Q&A: My first baby was delivered via Cesarean, but I want a vaginal birth for my next child.

It used to be, "Once a C-section, always a C-section." Then researchers began to study the safety of allowing vaginal deliveries after previous C-sections. Called VBAC (vaginal birth after cesarean), managed care embraced the idea once it was shown that it was relatively safe to try for a vaginal delivery the next time. There are some precautions and criteria, though.

First of all, the previous C-section had to be what was called a transverse C-section; that is, the incision on the uterus had to be low and horizontal. This is completely unrelated to the type of scar on the skin of the abdomen. Vertical scars on the uterus, like those used with twins and breech presentation, are weaker than horizontal scars and therefore are considered a rupture hazard with subsequent labor. Also, patients who had dilated to 10 centimeters and then had to have a C-section are more likely to have a failed VBAC trial and need a C-section again. So both of these groups should really consider having another C-section.

But if a patient had a transverse C-section for breech, fetal distress, or placenta previa, then this would be a patient who never had a trial of labor, and ought to be given the chance to try for a vaginal delivery. Even if the last C-section had been done because the baby was too big, the mother too small, or a combination of the two (called relative cephalopelvic disproportion, or CPD), still an attempt at a VBAC is not unreasonable.

In my practice, I encourage VBAC, but I don't insist on it if the mother wants to "just have another C-section." Of course, I make sure she understands that there's a greater chance of complications, transfusions, infections, and other problems than with a vaginal delivery. But because I think that C-section is a legitimate way to have a baby, I believe it should be the prospective parents' decision.