Like all things in medicine, when a VBAC goes well, it goes great; when it doesn't, it can go very badly. So before choosing VBAC, a VBAC really has to choose you -- you have to be a good candidate. If so, great! Full speed ahead. If not, have the crummy C-section, get a good baby, and get over it, because you may not be able to get over having complications you set yourself up for.
How Past C-Sections Effect Delivery
There are certain criteria that need be met to attempt a VBAC. The scar on your uterus is a big determining factor in whether a VBAC is even an option. There are two types of incisions that can be made on the uterus, vertical and horizontal (low transverse). The higher a vertical incision is up the dome of the uterus, the more it's referred to as a "Classical" incision--like the ones done a generation ago. It is less common to do vertical incisions, because they can more easily separate or even rupture with subsequent vaginal birth after Cesarean (VBAC). Today vertical incisions are done with difficult position of the baby or twins.
By far the safest incision is a horizontal one done on the lower uterine segment. This is the one a patient can labor against in a subsequent C-section. VBAC success seems to disfavor those who had a previous section after dilating all the way to 10 centimeters. The best success are those who were sectioned "cold" for breech or twins, or who underwent operative delivery before dilating to 10 (fetal distress, failure to progress). Therefore a careful history of what happened last baby could help a couple make a decision whether to attempt VBAC or electively schedule a repeat C-section.
Fear of VBACs
It was in the old days (circa 1979). The residents at Charity Hospital had been notified that all but the most crucial of power sources would be out while Maintenance did some electrical work. We had been delivering babies by flashlight, the better lighting reserved for surgical suites. We were good, well-trained--starting IVs by feel, running Labor and Delivery in the shadows without missing a beat. Childbirth went on in the non-air conditioned, unlit labyrinth of the 10th floor of that great gray building on Tulane Avenue. Now try to imagine, if you will, the tense scene that day.
I sat in the delivery room, waiting. My patient was completely dilated and pushing, her baby moments away from breathing room air instead of umbilical cord exchange. I prayed, though, that it would be that simple, for the patient had had a C-section two years earlier. She had arrived unannounced, with no prenatal care, ready to deliver. There was no time to prepare for a repeat C-section. "Once a C-section, always a C-section," played through my head according to my training.
I feared the force of expulsion that normally results in a delivery would tear the old scar in her womb (uterus), creating a hemorrhagic crisis for baby and mother. "Please don't rupture," I prayed. The nurse bit her lip as I uttered the words. It was melodramatic to say the least.
It was so silly, as it turned out.
At that time, soon-to-be published studies would confirm earlier research that concluded that vaginal birth after Cesarean (VBAC) was no more risky than any vaginal delivery. It's funny how times have changed.
Cost & Lower C-Section Rates
Enter capitalism. Looking to lower hospital costs for maternity services, managed care--HMOs, PPOs, and several other letter combinations-- welcomed the fortuitous results of the data, validating their push to lower C- section rates. The first immediate tier of the rate that could fall was the repeat C-section rate. VBAC was here to stay. Now openly encouraged, a specialist from twenty years ago would wonder if we were out of our minds. And now there are studies investigating vaginal delivery after more than one or two C-sections.
Even with the overwhelming evidence exonerating VBAC as completely safe, many patients still choose, even insist upon, repeat C-section. They fear a long fruitless labor, only to resort to surgical delivery anyway. They may want a scheduled birth, instead of the uncertainty of the onset of labor, which may not come for weeks after a scheduled C-section. They may fear that an uneventful C-section recovery may be easier than recuperating from a very difficult vaginal delivery. These are real concerns, and even though I encourage and favor VBAC, I still feel it should be the patient's decision. As long as she realizes that the infection and transfusion rate is ten times greater (although rare in private practice), she is qualified to take part in the decision.