Should I have a VBAC trial of labour after a previous caesarean?
Introduction
This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.
Key points in making your decision
In the recent past, a woman who had one baby by caesarean section delivery would have a caesarean for all future deliveries. Today, many women with one caesarean scar, or a past vaginal delivery plus two caesarean scars, can plan to go into labour (trial of labour) to deliver vaginally. This is called vaginal birth after caesarean (VBAC).
Whether you deliver vaginally or by caesarean section, you are unlikely to have serious complications. Overall, a routine vaginal delivery is less risky than a routine caesarean, which is a major surgery. But researchers have found that pregnant women who have a caesarean scar have a slight risk of the scar on the uterus breaking open during labour. This is called a uterine rupture.1
This information can help as you think about having a trial of labour and vaginal delivery after having had a caesarean delivery. Consider the following when making your decision:
- Even if you are a good candidate for VBAC and you have a trial of labour, it is still possible that you will need a caesarean. About 60% to 80% of women deliver vaginally after a VBAC trial of labour.1
- If the problem that led to a previous caesarean (such as breech position) doesn't repeat itself in this pregnancy, you are about as likely to have a successful vaginal delivery as women who have not had a previous caesarean.1
- Delivering a baby vaginally after one caesarean is a safe choice for most women. Whether it is right for you depends on whether you have any other risk factors that could make VBAC unsuccessful or unsafe.
- During VBAC, there is a remote risk of a caesarean scar on the uterus tearing open. This is called uterine rupture. This risk increases with each additional scar and with the use of medicine to start (induce) labour.1
- If you have had one or two cesareans but have also delivered vaginally before, your uterine rupture risk is much lower than if you had never delivered vaginally.1
- If you are planning to have more pregnancies, consider that with each additional scar on the uterus, there are more risks in the next pregnancy. Placenta problems are more likely to happen. It's best to try a trial of labour and avoid more scarring if you can.
- Some hospitals and doctors do not offer VBAC.
Medical Information
What is a VBAC?
A vaginal birth
after caesarean, or VBAC, is a birthing option for many women who have previously had:1
- One caesarean delivery.
- One or two caesarean deliveries and a past vaginal delivery.
When you go into labour with the plan to deliver vaginally, it is called a "trial of labour."
Is a VBAC trial of labour a good choice for you?
Delivering a baby vaginally after having one caesarean, or after having a vaginal delivery and two caesarean deliveries, is a safe choice for most women. Whether it is right for you depends on several factors, including:
- Why you had a caesarean previously. If you had a caesarean because of a problem that you now have in this pregnancy (such as a breech baby), a trial of labour is generally not recommended. However, most women have caesarean deliveries because of problems that develop during labour (not before labour), such as stalled labour or signs of fetal distress. Usually there is no reason to expect that the same problem will happen again (although it may).
- How many caesarean deliveries you have had. If you have had one caesarean, a trial of labour is generally safe. If you have had two cesareans, a trial of labour is only considered safe if you've also delivered vaginally before. A trial of labour is not recommended for women who have had more than two cesareans. The more caesarean deliveries you have had, the higher your risk of uterine rupture (though the risk is still low) and problems with the placenta that may cause difficulties during delivery.
- How many future pregnancies you are planning. The risks of complications during pregnancy and surgery increase with the number of caesarean scars you have.
- Your personal preference. If there is no medical reason for a repeat caesarean, the choice is yours. Women in similar situations may make different choices based on their own experiences and concerns.
- The hospital where you will deliver. In order to offer VBAC, a hospital must have the staff and the equipment to do rapid emergency caesarean at any time of the night or day.
What are the risks of VBAC?
Risks of a VBAC trial of labour include:
- Development of a typical labour problem (such as fetal distress) that requires a caesarean delivery to ensure your own or your infant's safety. This occurs in about 20% to 40% of women who are considered good candidates for a VBAC trial of labour.1
- Separation of the uterine scar (dehiscence). This usually causes no problems and, in some cases, is not even detected. It usually heals on its own.
- Uterine rupture, which can be life-threatening to mother and infant, although it is rare.
Women who have a trial of labour and then deliver by caesarean have a higher risk of infection. This means that infection risk is lower after a vaginal birth, and after a repeat caesarean without labour.1
No two births are alike, and the labour and delivery process is impossible to fully plan and control. No doctor can guarantee that you will have a successful trial of labour.
What are the risks of a caesarean delivery?
The risks of caesarean delivery include:
- Infections.
- Blood loss that requires a blood transfusion.
- Genital or urinary complications.
- Blood clots (thromboembolism).
- Risks related to anesthesia.
- Fetal injury during the delivery. The injury usually is not serious.
- A longer recovery time.
Future risks. With each surgery on the uterus, more scar tissue forms. If you are planning on a pregnancy after this one, scarring is an important factor to think about. After you have two scars, each additional scar in the uterus raises the risk of placenta problems in a later pregnancy, such as placenta previa or placenta accreta. These problems raise not only the risks for a baby but also your risk of needing a hysterectomy to stop bleeding.2
If you need more information, see the topics Vaginal Birth After Caesarean (VBAC) and Caesarean Section.
Your Information
Your choices are:
- Attempt a trial of labour.
- Plan another caesarean delivery.
This information does not apply to you if you have one or more risk factors for uterine rupture during this pregnancy.
The decision about whether to have a trial of labour takes into account your personal feelings and the medical facts.
Deciding about vaginal birth after caesarean (VBAC) Reasons to choose VBAC Reasons not to choose VBAC
- You are planning to have more pregnancies after this one.
- You have a childbirth history and current pregnancy that are favourable for VBAC.
- VBAC is less likely than a caesarean to cause complications for you.
- VBAC avoids another uterine scar and its related risks during future pregnancy.
- VBAC takes less time to recover from than a caesarean.
Are there other reasons why you might choose VBAC?
- You do not plan to have more pregnancies after this one.
- An unsuccessful trial of labour requires a caesarean delivery, which is often urgent.
- Caesarean after a trial of labour increases the chance of infection slightly more than after a caesarean without labour.1
- VBAC trial of labour poses a remote risk of uterine rupture.
- The hospital where you want to deliver does not offer VBAC.
Are there other reasons why you might not choose VBAC?
Deciding about scheduled repeat caesarean Reasons to choose scheduled repeat caesarean Reasons not to choose scheduled repeat caesarean
- Repeat caesarean delivery is necessary if you have one or more risk factors during this pregnancy.
- Caesarean delivery is more predictable than a VBAC.
- Repeat caesarean has a very low uterine rupture risk.
Are there other reasons why you might choose a repeat caesarean?
- Caesarean is more likely than a vaginal birth to cause complications for you.
- Caesarean delivery takes more time to recover from than vaginal delivery.
- Caesarean is painful and limits your activity while your incision heals.
- Planned caesarean can be too early if the due date is miscalculated. A premature delivery can lead to problems for the newborn.
- Each additional caesarean scar increases the risk of future placenta problems, such as placenta previa or placenta accreta. This can lead to serious problems for you and the fetus.
Are there other reasons why you might not choose a repeat caesarean?
These personal stories may help you make your decision.
Wise Health Decision
Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about having a VBAC trial of labour. Discuss the worksheet with your doctor.
Circle the answer that best applies to you.
I do not have a condition that requires a caesarean delivery.
Yes No Unsure I have delivered vaginally or had a long labour before, which improves my chances of a successful VBAC.
Yes No Unsure I was disappointed that I didn't deliver vaginally in the past. I will try again unless my doctor gives me a good reason not to.
Yes No Unsure I have not had a vaginal delivery before. So I understand that if I have another caesarean incision during this delivery, my future uterine rupture risk will be increased enough that I won't be able to try a VBAC in the future.
Yes No Unsure I am concerned about pain during a vaginal delivery.
Yes No Unsure I am concerned about pain while recovering from a caesarean.
Yes No Unsure I am concerned about the slight but serious risk of uterine rupture during VBAC.
Yes No Unsure My past labour experience was very difficult—something I don't want to go through again.
Yes No Unsure My hospital has the facilities and staff necessary for a VBAC.
Yes No Unsure I am more comfortable with having a caesarean delivery because I've been through it before.
Yes No Unsure I am planning to have one or more pregnancies after this one.
Yes No Unsure Use the following space to list any other important concerns you have about this decision.
What is your overall impression?
Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to have or not have a VBAC trial of labour.
Check the box below that represents your overall impression about your decision.
Leaning toward having a VBAC trial of labour
Leaning toward NOT having a VBAC trial of labour
Return to the topic:
| Author: | Kathe Gallagher, MSW Carrie Henley | Last Updated: June 18, 2007 |
| Medical Review: | Joy Melnikow, MD, MPH - Family Medicine Kirtly Jones, MD - Obstetrics and Gynecology | |
 | ||
| |