Vaginal Birth After C-Section - When Is It Safe?

Cesarean sections have become increasingly common, with c-section rates soaring all over the world in recent decades. A whopping 32 percent of all births are cesareans in the United States today — a figure that's remained more or less unchanged between 2012 and 2022. That is good news in a sense, because c-sections can be life-saving for mothers and babies alike — but sometimes, they're performed when they are not strictly medically necessary, as doctors err on the side of caution to save lives.

That's often the case, for instance, in mothers who have already had a c-section with a previous baby. When they are pregnant again, many OBGYNs will recommend a repeat cesarean without any second thoughts, and most mothers will accept this suggestion without question. In some circumstances you can, however, opt for a "VBAC" — a vaginal birth after a c-section.

First-time mothers have a similar c-section rate to those who already had a child or more. Did you have a cesarean? If you are planning another baby, you may wonder if “once a c-section, always a c-section” is still the going rule. 

What Happened To “Once A C-section, Always A C-section”? 

Have you heard that moms who gave birth by c-section once are stuck with all c-sections for all subsequent births? Whether it was a friend or a doctor telling you this, you may wonder what's up with all the contradictory information that floats around when it comes to how to handle childbirth after you had a c-section in the past. Here is a brief history of the cesarean section to explain it.  

Plenty of people have heard the story that Julius Caesar was the first to be born by c-section, and that the name “cesarean section” or Caesar's cut actually came from him. The story is almost certainly not true, but cesarean sections were indeed around in Roman times. Julius Caesar's mother became his advisor later on in life. Roman mothers who actually had the ancient equivalent of the c-section were less lucky.  

C-sections in the Roman Empire started out as a means to cut babies out of dead mothers. Later on, Roman physicians also performed “the cut” to save babies who were still in the womb after the mom had entered the tenth month of pregnancy. There are no known cases of Roman mothers surviving cesarean sections.  

The first “modern” cesarean section was carried out by German gynecologist Ferdinand Adolf Kehrer. They have continuously evolved since then. Classical incisions, where the cut is made vertically, were popular only decades ago. Now, a low horizontal incision is most common. This “bikini cut”, coupled with more sturdy double suturing styles, has made vaginal births after cesarean section (VBAC) much safer for mothers and babies.  

Once a c-section, always a c-section? That depends on the reasons for which a woman had a c-section, and on the type of cut used during the last c-section. The guidelines set forth by the American College of Gynecologists and Obstetricians (ACOG) probably describes the rules best: “Most women with a history of one or two uncomplicated low transverse caesarean sections, in an otherwise uncomplicated pregnancy at term and with no contraindications to vaginal birth, are candidates for and should be counseled about VBAC.”  

In other words, if you had a cesarean at term due to circumstances like a breech baby, twins, fetal distress, or other factors that are unlikely to repeat in the next pregnancy, you are very likely a good candidate for a VBAC, or vaginal birth after c-section — if you had a low transverse incision (bikini cut) and are now enjoying a low-risk pregnancy.  

Vaginal Birth After Cesarean — What Are The Risks?  

Would you like to have a vaginal birth after cesarean, but are worried about the risks involved with this choice? Up to date research shows that women making the decision whether to have a repeat cesarean section or try for a VBAC are not informed about the risks and benefits of both options at all.

The researchers' conclusion was that both repeat cesarean and VBAC are relatively safe in most cases, but that the lack of informed consent is a real problem. “Informed” is an integral part of “informed consent”, a doctrine that requires doctors to inform their patients about the risks and benefits of a medical care choice, so that they can agree or disagree. Without the facts, you cannot make a good decision. So, if your OBGYN just tells you to have a c-section again without even letting you know that a VBAC might be an option, that's not informed consent.

So, what are the risks involved with a VBAC, or trial or labor after c-section? 

Uterine Rupture

Uterine rupture is the one risk everyone talks about. This means that the uterus ruptures along the line of the previous cesarean incision during labor. There are two types of uterine rupture. With catastrophic uterine rupture, the uterus tears open along the scar line, and its whole contents are released into the abdominal cavity. This results in a lot of internal bleeding and both mom and baby's lives are in immediate danger as a result. 

Asymptomatic Uterine Rupture

Asymptomatic uterine rupture is the more common kind of uterine rupture. In this case, the scar opens part of the way, and the baby and amniotic sac remain inside. This is a dangerous situation to be sure, but everyone usually makes it through OK if a hospital is close by — which is definitely the case if you're having a VBAC in a hospital, as you'll be very carefully monitored. 

One in 200 women attempting a VBAC will rupture, which equals 0.5 percent of VBAC cases. Some of the possible consequences of uterine rupture are fetal death and hysterectomy — where the uterus has to be removed in an emergency procedure to stop the hemorrhage. A 2004 study published in the British Medical Journal shows the statistics: 

• Zero percent of uterine ruptures resulted in maternal death.

• Five percent of uterine ruptures resulted in fetal death.

• Thirteen percent of uterine ruptures resulted in hysterectomy.

 It is interesting to note that several other labor complications, not related to VBAC, are statistically more likely to occur during your vaginal birth after cesarean. They include shoulder dystocia, placental abruption, and umbilical cord prolapse. 

Repeat cesarean section — the risks 

Now that we have found out what can go wrong during a vaginal birth after c-section, it is time to examine the risks of a repeat cesarean section. Infections, hemorrhage and the need for blood transfusion, complications from the anesthetic received, and maternal death are two to four times more likely to occur as the result of a c-section. Psychological problems are also associated with c-sections.  

Babies born by c-section are more likely to be born prematurely, and have an increased risk of breathing difficulties right after birth and asthma later in life. Breastfeeding difficulties are another risk associated with c-section. 

Having a repeat cesarean section is a trade-off — you may lower the risk of uterine rupture in this pregnancy, but if you get pregnant again, a subsequent pregnancy is more likely to experience complications. Babies developing in a scarred uterus are more likely to have a low birth weight, to be born prematurely, and to be stillborn. Placenta previa and placenta accreta are placental complications in which the placenta covers the cervix or is embedded in the uterus more deeply than it should, respectively. These two are also more likely to happen in a scarred uterus. 

Scientific research shows that a VBAC is generally more safe than a planned repeat cesarean section, but also that a trial of labor turned emergency c-section carries the highest risk of the complications we just mentioned. The researchers (see source list at the bottom of this article) came up with a list of factors that to asses the likelyhood of emergency c-section after trial of labor: 

• No previous vaginal delivery.

• Increased maternal age.

• Lower maternal weight and height.

• Induction of labor.

• Labor after the 40-week mark. 

If You Want A VBAC, But Your Doctor Doesn't Agree

Some hospitals have no-VBAC policies, and some individual doctors are opposed to giving women a trial of labor after they have had a cesarean section. If this happens to you, it is important to find out what the underlying reason for your medical team's refusal to assist you with a VBAC is. 

It is possible that you are simply not a good candidate for a trial of labor. Did you have a classical or T-shaped incision during your previous c-section, perhaps? Or does your pregnancy have other risk factors that contraindicate a trial of labor, like breech or a low-lying placenta? In that case, accepting that a repeat cesarean section is the safest choice for you is probably the only option you have. 

If, on the other hand, your doctor or hospital has a blanket policy against vaginal birth after c-section, there are several things you can do. Pointing out the ACOG guidelines on VBAC may help, as will showing your medical records to reassure the doctor that your type or incision and sutures are combatiple with a trial of labor. You could also ask what would happen if you simply refused to undergo the surgery unless there is a clear medical reason. 

Do these questions result in a hostile attitude and more refusal? Then, your best bet is to search for a hospital or doctor that is supportive of VBAC. Searching the internet may be really helpful if you are trying to locate such a doctor, but you could also seek out local organizations where other moms are likely to have this information. The La Leche League, babywearing support groups, or even c-section support groups (they exist!) are all good places to start looking.