Vaginal Birth After Cesarean Delivery

If you delivered a baby by C-section, you may be able to have your next baby through the vagina. At one time, it was thought that once a woman had a cesarean birth, she would always have a cesarean birth in any subsequent pregnancies. But today, many women have successful vaginal deliveries after C-section.

Why Attempt Vaginal Delivery?

The major goal of prenatal care is a healthy mother and child. It's important to keep in mind that whether your baby is born by cesarean or vaginal birth, the overall health and well-being of you and your baby always come first.

There are several reasons to consider a vaginal birth after a previous cesarean:

• Less Risk. A vaginal delivery has fewer complications for the mother than cesarean birth. A cesarean birth requires major surgery and is performed with anesthesia. As with any operation, there is risk of infection, bleeding and transfusion, as well as other problems that can occur with any surgery and anesthesia. With a vaginal birth, there is no abdominal incision, so these risks tend to be lower.
• Shorter Recovery. The mother's stay in the hospital is shorter after a vaginal delivery and she will have less discomfort than after a cesarean. The average time spent in the hospital is usually a few days longer after a cesarean birth than after a vaginal birth. Recovery at home is usually faster after a vaginal birth, too. Women who deliver by cesarean birth may need to limit their activity for a few weeks to allow the incision time to heal. Those who deliver vaginally can usually resume normal activities sooner.
• More Involvement. Some women wish to be awake and fully involved in the birth process. Sometimes general anesthesia is used during cesarean delivery, in which case the mother is not awake and cannot experience the actual birth. There also may be more limits on the presence of others in the delivery room during a cesarean birth.

Some women may not wish to attempt vaginal birth after cesarean because of a previous painful labor. Pain relief is available for women attempting vaginal birth after a previous cesarean. A form of anesthesia called epidural block—in which drugs are injected into the lower back to numb the lower half of the body—may be used, if available. Of course, if the mother does not wish to attempt a vaginal delivery under any circumstances, she has the right to make this choice.

Factors to Consider

Type of Incision in the Uterus

In addition to your own wishes, there are a number of medical factors that will be weighed in the decision of how your baby will be born. One of these is the type of uterine incision that was used in your previous cesarean.

Your doctor will need to consult your medical records from the previous cesarean birth to verify which type of uterine incision was used. This is because the main risk to both you and your baby during an attempted vaginal birth is separation or rupture of the scar left by that incision. Rupture may be more or less likely, depending on what type of incision was used.

It is important to realize that in a cesarean delivery, the type of incision made in the skin may not be the same as the type of incision made in the uterus. For this reason, it is not possible to tell what type of uterine incision you had just by looking at the scar on your abdomen. If it is not possible to determine this, your doctor will help you decide whether you may be a good candidate for attempted vaginal birth.

There are three types of uterine incisions used for cesarean delivery:

• The transverse incision, which is made across the lower, thinner part of the uterus, is usually preferred for cesarean delivery. It heals with a stronger scar and is least likely to result in complications in a subsequent vaginal delivery.
• The low vertical incision is an up-and-down cut made in the lower, thinner area of the uterus. The risks involved in vaginal birth after this type of uterine incision are not well defined. If you have had this type of incision, discuss the options with your doctor.
• The classical (high vertical) incision is an up-and-down cut made in the upper part of the uterus. This was once the most common type of incision used in cesarean births. Unfortunately, a complete rupture, or opening, of the scar is more likely to occur during labor if a classical incision was used in a previous cesarean delivery. This can result in serious bleeding that can pose danger to both the fetus and the mother.

Other Factors

Other factors that may affect the decision about having a vaginal birth after a previous cesarean must be assessed on an individual basis. These include:

• Small pelvis-large baby—when the baby is too large to pass safely through the mother's pelvis during delivery.
• Multiple pregnancy—a pregnancy with two or more fetuses.
• Breech presentation—a situation in which the baby is positioned buttocks or feet downward.
• Other complications of pregnancy—medical problems such as high blood pressure or diabetes.

Labor and Delivery

After all the medical factors have been weighed and your own wishes have been considered, you may decide to attempt a vaginal delivery. Because an attempt to deliver vaginally after a previous cesarean birth carries some risk, certain protective measures will be taken during labor and delivery.

It is important that the setting in which you give birth be equipped to perform necessary procedures quickly so that if a problem does occur during labor, an emergency cesarean delivery can be carried out.

During labor, fetal monitoring will be used to detect unusual changes in the fetus' heart rate.

With this procedure, the heartbeat and activity of the fetus, as well as contractions of the mother's uterus, are measured and recorded. Fetal monitoring cannot always prevent a problem, but it can help your doctor be alert to warning signs.

Finally ...

Because of the increased risks of cesarean delivery, many women who have had cesareans in previous pregnancies are now being encouraged to consider vaginal delivery.

For most of these women, the benefits of attempting vaginal birth outweigh the risks. Even many women who have had two or more cesareans can attempt to safely give birth through the vagina.

With careful monitoring, proper medical support and no major medical problems, most women who attempt vaginal birth after a previous cesarean delivery do so safely and satisfactorily if no risk factors are present.

In making this decision together, you and your doctor will want to discuss all the details of your individual situation.