Once a caesarean, always a caesarean- Really? (Vaginal Birth after caesarean- VBAC)

Ladies, are you all under the assumption that you can't go back to a normal vaginal delivery once you have had a caesarean section? Do not fall for the age-old "once a caesarean, always a caesarean" tale. It's a myth. A trial of labor after cesarean (TOLAC) is a viable option for many women if there are no other medical contra-indications for the procedure and it can be really helpful in future if you are able to avoid surgery & deliver vaginally. Did you know that most published studies indicate that about 60% -80% of women who underwent a trial of labor after a previous cesarean were successful and delivered vaginally?

Having a vaginal birth after a caesarean section (VBAC) or a planned caesarean procedure in a future pregnancy is usually safe. Still, each option comes with its own set of risks and benefits. Let us guide you through its pros and cons:

Benefits of choosing a trial of labor after cesarean:

• Future pregnancies: Want to have more babies in the future? In that case, choosing VBAC will help you avoid the hazards of multiple cesarean deliveries, namely placenta previa or placenta accreta. Placenta previa is a serious complication in which the placenta grows in the lower portion of the uterus and covers all or some part of the cervix opening. Multiple C-sections increases your risk of placenta previa by 1.5 to 6 times compared to vaginal delivery. In placenta accreta, the placenta develops too far into the uterine wall.
• Shortened recovery time: Your hospital stay will be shortened considerably after a vaginal delivery. This will also help you to resume your normal day to day activities much sooner.
• Surgical complications are less likely: The chances of developing an infection, excessive bleeding, thromboembolism, anesthetic complications are lower with a vaginal delivery. VBAC may also reduce the chance of injury to abdominal organs like the bladder or bowel that may happen during a Caesarean section.
• Future deliveries: VBAC also improves your chances of having a natural birth in the future.
• In addition to the above-mentioned benefits, vaginally delivered newborns also have a lower chance of respiratory problems.

Risks of VBAC:

• Even if you think that you are fully prepared for VBAC, things can go out of hand in a matter of seconds. There's a chance you'll need an emergency caesarean section during labor, which carries higher risks of bleeding, injury to intestines/ urinary bladder or large blood vessels and infection as compared to a planned C-section.
• Your chances of surgical complications increase if you have an unplanned C-section after labor.
• There is less than 1% risk of suffering from a uterine rupture. This can lead to serious blood loss & risk of life for the mother and oxygen deprivation for the baby leading to serious complications or even mortality.

Before planning for VBAC, it is essential to determine if you are a good candidate for it. The success of VBAC depends on various factors such as a history of vaginal birth, previous successful VBAC, spontaneous labor onset, and absence of complications or risk factors during pregnancy.

Your chances of vaginal birth after caesarean are better if:

• You have a singleton pregnancy
• Baby is in cephalic ( ie head down) position
• Baby is average size, not macsrosmic
• You have a roomy pelvis proportionate to the size of the baby
• If labor contractions start by themselves & do not need to be induced
• You have had a vaginal delivery in any previous pregnancy
• Previous caesarean section was through a low transverse incision on the uterus and not a vertical or high incision
• You do not have any co-existing medical complications like diabetes, hypertension, heart disease etc
• The healthcare team at the hospital is well experienced & equipped to deal with TOLAC & VBAC

Chances of a successful VBAC decreases if you have any of the following:

• No history of prior vaginal birth
• Getting pregnant at an older age
• A body mass index (BMI) of 30 or higher
• A pregnancy that goes on for more than 40 weeks
• Complications during pregnancy
• A gap of 18 months or less between two consecutive pregnancies
• Being pregnant with triplets or more
• If your labor needs to be induced. If you've had a c-section, many of the cervical ripening treatments used to induce labor aren't safe.

Certain conditions make you an unfit candidate for VBAC.

They are as follows:

• History of uterine rupture
• Three or more caesarean deliveries in the past
• Having a high / vertical incision on the uterus in previous caesarean section or other surgeries
• History of certain uterine surgeries such as fibroid removal
• Having a contracted pelvis
• Good size baby with expected weight ≥4 kg
• Baby in a breech or transverse lie
• Placenta praevia

How can you prepare for VBAC?

If you are pregnant and want to have a normal vaginal delivery this time after having a C-section the last time, it is best to start discussing your options with your doctor in early pregnancy. Provide your doctor with all necessary medical history which will help them to guide you better. Your medical history will be used by your health care practitioner to determine the possibility of a successful VBAC. Discuss in detail with your doctor & healthcare team to prepare a comprehensive birth plan for managing the labor and be clear about the possibility of the need for a caesarean section if a medical emergency arises.

• Apart from this, it is important to keep yourself motivated & determined to handle the labor pains while trying for VBAC.
• Your physical & mental fitness is also essential to be able to bear the stress of labor. So join some antenatal classes and be regular with your exercise regime to ensure physical fitness. Also practice some breathing exercises & relaxation techniques that will help you bear the labor pains.
• Focus on consuming a well balanced diet and avoid excessive weight gain during the pregnancy.
• Be regular with your antenatal visits so that your pregnancy can be closely supervised and any signs of complications can be identified & handled promptly.
• Remember that a VBAC & TOLAC requires very close monitoring of the mother & baby during labor in order to ensure their wellbeing and identify any early signs of complications or impending rupture of the uterus. This includes regular monitoring of the mother’s BP, Pulse rate, O2 saturation, temperature, clinical examination by experienced obstetricians, continuous heart rate monitoring of the baby and the facility for Emergency caesarean section anytime of the day or night whenever needed during labor. Apart from an experienced obstetrician, this also requires the presence of a paediatrician, anaesthetist & Operation theatre availability round the clock.

Many hospitals do not provide facilities for VBAC due to a shortage of resources or experienced manpower. Therefore, make sure to choose a hospital in advance that is equipped to handle the necessary care required for VBAC & an emergency C-section.

To summarize, the decision for a TOLAC or VBAC in a pregnancy after caesarean section is highly individualized and one needs to consider the balance between the risks & benefits along with the possibility of success in an individual case. So weigh all your options carefully and discuss with your doctor to decide whether or not it is feasible in your case and if yes, then assess whether you are prepared to undergo the process of trial or not. In the end, the aim of every pregnancy & delivery is to ensure the birth of a healthy baby with a healthy mother, so choose your options wisely and prepare accordingly.