Labour & Delivery
What are the chances of having vaginal birth after second c- section?
Subject :Re:What are the chances of having vaginal birth after second c- section?
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In a situation in which a woman has had only one cesarean, the benefits and risks of vaginal delivery versus cesarean are different. VBAC (vaginal birth after cesarean) is sometimes called TOLAC or TOL (Trial of Labor after Cesarean or Trial of labor).
Benefits of a vaginal delivery after a cesarean may include: Reduced risk of blood clot in the leg or lung Shorter length of hospital stay in most women Less likely to need a blood transfusion Possibly lower rate of postpartum fever, would infection, and uterine infection Fewer neonatal breathing problems
Cesareans may cause more bleeding, adhesions or scars from the surgery, more pain that lasts longer, a slower recovery, increased risk for a twisted bowel, a longer hospital stay with increased risk for return to the hospital, less contact with the baby early on, more challenges with breastfeeding. The baby may also have small risks of being cut during surgery (usually a minor cut), have trouble breathing at birth, and experience asthma in childhood. In the future, there is an increased risk for other pregnancies after cesarean that the baby could be born too earl, have a low birth weight, or there may be placental problems among the mother.
The risks of vaginal birth after cesarean include an increased risk of uterine rupture (where the scar tissue breaks open). In general, women with VBAC have a low risk of uterine rupture. It occurs in less than 1% of deliveries. When it does occur, it is a medical emergency for both the mother and the baby, and there is an increased risk of infant death within a very short period of time. When it happens, it is rare, but it is catastrophic for the mother, the infant, and all those that love and care for them.
Risk of uterine rupture depends on many different factors. Part of it depends on how the uterus was cut at the time of cesarean, which may be different from the scar on the outside in the skin. If the uterus was cut in a T-shaped incision or from top to bottom (up and down, vertically), the risk of uterine rupture is 4 to 9 percent; and if the uterine cut is transverse (horizontal or side to side), the risk of uterine rupture is between 0.2 percent to 1.5 percent (Macones, GA, Peipert, J, Nelson, DB et al., 2005).
In general, the risk of uterine rupture with a single cesarean and a low side to side (transverse) incision is very low, but it is slightly higher than having a repeat cesarean. Since the risk of fetal death is higher with uterine rupture, there are more fetal deaths with VBAC than with repeat cesarean. With cesareans and VBACs, maternal deaths are low in both cases. A uterine scar is more likely to give way if the type of scar is not known, the baby is over 4,000 grams (8 pounds 13 oz) the pregnancy goes beyond the due date of 40 weeks gestational age. It can also be impacted by having twins, or if the baby is turned or manipulated from a breech (head up position).
In general, the American College of Obstetrics and Gynecologists considers that VBAC is okay for women who have a baby in the right position (vertex/cephalic/head down), do not have other medical conditions like placenta previa, do not have additional uterine scars other than one, have never had an incidence of uterine rupture, only have a single low transverse uterine incision, and do not have other pelvic problems or conditions to inhibit the baby being born normally. Considering that VBAC although usually normal, can result in a sudden emergency in which mother and infant are at risk, it is important to pick out a place of delivery in which there will be a physician who is a surgeon that performs cesareans, nursing staff, and anesthesia teams available in case things take a turn in which it would be important to go back for a sudden cesarean. If a woman were to experience a sudden cesarean, she may even end up with general anesthesia in which she is sedated and put to sleep for the delivery.
If about 10,000 women are doing a VBAC, 27 have a scar that gives way. In about 10,000 VBAC, 1-2 babies may die, and 3-4 women may have to have an emergency hysterectomy (removal of the uterus) to save her life. Every 3 out of 4 women who try for a VBAC have a vaginal delivery.
Additionally, a woman trying for VBAC should go into labor naturally, other medications like misoprostol and many ripening agents / induction medications may increase the risk for uterine rupture so most providers are not comfortable inducing a woman who does not go into labor on her own. If a woman has a had a previous successful vaginal delivery, if she has a normal labor that does not slow or stall out, if she is not induced, and if her baby is a normal size, she is more likely to have a successful VBAC. Her chances also increase if her original cesarean was for a reason like breech position or herpes lesions that were not related to problems with labor. Her chances of success are also improved by only having on cesarean, and if the initial cesarean was done early in labor before she was fully dilated.
In your case, you ask about Multiple scars in the uterus. The more cesareans you have, the increased risk there is for future pregnancies and birth. In addition to risk of scar rupture (which can go up to 3.7% if you have more than one cesarean).There are increased risks for the scar giving out, ectopic pregnancy (in the tubes, outside of the uterus in which future fertility can be decreased), placenta previa where the placenta grows over the cervix (the opening of the uterus), placenta abruption in which the placenta separates from the uterus before the baby is born, and placenta accreta in which the placenta is growing abnormally. Women who have had two previous cesarean are five times more likely to have a uterine scare that gives way than women who have had only one (Caughey, AB, Shipp, TD, Repke, JT, ZElop, CNM, Cohen, A, Lieberman, E. 1999), in that study the rate of the scar giving way was 3.7% to 4.8%. In another study (Macones, GA, Cahill, A, Pare, E, STamilio, DM, Ratcliff, S, Stevens, E., Sammel, M, and Peipert, J. 2005), in women that had 2 prior cesareans and attempted a VBAC there was a greater risk for complications like hemorrhage, infection, removal of the uterus, and things of that nature. In women that try a VBAC after having had two or more cesareans, their success at a vaginal delivery is between 9% to 49%
What are symptoms of a uterine rupture? Usually, they can occur any time, but they are most likely in labor. They can occur prior to labor. The signs include a low fetal heart rate that does not come back up, and if the infant goes all the way out of the uterus into the maternal abdomen the outcomes are the worst. Other symptoms include abdomenal pain and hemorrorhage, rapid maternal heart rate, low maternal blood pressure, sudden stopping contractions, change of uterine shape, the fetal head or other presenting part is no longer found with exams, uterine tenderness, persistent vaginal bleeding.
Now what to do? Keep looking at the information, talk it over with your healthcare provider, check out the place of delivery and see if they would be able to respond in the event that an emergency were to come about (do they have 24 hour anesthesia that is available, do they have staff to monitor closely for signs of uterine rupture, will the physician stay at the hospital while you are in labor to be available if needed?). In the end, how would you feel about things? If you had a positive outcome and vaginal delivery, would you feel good? If you tried a VBAC and ended up with a repeat Cesarean would you be exhausted and feel frustrated you didn't have the cesarean to begin with? If you ended up with an adverse outcome, like having the uterus removed or the baby dying (even though it is very rare this would occur) would you look back and feel like you made the right decision and accept that outcome? Can you find a healthcare provider that is supportive of your decision? What truly is best for you, your baby, your family, and your situation? How does your husband feel about it? How does your family feel about your decision?
Additional resources to look at for more info: Please check out
National Library of Medicine www.nlm/nih/gov/medlineplus/healthtopics.html
The Mayo Clinic www.mayoclinic.com
American College of Nurse Midwives www.midwife.org (search for VBAC)
Macones, GA, Peipert, J. Nelson, DB, et al. (2005) Maternal complications with vaginal dbirth after cesarean: a multicentery study.
American Journal of Obstetrics and Gynecology, 193, 1655 American College of Obstetrics and Gynecology (ACOG) (2004) Bulletin #54: Vaginal birth after previous cesarean. Obstetrics and Gynecology, 104, 203.
Caughey, AB, Shipp TD, Repke, JT, ZElop, CM, Cohen, A. Lieberman, E., (1999) Rate of uterine rupture among trial of labor in women with one or two prior cesarean deliveries. American Journal of Obstetrics and Gynecology, 181, 4, 872-876.
Mozerkewish, EL, Hutton, EK. (2000). Elective repeat cesarean versus trial of labor: a meta-analysis of the literature from 1989 to 1999. American Journal of Obstetrics and Gynecology, 183, 1187.
Montgomery, AA, Emmett, CL, Fahey, T., et al. (2007). Two decision aids for mode of delivery among women with previous cesarean section: randomized controlled trial. BMJ, 334, 1305.