Vaginal Birth after Cesarean
Reasons for Cesarean Delivery
A cesarean delivery (Cesarean section or “C-section”) is the delivery of the baby through an incision in the abdomen and through an incision in the uterus. Much has been written in the lay press about C-section and the number of C-sections performed in the United States. Nationally, about 20% of pregnancies are delivered by C-section.
There are no hard and fast rules with regard to cesarean deliveries because each pregnancy has its own unique characteristics. The reasons for performing cesarean delivery can be categorized as individual reasons, but it should be recognized that often a combination of individual factors must be considered.
- Conditions of the mother – The woman may have medical conditions that worsen as pregnancy progresses or a condition that will not allow the woman to tolerate labor and vaginal delivery. In addition, there may be problems with the uterus or other pelvic organs, which would prevent a successful vaginal birth.
- Conditions of the fetus – The baby may have medical conditions that result in its inability to tolerate the stresses of labor. The baby may also be coming down through the birth canal in an unusual position so that a vaginal birth is not possible.
- Conditions of the mother/baby – It is not uncommon that the baby cannot be delivered as a vaginal birth because it will not “fit” through the birth canal. This may be due to the baby’s size, the shape of the bones of the mother’s pelvis, or the contractions of the uterus not being adequate.
- Conditions of the afterbirth – In some cases, the afterbirth (placenta) may be in the way of a vaginal delivery (placenta previa) or may separate prematurely (placental abruption) which would require cesarean delivery.
Because there is a higher risk associated with cesarean delivery over vaginal delivery, the physician tries to consider every possibility to get both a healthy mother and healthy baby. In some instances, the cesarean delivery is decided upon before labor and attempted vaginal delivery is started. In many cases, however, the cesarean delivery is only decided upon after extensive attempts to achieve vaginal delivery.
Once a Cesarean, always a Cesarean?
In years past, once a woman had a cesarean delivery, it was expected that all subsequent deliveries would also be by cesarean. This was due to a fear that the uterus had been weakened by the previous cesarean section. It is now felt that patients who have had a cesarean delivery in which the incision of the uterus (womb) is across (low transverse) the uterus rather than up and down (high or low vertical), are considered candidates to have attempts at vaginal delivery in subsequent pregnancies (vaginal birth after cesarean section – “VBAC”). The physician and the patient should be able to discuss the need for future cesarean deliveries if that is a consideration for the patient.
Risks and Benefits of VBAC
Approximately 60% to 80% of woman who are given an opportunity to attempt a trial of labor after a previous cesarean delivery can successfully deliver as a vaginal birth. Unfortunately, there are no ways to tell which patients are more likely to be able to deliver vaginally in pregnancies after a cesarean delivery. The primary benefits of a VBAC include shorter hospital stays, less need for blood transfusions, and a lower chance of infections. The most serious risk associated with VBAC is the possibility of the uterus rupturing at the site of the previous incision. The likelihood of this is less than 1%. This has been found to be more likely when a woman has had more than one cesarean delivery or may have had an abnormally difficult labor during the current pregnancy. In order to minimize risks to the mother and the baby, close monitoring of the mother and baby’s condition as well as the ability to perform emergency surgery are needed if a trial of labor is being considered.
The Operation and the Operating Room
Under some circumstances, the cesarean delivery is considered “elective” in which the decision for cesarean delivery is planned and scheduled. Sometimes, possibly during the labor process, a cesarean delivery is decided upon for emergency reasons. If this occurs, there may be a great sense of urgency as the doctors, nurses, and other hospital personnel rush the patient to the operating room to perform the procedure. In either situation, the operation itself is performed with adequate anesthesia so the patient does not feel the actual cutting of tissue.
Depending on the policies of the particular hospital, the patient may or may not be able to have a support person in the operating room with her as the procedure is done. If so, that person will sit at the head of the table next to the patient’s head, out of the area in which the surgery will be performed. The operation is performed by a surgical team under sterile conditions. If the patient receives the type of anesthetic in which she is awake, she will hear the surgical team talking and feel the pulling of the tissues but should not feel any pain. The baby, once delivered, is handed over to personnel who will tend to its needs. Sewing up or “closing” the procedure will take several minutes after the delivery is accomplished.
After the operation, the patient will initially have an intravenous (IV) line to provide medicine, fluids, and nourishment. There will also be a catheter that was placed in the bladder prior to surgery, which will continue to drain urine into a bag. When the anesthesia wears off after the operation, there will be some pain in the abdomen. The patient’s blood pressure, temperature, and pulse will be monitored closely every few hours and the incision will be examined on a regular basis. The patient will be encouraged to cough, deep breathe, and move about in bed, getting out of bed as soon after surgery as is practical. This promotes good, deep breathing which will prevent lung problems such as pneumonia.
Even though there will be discomfort in the lower abdomen, short walks in the hospital room or in the hallways of the hospital will make for a more rapid recovery. Initially, hospital personnel will help the patient in and out of bed. The incision will be sore and tender. Medication is always available for pain, nausea and other needs the patient may have.
Often, immediately after surgery, clear liquids can be taken. Under certain conditions, the intestines may be delayed a day or two before they start working again. The doctors will decide what type of diet the patient’s system can tolerate. Similarly, the bowels may not return to normal function until the patient is on a more regular diet. It is not unusual to also have gas pains in the lower abdomen.
Both in the hospital and the first few days after the patient goes home, she may feel discomfort such that holding or feeding the baby may be more difficult that she would like. Bonding with the newborn as well as recovering from the cesarean delivery at the same time is more challenging than after a vaginal birth. In addition, mood swings may occur just like they occur after vaginal delivery. Difficulty with emotions should be discussed with the nurses or the woman’s physician to prevent any significant problems.
By the time the patient goes home, she will be able to eat anything she wants. She will not have an IV or catheter and the incision should be healing well. Activities will be gradually increased as the new mother gets stronger and more confident in her ability to walk up and down stairs, take longer walks, and provide for the baby. Breastfeeding, if desired, is not affected by a cesarean delivery.
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