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decision pointShould I have a VBAC trial of labor after a previous cesarean?

In the recent past, a woman who had one baby by cesarean section delivery would have a cesarean for all future deliveries. Today, many women with one cesarean scar, or a past vaginal delivery plus two cesarean scars, can plan to go into labor (trial of labor) to deliver vaginally. This is called vaginal birth after cesarean (VBAC).

Whether you deliver vaginally or by cesarean section, you are unlikely to have serious complications. Overall, a routine vaginal delivery is less risky than a routine cesarean, which is a major surgery. But researchers have found that pregnant women who have a cesarean scar have a slight risk of the scar on the uterus breaking open during labor. This is called a uterine rupture.1

This information can help as you think about having a trial of labor and vaginal delivery after having had a cesarean delivery. Consider the following when making your decision:

  • Even if you are a good candidate for VBAC and you have a trial of labor, it is still possible that you will need a cesarean. About 60% to 80% of women deliver vaginally after a VBAC trial of labor.1
  • If the problem that led to a previous cesarean (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 cesarean.1
  • Delivering a baby vaginally after one cesarean 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 cesarean 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) labor.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 labor and avoid more scarring if you can.
  • Some hospitals and doctors do not offer VBAC.

What is a VBAC?

A vaginal birth camera.gif after cesarean, or VBAC, is a birthing option for many women who have previously had:1

  • One cesarean delivery.
  • One or two cesarean deliveries and a past vaginal delivery.

When you go into labor with the plan to deliver vaginally, it is called a "trial of labor."

Is a VBAC trial of labor a good choice for you?

Delivering a baby vaginally after having one cesarean, or after having a vaginal delivery and two cesarean deliveries, is a safe choice for most women. Whether it is right for you depends on several factors, including:

  • Why you had a cesarean previously. If you had a cesarean because of a problem that you now have in this pregnancy (such as a breech baby), a trial of labor is generally not recommended. However, most women have cesarean deliveries because of problems that develop during labor (not before labor), such as stalled labor or signs of fetal distress. Usually there is no reason to expect that the same problem will happen again (although it may).
  • How many cesarean deliveries you have had. If you have had one cesarean, a trial of labor is generally safe. If you have had two cesareans, a trial of labor is only considered safe if you've also delivered vaginally before. A trial of labor is not recommended for women who have had more than two cesareans. The more cesarean 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 cesarean scars you have.
  • Your personal preference. If there is no medical reason for a repeat cesarean, 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 cesarean at any time of the night or day.

What are the risks of VBAC?

Risks of a VBAC trial of labor include:

  • Development of a typical labor problem (such as fetal distress) that requires a cesarean 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 labor.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 labor and then deliver by cesarean have a higher risk of infection. This means that infection risk is lower after a vaginal birth, and after a repeat cesarean without labor.1

No two births are alike, and the labor and delivery process is impossible to fully plan and control. No doctor can guarantee that you will have a successful trial of labor.

What are the risks of a cesarean delivery?

The risks of cesarean 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 Cesarean (VBAC) and Cesarean Section.

Your choices are:

  • Attempt a trial of labor.
  • Plan another cesarean 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 labor takes into account your personal feelings and the medical facts.

Deciding about vaginal birth after cesarean (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 favorable for VBAC.
  • VBAC is less likely than a cesarean 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 cesarean.

Are there other reasons why you might choose VBAC?

  • You do not plan to have more pregnancies after this one.
  • An unsuccessful trial of labor requires a cesarean delivery, which is often urgent.
  • Cesarean after a trial of labor increases the chance of infection slightly more than after a cesarean without labor.1
  • VBAC trial of labor 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 cesarean
Reasons to choose scheduled repeat cesarean Reasons not to choose scheduled repeat cesarean
  • Repeat cesarean delivery is necessary if you have one or more risk factors during this pregnancy.
  • Cesarean delivery is more predictable than a VBAC.
  • Repeat cesarean has a very low uterine rupture risk.

Are there other reasons why you might choose a repeat cesarean?

  • Cesarean is more likely than a vaginal birth to cause complications for you.
  • Cesarean delivery takes more time to recover from than vaginal delivery.
  • Cesarean is painful and limits your activity while your incision heals.
  • Planned cesarean can be too early if the due date is miscalculated. A premature delivery can lead to problems for the newborn.
  • Each additional cesarean 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 cesarean?

These personal stories may help you make your 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 labor. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

I do not have a condition that requires a cesarean delivery.

Yes No Unsure

I have delivered vaginally or had a long labor 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 cesarean 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 cesarean.

Yes No Unsure

I am concerned about the slight but serious risk of uterine rupture during VBAC.

Yes No Unsure

My past labor 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 cesarean 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 labor.

Check the box below that represents your overall impression about your decision.

Leaning toward having a VBAC trial of labor

 

Leaning toward NOT having a VBAC trial of labor

         
  • Cesarean Section
  • Vaginal Birth After Cesarean (VBAC)

Citations

  1. American College of Obstetricians and Gynecologists (2004, reaffirmed 2007). Vaginal birth after previous cesarean delivery. ACOG Practice Bulletin No. 54. Obstetrics and Gynecology, 104(1): 203–212.

  2. Paré E, et al. (2005). Vaginal birth after caesarean section versus elective repeat caesarean section: Assessment of maternal downstream health outcomes. British Journal of Obstetrics and Gynaecology, 113(1): 75–85.

Author Sandy Jocoy, RN
Editor Kathleen M. Ariss, MS
Associate Editor Pat Truman, MATC
Primary Medical Reviewer Sarah Marshall, MD - Family Medicine
Specialist Medical Reviewer Kirtly Jones, MD - Obstetrics and Gynecology
Last Updated April 17, 2009

WebMD Medical Reference from Healthwise

Last Updated: April 17, 2009
This information is not intended to replace the advice of a doctor. Healthwise disclaims any liability for the decisions you make based on this information.

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