By Mikaela G. Martinez-Bucu, M.D.
A cesarean section or a “c-section” refers to an abdominal delivery wherein the uterus is incised to deliver the baby. C-sections are specialized operative procedures that are only recommended by an obstetrician when delivery through the birth canal will be harmful to the mother or the baby. During the early 1900s, the dictum of “once a cesarean, always a cesarean” prevailed.
Nowadays, years of research have improved surgical techniques and mothers can deliver normally even after abdominal delivery, as long as the indication for the previous C-section is not a permanent or recurring one and the procedure should be done under strict medical supervision.
Pregnant women with a previous cesarean section now have two options on how to deliver their babies: a planned repeat C-section or through a vaginal delivery, known as Vaginal Birth After Cesarean delivery (VBAC). A successful VBAC has the benefits of a shorter recovery period hence shorter hospital stay, decreased blood loss, lower risk of infection and lowers the other risks that accompany repeated abdominal surgeries. However, not all women are eligible to undergo VBAC. Here are some more information about VBAC to help you discuss with your doctor if this is the best option for you.
Who can undergo VBAC?
Proper patient selection plays a vital role in achieving a successful VBAC and preventing its complications. The following are the criteria for VBAC:
• Women who had a previous “low transverse” or “low segment” cesarean section. The scar on your skin is not the same as the scar on your uterus. Retrieve your medical records to be able to obtain this information.
• The weight of the current baby is less than the birthweight of the previous baby for which the cesarean section was performed.
• The baby’s head should present first or what’s called as “cephalic presentation.”
• The indication for the previous cesarean section should not be present for the current pregnancy.
• There should be no cephalopelvic disproportion. This means that the mother’s pelvis is roomy enough to accommodate the complete passage of the baby.
• There should be informed consent, meaning the mother fully understands the procedure as well as the possible complications of VBAC.
• The equipment, facilities and a team to perform an emergency cesarean section should be readily available in case maternal and fetal complications arise during the labor and delivery.
What are the complications associated with VBAC?
VBAC can be complicated by infection and blood loss. A rare but catastrophic complication of VBAC is uterine rupture, where the previous cesarean section scar on the uterus tears or breaks open. This is an indication that an emergency abdominal delivery should be done. Uterine rupture can lead to the death of the mother and the baby if timely intervention is not executed.
Where should a patient undergo VBAC?
VBAC or trial of labor after cesarean should be done in facilities where an emergency C-section can be performed in the event of an “immediate threat to the life of the woman or the fetus,” as mentioned in the American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin Number 205 dated February 2019. VBAC should NOT be attempted as a home birth because uterine rupture is unpredictable and can be fatal.
Who should NOT undergo VBAC?
Women who have a high risk for uterine rupture should not undergo trial of labor after cesarean. These include women who had a classical/vertical or T-shaped uterine scar, women with two or more previous C-sections, those who have a history of uterine rupture, women with interpregnancy interval of less than 18 months, and those who have previous incisions of the uterus from gynecologic surgeries such as removal of myoma or repair of uterine anomalies. In addition, the presence of conditions that may prohibit vaginal delivery (such as placenta previa) is also an absolute contraindication to VBAC.
While modern obstetrics have made it possible for a mother to undergo normal delivery after a previous C-section, we should understand that VBAC cannot be performed for all pregnancies, as it is a complex procedure with inherent risks. Consult with your doctor to ensure that your birth plan will be what is safest and best for you and your baby.
Mikaela G. Martinez-Bucu, MD, FPOGS, FPSRM is a Clinical Associate Professor at the UP College of Medicine-Philippine General Hospital (UP-PGH) and Active Consultant at Manila Doctors Hospital. She is a graduate of the UP-PGH where she also completed her OBGYN residency and her fellowship training in Reproductive Endocrinology and Infertility. As a new mother to a one-year old son, she is an advocate for breastfeeding and Early Intrapartum and Newborn Care/EINC (Unang Yakap).