Vaginal birth after caesarean (VBAC) refers to the practice of delivering a baby

Childbirth

Childbirth is the culmination of a human pregnancy or gestation period with the birth of one or more newborn infants from a woman's uterus...

 vaginally after a previous baby has been delivered through caesarean section

Caesarean section

A Caesarean section, is a surgical procedure in which one or more incisions are made through a mother's abdomen and uterus to deliver one or more babies, or, rarely, to remove a dead fetus...

 (surgically). According to the American Pregnancy Association, 90% of women who have undergone cesarean deliveries are candidates for VBAC. Approximately 60-80% of women opting for VBAC will successfully give birth vaginally, which is comparable to the overall vaginal delivery rate in the United States in 2010.

VBAC trends in the United States

Although cesarean sections made up only 5% of all deliveries in the early 1970s, among women who did have primary cesarean sections, medical dogma historically held, "Once a caesarean, always a caesarean." A consumer-driven movement supporting VBAC changed standard medical practice, and rates of VBAC rose in the 1980s and early 1990s. A major turning point occurred in 1996 when one well publicized study in the New England Journal of Medicine reported that vaginal delivery after previous caesarean section resulted in more maternal complications than did repeat cesarean delivery. The American College of Obstetrics and Gynecology subsequently issued guidelines which identified VBAC as a high-risk delivery requiring the availability of an anesthesiologist, an obstetrician, and an operating room on standby (Int J Gyn Obs; 1999; vol 66, p197). Logistical and legal (professional liability) concerns led many hospitals to enact overt or de facto VBAC bans. As a result, the rate at which VBAC was attempted fell from 26% in the early 1990s to less than 10% today.
In March 2010, the National Institutes of Health met to consolidate and discuss the overall up-to-date body of VBAC scientific data and concluded, "Given the available evidence, trial of labor is a reasonable option for many pregnant women with one prior low transverse uterine incision.". Simultaneously, the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality reported that VBAC is a reasonable and safe choice for the majority of women with prior cesarean and that there is emerging evidence of serious harms relating to multiple cesareans. In July 2010, The American College of Gynecologists and Obstetricians (ACOG) similarly revised their own guidelines to be less restrictive of VBAC, stating, "Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans."
Enhanced access to VBAC has been recommended based on the most recent scientific data on the safety of VBAC as compared to repeat cesarean section, including the following recommendation emerging from the NIH VBAC conference panel in March 2010, "We recommend that hospitals, maternity care providers, health care and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to trial of labor." The U.S Department of Health and Human Services' Healthy People 2020 initiative includes objectives to reduce the primary cesarean rate and to increase the VBAC rate by at least 10% each.

Drawbacks and benefits

A caesarean section leaves a scar in the wall of the uterus which is weaker than the normal uterine wall. During labor in a subsequent pregnancy, there is a small risk of a ruptured uterus (0.47% chance among women having a trial of labor versus 0.03% among women scheduling repeat cesarean deliveries). If a uterine rupture does occur, the risk of perinatal death is approximately 6%. Mothers with a previous 'bikini cut' or lower uterine segment caesarian are considered the best candidates, as that region of the uterus is under less physical stress during labor and delivery. Aside from uterine rupture risk, the drawbacks of VBAC are usually minor and identical to those of any vaginal delivery, including the risk of perineal tearing. Maternal morbidity, NICU admissions, length of hospital stay, and medical costs are typically reduced following a VBAC rather than a repeat cesarean delivery.
Risks of caesarean section include a higher chance of re-hospitalization after birth, infertility, uterine rupture

Uterine rupture

Uterine rupture is a potentially catastrophic event during childbirth by which the integrity of the myometrial wall is breached. In an incomplete rupture the peritoneum is still intact. With a complete rupture the contents of the uterus may spill into the peritoneal cavity or the broad ligament...

 in the next pregnancy, injury to the baby, premature birth and respiratory problems in the baby, as well as bonding and breastfeeding difficulties. The risk of post-operative infection

Infection

An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...

 doubles if vaginal delivery is attempted but results in another cesarean. All complications of cesarean section are more likely and more severe if it is done as an emergency after a failed attempt at vaginal delivery rather than as a planned operation.
Repeat caesarean sections get increasingly complicated with each subsequent operation, as the probability of internal abdominal adhesions, bladder injuries, and abnormal placentation(placenta previa or placenta accreta) increases dramatically, with placenta accreta reportedly affecting 50-67% of women having three or more cesarean sections. According to the United States Agency for Healthcare Research and Quality, "Abnormal placentation has been associated with both maternal and neonatal morbidity including need for antepartum hospitalization, preterm delivery, emergent cesarean delivery, hysterectomy, blood transfusion, surgical injury, intensive care unit (ICU) stay, and fetal and maternal death and may be life-threatening for mother and baby."

Eligibility

Eligibility to pursue a VBAC varies widely by provider and birth setting (hospital, birthing center, or home). Some commonly employed criteria include:

• If the previous caesarean(s) involved a low transverse incision there is less risk of uterine rupture than if there was a low vertical incision, classical incision, T-shaped, inverted T-shaped, or J-shaped incision.
• A previous successful vaginal delivery (before or after the caesarean section) increases the chances of a successful VBAC.
• The reason for the previous caesarean section should not be present in the current pregnancy.
• The more caesarean sections that a woman has had, the less likely she will be eligible for VBAC.
• The presence of twins
  TWINS
  Two Wide-Angle Imaging Neutral-Atom Spectrometers are a pair of NASA instruments aboard two United States National Reconnaissance Office satellites in Molniya orbits. TWINS was designed to provide stereo images of the Earth's ring current. The first instrument, TWINS-1, was launched aboard USA-184...
  
   will decrease the likelihood of VBAC. Some doctors will still allow VBAC if the twins are positioned properly for birth.
• VBAC may be discouraged if there are other medical complications (such as diabetes), if the mother is over 40, if the pregnancy is post due date
  Due Date
  Due Date is a 2010 American comedy road film directed by Todd Phillips, co-written by Alan R. Cohen, Alan Freedland, and Adam Sztykiel, and starring Robert Downey, Jr. and Zach Galifianakis. The film was released on November 5, 2010...
  
  , or if the baby is malpositioned.

According to ACOG guidelines, the following criteria may reduce the likelihood of VBAC success but should NOT preclude a trial of labor: having two prior cesarean sections, suspected fetal macrosomia (fetus greater than 4000-4500 grams in weight), gestation beyond 40 weeks, twin gestation, and previous low vertical or unknown previous incision type, provided a classical incision is not suspected (ACOG Practice Bulletin Number 115, August 2010).
Depending on the provider, special precautions may be taken during a trial of labor following a cesarean section, including IV or IV port placement, continuous or intermittent fetal monitoring, and conservative or absent labor induction and augmentation. Other intrapartum management options, including analgesia/anesthesia, are identical to those of any labor and vaginal delivery.

Community Resources

There are a variety of community and national resources for women seeking to find out more information.

Books:


The latest book on VBAC :


Birthing Normally After A Cesarean or Two : A Guide for Pregnant Women - Exploring Reasons and Practicalities for VBAC
(2011),by Hélène Vadeboncoeur, Fresh Heart Publishing (US edition)

Birthing Normally After A Caesarean or Two : A Guide for Pregnant Women - Exploring Reasons and Practicalities for VBAC
(2010),by Hélène Vadeboncoeur Fresh Heart Publishing (UK edition)

Birth Choices (2006) by Allison Shorten

Websites:

http://www.vbac.com is a user friendly website that guides women through what a VBAC is and holds a large amount of information and resources for women in all stages of learning about VBAC.

http://www.doulamatch.net is a website that can help women find a doula in their area, as well as read reviews about them

http://www.dona.org/mothers/find_a_doula.php a website that can also help women find a doula, as well as offering a large amount of helpful information on what a doula is and what they do.

http://ican-online.org/ a nonprofit organization that aims to prevent unnecessary c-sections.

http://advocatesforpregnantwomen.org/ this organization works to preserve the human and civil rights of all women, focusing predominantly on the pregnant or parenting, and those who are most vulnerable.

http://birthingbeautifulideas.com/ a personal blog documenting a woman’s experiences in pregnancy and birthing.

External links

• International Cesarean Awareness Network: a consumer-driven organization that supports cesarean and VBAC awareness.
• www.caesarean.org.uk: Independent UK website providing information and support on caesarean and VBAC issues. this is a good summary of the current knowledge and opinion on this subject.
• www.vbacfacts.com: a mom's quest for evidence-based information - includes studies, changes in midwifery laws in the United States, VBAC advocacy and personal stories.
• http://www.storknet.com/cubbies/vbac/4studies.htm: 4 recent studies on VBAC
• http://www.vbac.com/hottopic/finalusbirthtrends2003.html: Total and Primary Cesarean Rate and Vaginal Birth After Previous Cesarean (VBAC) Rate --- United States, 1989—2003
• http://consensus.nih.gov/2010/vbacstatement.htm: Statement from panel of medical experts regarding VBAC safety.
• http://www.ahrq.gov/clinic/tp/vbacuptp.htm: Detailed summary of scientific research regarding the safety of VBAC and repeated Cesarean section is included in an evidence report pdf at the bottom of the page.
• http://www.acog.org/from_home/publications/press_releases/nr07-21-10-1.cfm: Updated ACOG guidelines regarding VBAC.
• http://www.guideline.gov/syntheses/printView.aspx?id=25231 : Comparison of the current ACOG (USA) and RCOG (UK) guidelines related to VBAC management.