Vaginal Birth After Caesarean (VBAC): Process & Risks


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What is Vaginal Birth After Caesarean (VBAC)? 

Attempting a vaginal birth after caesarean (VBAC), i.e. during the second pregnancy, is known as a Trial of Labor After Cesarean (TOLAC). Approximately 90% of the women who have undergone cesarean deliveries are possible candidates for VBAC during their next pregnancy. And 60% - 80% among them are able to have successful vaginal deliveries. 

Am I eligible for VBAC?

You are eligible for VBAC if:

  • You are younger than 35 years of age. (A study done in 2007 shows that women below 35 years experience fewer complications with VBAC.)
  • If you’ve had a previous vaginal delivery, including a successful VBAC.
  • Your chances of success with VBAC increases if your earlier C-section was due to the baby’s health, (such as, a breech baby or abnormal fetal heart tracing) and not because of the actual labor process.
  • If you have undergone only one prior C-section.
  • Your earlier delivery a caesarean in which the incision was horizontal as opposed to vertical.
  • Your pelvis is large enough to allow your baby to pass through safely.
  • You've never had any other extensive uterine surgery, such as a myomectomy to remove fibroids.
  • You've never had a uterine rupture.

 When is VBAC not advisable? 

In contrast, your doctor may recommend a planned caesarean if:

  • are older than 35 years
  • you have pregnancy-related complications such as high blood pressure (Preeclampsia), your baby is in the breech position, the size of the baby, or the baby’s health  etc
  • the reason you had your previous C-Section still exists
  • in the previous C-Section, the incision was vertical instead of horizontal
  • you’ve never experienced vaginal deliveries and have had more than one caesarean
  • there are two or more babies to be delivered such as twins, triplets etc.
  • you are obese with a body mass index of 30 or higher
  • the previous caesarean you had was within the last 19 months

What happens during a VBAC?

Please Note: You may face the slight risk of uterine rupture because of the scarring due to the earlier caesarean delivery. Before you decide to undergo a VBAC, consult with your doctor and the hospital staff to make sure an anesthesiologist will be present throughout the procedure so that at any point, if an emergency C-section is required, anesthesia can be administered to you immediately. 

There are three major stages you will undergo during normal childbirth:

  1. Labour and effacement of the cervix
  2. Pushing & birth of the baby
  3. Delivering the placenta

1. Labour and effacement of the cervix

This is the first stage of the normal delivery process and of labor. For the baby to be born, the cervix needs to become malleable, soften and stretch so that the baby can be delivered.

This first stage can last for upto 13 hours for a woman who is delivering a baby for the first time, and for seven to eight hours for a second or third child. Contractions occur which helps to dilate the cervix. 

This first stage has three sub-stages:

  • Early labour: The cervix of the expectant mother opens to about 4 centimeters. You will probably spend most of the early labor at home. At this stage, the expectant mother can continue to perform her usual activities, relax often, drink plenty of clear fluids, eat light meals whilst keeping keep track of the contractions. With time the contractions grow stronger and when the expectant mother gets more frequent and stronger contractions and is not able to talk during contractions, it means she has moved to the stage of active labour.
  • Active labour: At this stage, the cervix of the expectant mother may open from 4 to 7 centimeters. This is the stage when the mother should be taken to the hospital. The contractions occur every 3 to 4 minutes and each of them lasts for about 60 seconds. These contractions show that the cervix is opening faster (about 1 centimeter per hour). As the labor progresses, the water may break causing a gush of fluid. Once the water breaks, the frequency of contraction speeds up. The expectant mother at this stage needs to relax. She can change positions, receive gentle massages or hot and cold compresses, walk slowly or sit upright all of which will help. Relaxing in between the contractions is very important as it will help the cervix to widen. The expectant mother can also soak herself in a tub which will ease the discomfort.
  • Transitioning to the second stage: The cervix at this stage opens from 7 to 10 cms. This is the most painful and stressful part of the labor for most women as the cervix widens up to its fullest. The contractions occur every two to three minutes and last for upto 60 to 90 seconds. The mother at this stage may feel a strong urge to push because she feels the pressure in the rectal area and stinging in the vaginal area, as the baby's head slowly moves down toward the vaginal opening. But she should not push at this stage and wait for her health caregiver to give the go-ahead to start pushing. The health caregiver will give the signal once the cervix is fully dilated. The expectant mother may feel fatigued, irritated, nauseous and alternately hot or cold. Slow and relaxed breathing is highly effective during this period.

2. Pushing & birth of the baby

Once the cervix completely widens or dilates the second stage of labor begins. The contractions at this stage continue to be strong, though they often come farther apart.
The frequent contractions help to push the baby down head first through the birth canal. The expectant mother’s health care provider may ask her to push with every contraction. The mother will feel an intense pressure similar to the urge while undergoing a bowel movement. 

The mother may feel highly irritated at this stage and may alternate between wanting to be touched/soothed or being left alone. She will be highly fatigued and may also feel nauseous. The intensity at the end of the first stage of labor will continue in this pushing phase. 

The mother may experience intense pain around your vaginal and the surrounding pelvic areas as the baby's head protrudes through the vaginal opening. It is at this stage that the attending doctor may decide to perform an episiotomy, i.e. an incision made in the area between the vagina and the rectum to widen the vaginal opening so that the baby can emerge smoothly if required. The mother may be asked to push gently or slowly as the rest of your baby's head and body emerge, till the baby finally emerges into this world.

3. Delivering the placenta

After the birth of the baby, the contractions continue to push out the placenta a process also known as the afterbirth. The delivery of the placenta can take a few minutes to a half hour after the baby is born.

The healthcare provider may ask the mother to place the baby on her breast, as this stimulates uterine contractions. Alternatively, the healthcare attendant may gently massage the new mother’s abdomen to help stimulate placental separation.

Most babies are ready to nurse a few minutes immediately after birth while others may take a little longer. Healthcare providers usually ask the mother to nurse the child as soon as possible after birth, provided the mother is willing to breastfeed. 

Nursing right after birth also helps the uterus to contract and so decrease the amount of bleeding. 

How to prepare myself for  VBAC?

To increase your chances for a successful VBAC you can:

  • Manage your weight. Talk to your doctor as you plan your pregnancy and prepare a healthy diet chart that you can follow with your doctor’s inputs.  Follow an exercise routine after consulting with your doctor. Stay active and continue exercising (with your doctor’s guidance) even during your pregnancy.
  • Make sure you ask all about the guidelines you need to follow for a successful VBAC. Make enquiries and find out if the hospital is properly equipped to handle any emergencies during the VBAC. Most importantly ask if an anesthesiologist will be available during the process of delivery so that anesthesia can be quickly administered to you if an emergency crops up.
  • Opt to go into labour on your own instead of induced labour, as there is a slight risk of uterine rupture if you are induced

What are the risks of VBAC? 

The risks of VBAC include:

  • Uterine rupture
  • Heavy bleeding or bleeding complications that require hysterectomy or blood transfusion
  • Failed labour or failed TOLAC
  • Surgical wounds in cases of failed TOLAC
  • Infections that may also pass on from the mother to the baby

What are the advantages of VBAC? 

The advantages of VBAC include:

  • Less blood loss
  • No surgery required
  • Faster recovery compared to a C-Section, therefore, shorter hospital stay
  • Feed and bond with your baby immediately after birth
  • Lower risk of infections
  • You are not likely to suffer an injury to your bladder or bowel
  • Less risk of complications during future pregnancies

What are the guidelines to be followed before a VBAC?

Before getting admitted for a VBAC make sure:

  • The hospital is one where a timely caesarean section is available. You must be aware of the hospital resources and the availability of obstetric, anesthetic, pediatric, and operating-room staff.
  • In the case of a TOLAC, an approximate time frame of 30 minutes should be considered adequate in the set-up of an urgent laparotomy (surgery).
  • There is continuous fetal monitoring while TOLAC is being attempted.
  • If a uterine rupture is suspected the hospital should be able immediately arrange for a surgery without delay.

What to expect during the postpartum recovery period after a VBAC? 

 After a VBAC you may face a few issues which will need some care such as:

  • Vaginal discharge and bleeding: When bleeding, expect a heavy bright red flow for the first few days after the delivery as it happens during the monthly periods. It then slowly tapers off becoming pink or brown or yellow or white. You need to immediately call your doctor if you have a fever or are bleeding too much and changing the sanitary pads every hour or you are passing big blood clots.  
     
  • Vaginal soreness: If you had a vaginal tear during delivery the wound may hurt for upto six weeks, though if the tearing was severe it could take more time than that to heal. While sitting down it can be painful, so you can use a pillow or a donut cushion that helps you to sit down with any pressure on the perineum.
    You can place an ice pad between the sanitary napkin and the wound which will provide some relief from the pain.
    Make sure you take your painkillers and stool softeners so that as recommended by your doctor.

     
  • Pain while urinating or having bowel movements: As the tissue around your bladder and urethra may be swollen or bruised, you may find it painful to urinate. Doing Kegel exercises during this period with doctor’s advice will help. It will tone your pelvic muscles.
    Further, you could also have constipation since you could be taking iron supplements which are prescribed by the doctor to get your blood count up. Make sure you take the stool softeners prescribed by the doctor. Also, drink plenty of water, 8-10 glasses per day to make up for the dehydration breastfeeding may cause, and add high-fiber foods to your regular diet.
    If you notice very painful bowel movements you may also have haemorrhoids. To get relief from haemorrhoids you can soak the lower part of your body in a tub of warm water. You may also be prescribed some topical medication by the doctor to apply in the affected area.  

     
  • Contractions: Also known as afterpains, contractions may occur for a few days immediately after delivery. These contractions are actually good in a way as it means your uterus is shrinking back into size and the blood vessels are being compressed preventing excessive bleeding. Contractions can especially occur when you are nursing your baby.

  • Hair loss: The rise in hormones during pregnancy keeps you from losing your hair. After childbirth, as the hormones return to normal levels it causes the hair to fall out and return to the normal hair fall and growth cycle. The normal hair loss that was delayed during pregnancy may fall out all at once after delivery.

  • Mood changes: After childbirth, it is normal for the new mother to undergo frequent mood changes such as irritation, frustration, anxiety etc . Many new moms also undergo what is known as postpartum depression. If the depression deepens the mother may need prompt therapeutic help in the form of psychological counseling.

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References

1. Srinivas S, Stamilio D, Sammel M, Stevens E, Peipert J, Odibo A et al. Vaginal birth after caesarean delivery: does maternal age affect safety and success? [Internet]. NCBI. 2007 [cited 15 May 2018]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17302640

2.Thornton P. Limitations of Vaginal Birth After Cesarean Success Prediction [Internet]. https://onlinelibrary.wiley.com/. 2018 [cited 15 May 2018]. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/jmwh.12724

3. Bangal V, Giri P, shinde K, Gavhane S. Vaginal Birth after Cesarean Section [Internet]. https://www.ncbi.nlm.nih.gov/. 2013 [cited 15 May 2018]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3624716/

4. Budin W. Back to Vaginal Birth After Cesarean [Internet]. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4719104/. 2016 [cited 15 May 2018]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4719104/

5. Spong C. To VBAC or Not to VBAC [Internet]. http://journals.plos.org/plosmedicine/. 2012 [cited 15 May 2018]. Available from:http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001191

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Did you know?

Success rate of VBAC

Research conducted on women who attempt a trial of labor after cesarean (TOLAC) shows that about 60 to 80 percent of them have a successful vaginal delivery.

A gap between the first pregnancy C-section and VBAC during the next pregnancy

Most medical professionals advise at least a 2 years gap between pregnancies if you are planning for a VBAC. This allows sufficient healing time for the uterus after the C-section during the first pregnancy.

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