association, Yale Obstetrical and Gynecological Society and the Women's Medical Association of Fairfield County. She is a magna cum laude graduate of Tufts University, completed her medical training at George Washington University Medical Center and completed her internship and residency in obstetrics and gynecology at Yale-New Haven Hospital. Dr. Brown has a busy obstetrical practice in Stamford, Connecticut and, as a clinical attending, actively teaches residents from Stamford Hospital and medical students from Columbia Presbyterian Hospital in New York.

Copyright © Michele Brown. Permission to republish granted to Pregnancy.org, LLC.