VBAC – Normal Delivery After CAESAREAN

Doctor…

I had previous Cesarean delivery, could I deliver normally in next pregnancy?

I had two C-sections now I want to try for a normal delivery, what do you suggest?

Is there a trend of C-section?

What are the risks of normal delivery after C-section?

These are very commonly asked questions as now a days Cesarean section is a commonly performed surgery for maternal or fetal problems. Abdomen is given transverse (Pfannenstiel) incision and uterus is incised and the baby is delivered abdominally.

Do you know if you previously had a C-section; then there is a 60% to 80% chance of a normal delivery? This is called vaginal birth after Cesarean (VBAC). If you are healthy, with uncomplicated pregnancy with previous transverse uterine incision, then discuss risks and benefits with your doctor. Get proper assessment BEFORE taking a trial of scar.

This blog would guide you about common queries about VBAC.

What are the types of uterine incisions for a C-section?
Uterus can be incised by either of two types of incisions:

1. Classical (vertical), or
2. Lower segment (horizontal)

Which type of uterine incision is safe?
Lower segment C-section is much safer as compared to classical C-section as there are less chances of scar dehiscence and rupture.

Who can take the trial of a normal delivery after C-section?

1. Healthy women in absence of medical disorders
2. Single pregnancy
3. Confirmed transverse scar of uterus

Where VBAC could occur?
It should always be in a tertiary care hospital, where facilities of emergency C-section, ICU, blood bank, lab, nursery, and full team of consultants is available. Always confirm whether the hospital where you are planning to deliver, gives permission for VBAC, as it is an elevated risk and complicates delivery.

Which women have more chances of normal delivery after C-section?

1. Healthy Women and child throughout during the pregnancy
2. Labor starting naturally before expected date of delivery

In which cases trial of scar is contraindicated?

1. Previous classical or vertical scar on uterus
2. Previous history of scar rupture
3. At term Scar thickness less than 4 mm
4. More than one Cesarean
5. History of uterine surgery (fibroid removal)
6. Multiple pregnancy
7. Low lying placenta
8. Malpresentations (breech or transverse lie)
9. Baby weight more than 3.5kg
10. Elevated risk pregnancies with medical diseases (high blood pressure, diabetes, cardiac or renal disease, genital Herpes)

Which women are unlikely to deliver normally after Caesarean?

1. Maternal age more than forty (40)
2. Obese women with BMI more than forty (40)
3. Excessive weight gain during pregnancy
4. Postdate pregnancy
5. Delayed and prolonged labor
6. Medical problems of high blood pressure, diabetes
7. Previous delivery within 18 months
8. Need of induction of labor for closed cervix
9. History of C-section for fetal distress (abnormal heart rate of baby)

How could be patient selected for VBAC?

History and examination are helpful for maternal and fetal risk evaluation.

How ultrasound guides us for VBAC?

1. Number of fetuses
2. Lie
3. Presentation
4. Weight of baby
5. Size of baby (growth assessment)
6. Amount of fluid around baby
7. Placental localization
8. Previous Scar thickness (< 4 mm)
9. Fetal blood flow (doppler)

What are risks associated with VBAC?
There are risks of:

1. Difficult, prolonged labor, fetal distress again requiring a C-section
2. Scar rupture
3. Emergency C-section
4. Massive bleeding which could endanger mother and baby life
5. In cases of uncontrollable bleeding, uterus could be removed (hysterectomy) after which there are no periods and no chances pregnancy or birth of a child.

What are benefits of VBAC?

1. There are no risks of anesthesia or surgery
2. Less pain
3. Less blood loss
4. Less chances of injury to bladder or bowel
5. Reduced chances of infection
6. Fast recovery
7. Early return to daily life activities
8. Less complications for future deliveries

REMEMBER, the main aim of modern obstetrics is a safe delivery BOTH for mother and child. Whatever the mode of delivery, outcome should be fruitful. Always seek an expert opinion for VBAC for proper risk evaluation. IF taking a trial of labor, deliver at a tertiary care center for proper monitoring and a safe delivery.

Dr. Ayesha Azam Khan