Trying to decide between a VBAC vs repeat c-section? When it comes to 2nd, or 3rd, 4th, or more deliveries, many people will be faced with making the decision of attempting a TOLAC (trial of labor after c-section) vs scheduling a repeat c-section. I am one of those people. My first delivery was a vaginal delivery and my second was a planned c-section due to my other health complications at the time. Then, I had to make a decision with my third.
But what factors go into this decision? What should we be thinking about? Which is the best route? We know that the safest route of delivery for both patient and baby is a:
- TOLAC with VBAC (vaginal birth after c-section), followed by a:
- Scheduled c-section, followed by a:
- Failed TOLAC resulting in an unplanned c-section.
But the problem is, we don’t know if someone will fall into 1 or 3 ahead of time.
What is a VBAC?
Vaginal Birth After Cesarean (VBAC) is a delivery method where a woman who has previously undergone a cesarean section gives birth vaginally in a subsequent pregnancy. This process involves carefully assessing the risks and benefits based on individual circumstances to determine if it’s a safe option for the mother and baby. Factors such as the reason for the prior cesarean, the type of incision made during the previous surgery, and the current pregnancy’s conditions all play significant roles in the decision-making process. VBAC can be a suitable choice for those seeking a more natural birth experience after a cesarean delivery, provided certain criteria are met to ensure the safety of mom and baby.
We can do our best to estimate the success of a VBAC based on patient characteristics and history by using a VBAC calculator, but while this can be a useful tool, it still has limitations.
What is a VBAC calculator?
A VBAC calculator is a tool we use in obstetrics to assess the probability of a successful VBAC for women who have undergone a previous cesarean section. This calculator typically takes into account various factors such as the woman’s age, BMI (Body Mass Index), gestational age, previous cesarean delivery details (such as the reason for the cesarean, type of incision made, and number of prior cesarean births), and other relevant medical history to estimate the likelihood of a successful VBAC attempt. The calculated result helps us (and you!) make informed decisions regarding the mode of delivery for subsequent pregnancies.
Risks, Benefits, and Candidate Criteria for Trial of Labor After Cesarean (TOLAC):
We also have to consider the risks involved with TOLAC vs repeat CS. One of the main complications we consider is risk of uterine rupture, or the risk that the previous CS scar tears open which can be dangerous for both patient and baby. For a prior low transverse uterine incision (type of incision on the uterus, not on the skin), risk of uterine rupture during a TOLAC is about 0.5-0.9% and risk of severe neonatal injury or death is approximately 0.5 per 1000. Risk of significant injury is low, but it’s not zero.
Risks:
- Uterine Rupture: This can lead to severe complications for both the mother and the baby.
- Failed VBAC: There is a possibility that the trial of labor may not result in a successful vaginal birth, leading to the need for an emergency cesarean section.
- Infection and Hemorrhage: Like any childbirth, there are risks of infection and excessive bleeding during TOLAC.
Benefits:
- Avoiding Repeat C-Section: VBAC can allow you to experience vaginal childbirth, which may have benefits such as reduced recovery time, decreased risk of surgical complications, and a more natural birthing experience.
- Shorter Hospital Stay: Successful VBACs often result in shorter hospital stays compared to scheduled repeat cesarean sections.
- Less Risky for Future Pregnancies: VBAC may reduce the risks associated with multiple cesarean deliveries, such as placenta previa or placenta accreta.
Who is an appropriate candidate?
- One Prior Low-Transverse C-Section: Women with a history of one prior low-transverse cesarean delivery, as this type of incision carries the lowest risk of uterine rupture during TOLAC.
- Healthy Pregnancy: Candidates should have an uncomplicated current pregnancy with no known fetal or maternal health concerns that would increase risks during labor.
- Informed Decision-Making: Know the risks and benefits and have access to appropriate medical care and monitoring during labor.
- Facilities for Emergency Care: Access to facilities equipped for emergency cesarean sections is crucial in case complications arise during TOLAC.
There is so much to consider when making this decision, and there is often no one right answer. If you are trying to decide between a VBAC vs Repeat C-Section, I hope this helps! As OB docs, we are here to help guide those decisions the best we can. But ultimately, it’s up to the patient.
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