There is still a widespread belief that a woman who has a cesarean delivery is conditioned that future deliveries are also like this, despite the fact that numerous studies carried out over the last few years have proven that having a vaginal delivery after a cesarean section (PVDC) is possible and safe.
But, is it also possible to speak of vaginal delivery after two, three or more cesarean sections? What do gynecologists and studies say? We analyzed the data we have found in this regard, as well as the opinion of a midwife on the safety of attempting a vaginal delivery after one or more cesarean sections .
Up to 76% of women with a previous cesarean section later achieve a vaginal delivery
Several studies published in the 1980s have already concluded that it is possible to have a vaginal delivery after a cesarean section , as long as the health conditions of the mother and the characteristics of the pregnancy allow it.
This general percentage decreases or increases based on certain characteristics, such as:
- gestational age : above 41 weeks the chances of achieving a vaginal birth decrease from 75%, between weeks 37-40, to 65%
- if the woman had a vaginal birth at some point : in this case, the chances of having it again, despite having had a previous cesarean section, rise to almost 87%
- the reasons why the previous cesarean section was indicated , thus, in the case of having been due to shoulder dystocia the chances of achieving a successful vaginal delivery are 63%, while if the cesarean section was indicated at the time due to abnormal position of the baby, the chances of having a vaginal delivery afterwards rise to 84%
For all these reasons, the SEGO recommends a vaginal birth in women with a previous cesarean section , provided that possible contraindications have been ruled out and the risks / benefits of a vaginal birth after cesarean section (VBAC) have been duly informed.
What is the risk of uterine rupture in a VBAC?
The main risk faced by women attempting a vaginal delivery after cesarean section is uterine rupture as a result of the scar on their uterus. This risk is increased if labor is not triggered spontaneously , but is induced.
In this sense, a meta-analysis carried out in 2000 identified that the number of uterine ruptures in women with previous cesarean section undergoing labor was 0.4% (90 women out of 22,982), compared to 0.2% that occurred among women with a prior cesarean section who decided to undergo a subsequent elective cesarean section.
Even so, and as we can read in the magazine of Spanish-speaking health professionals, Portales Médicos, it is difficult to give concrete values about the real risk of uterine rupture , since this data depends on numerous factors, such as the place where delivery, the type of incision, the intergestational period, the number of previous vaginal deliveries or the care received during delivery.
For this reason, from El Parto es Nuestro they assure that the best way to avoid this complication is by minimizing the interventions as much as possible ; that is to say, “avoid inductions, favor the freedom of time and movement in expansion and expulsion, intimacy, empowerment” .
In which cases is a VBAC NOT recommended?
But there are a number of factors that make it not advisable to attempt a vaginal delivery after cesarean section . According to SEGO, these factors would be:
- Having a prior or inverted T-shaped caesarean section
- Previous hysterotomy or myomectomy with entry into the uterine cavity
- Previous uterine rupture
- The existence of factors that contraindicate a vaginal delivery
- Have three or more previous cesarean sections
With regard to twin pregnancy, gestational diabetes, macrosomia or breech presentation, the SEGO establishes that they are not a cause of contraindication for VBAC, although due to the scarcity of information one must act with prudence and individualize each case.
Likewise, it is important to take into account the time elapsed between the last cesarean section performed on the woman , since the SEGO considers that there is a “high risk of uterine rupture” when the period is less than 18 months.
Elective caesarean section after previous caesarean section
A study carried out between January 2012 and January 2015 at the Puerta de Hierro Hospital in Madrid – and published in the SEGO magazine – analyzed the delivery of 638 women with full-term pregnancy and a history of cesarean section. Of these, 54.5% attempted vaginal delivery (with an almost 82% success rate), while the remaining 45.5% opted for elective caesarean section .
And it is that the law in Spain contemplates the right of the woman to decide if she wants a cesarean section to be performed after a previous one, despite the fact that there is no medical condition that indicates it. According to the SEGO, this fact would contribute to the increase in the rate of caesarean sections in our country.
For this reason, and in order to reduce the rate of unnecessary cesarean sections, experts consider fluid communication between doctor-patient essential to guarantee teamwork by healthcare personnel and a relationship of trust with the pregnant woman.
In this way, and as an example, SEGO proposes:
- Identify women who choose a new cesarean section for fear of vaginal delivery , presenting them with adequate information that alleviates this tension and gives them security
- Give detailed information to women who have undergone a first cesarean section, clarifying the causes of it and anticipating that in the future you can try a vaginal delivery if there are no contraindications
- Offer evidence-based information , not only on the potential risks of attempting a VBAC, but also on the risks posed by cesarean section itself
- Inform women about the data that indicate the success of having a VBAC
Risks / benefits of a new cesarean section and VBAC
Women who, with a previous cesarean section, opt for a new cesarean section, should be informed of the following risks and benefits:
- Among the risks would be those derived from this major surgery, such as bleeding, infections, damage to neighboring organs or cuts in the baby, as well as thromboembolic phenomena and future infertility problems.
- But in specific cases, the benefits of opting for a new cesarean section would outweigh the possible risks, although in general it has been proven that opting for a vaginal delivery after a cesarean section can be just as safe as a second cesarean section.
As regards women who decide on a VBAC, they should be informed of:
- The risks of uterine rupture that in your specific case may exist, and what this complication implies during childbirth depending on its severity (hemorrhage, hysterectomy, fetal hypoxia, or even the death of the mother and / or the baby)
- Benefits include a lower risk of bleeding, better recovery, and shorter hospital stay.
“I have two, three or more caesarean sections: can I try a vaginal delivery?”
Although, as we saw above, in general the SEGO advises against attempting a vaginal birth in women with three or more cesarean sections , most gynecologists establish this limit at two cesarean sections:
“Based on the professional experience I have had, attempting a vaginal delivery after two cesarean sections depends a lot on the doctor who attends to the mother , since there are some who do not even decide to evaluate this option since they consider that the risk of uterine rupture increases as it increases. the number of cesarean sections “- explains midwife Carla Quintana, head of the ‘Midwife for me’ project
However, the UK Royal College of Obstetricians and Gynaecologists (RCOG) delivery care guide indicates that up to 71% of women with two or more cesarean sections can have a vaginal delivery , so it is recommended try it if there are no risk factors that contraindicate it.
For its part, a study carried out ten years ago and published in the scientific journal BJOG (International Journal of Obstetrics & Gynaecology) concluded that women with three previous caesarean sections did not have a greater risk of suffering a uterine rupture during vaginal delivery than those who had had only one cesarean. In addition, in these cases the chances of having a successful vaginal delivery rose to 80% , compared to 75% of women who achieved it after one or two previous cesarean sections.
How many cesarean sections can I have?
As for the number of cesarean sections that can be safely performed , most medical professionals consider three. Not surprisingly, many hospitals offer a woman who undergoes a third cesarean the option of also having a tubal ligation, although it is a very personal decision that must be valued by the woman.
” I have personally attended women with up to six cesarean sections . But both in pregnancy and postpartum there is no doubt the risk that this mother assumes, not only of uterine rupture, but of postpartum hemorrhage – although this is something that increases with each new delivery, and not exclusively because it is a cesarean section-, future problems of the pelvic floor and adhesions “
” For a uterus with so many caesarean sections to contract correctly and there are no complications, a lot of medication and special care are required. That is why it is important to inform the woman well and that she ultimately make the decision she considers best” – indicates the midwife.
Therefore, if you have had a cesarean section and want to try a vaginal delivery later, it is very important that you speak confidently with your doctor or midwife about the possibilities of achieving it successfully, as well as assessing the benefits and risks that in your specific case may introduce oneself.
Photos | iStock
Acknowledgments | Carla Quintana, midwife and head of the ‘Matrona for me’ project
In Babies and More | “Anatomy of a cesarean section”, the viral video that shows in a practical way how this important surgery is performed, Can you have a vaginal delivery after a cesarean section? A video proves yes, Caesarean scar care: what you need to know
