Tips & Tools: VBAC or Repeat C-Section

How should I move forward after deciding to plan either a VBAC or a repeat c-section?

If your birth plan is for VBAC, there are no guarantees that you will avoid another cesarean. However, you can take steps to increase your chances for having a safe and satisfying vaginal birth. Most of these steps are strongly supported by good research. Advance preparation in pregnancy can make all the difference. Careful choice of a doctor or midwife and birth setting that support and encourage VBAC and a trained or experienced companion who will be available to provide continuous labor support may be the most important things you can do. The Q&As that follow give detailed guidance about these and other tips to include in your pregnancy and birth plans.

While overall risks favor vaginal birth, you may have a repeat cesarean delivery for various reasons. There may be special considerations in your individual case, or some risks may be especially important to you and override others. Or your options may be limited by what is available in your community or through your health plan. Finally, no one can know what labor may bring. For these reasons, this section concludes with tips for having a safer and more satisfying cesarean birth.

WHEN PLANNING VBAC, what are some tips that can help avoid problems with the scar in my uterus in labor?

• Wait at least 9 months before trying to conceive again: While the difference is small (1 more woman in every 100), research suggests that you are less likely to have a problem with the scar opening in labor with a birth-to-birth interval of 18 months or more compared with a shorter time period.
• Avoid induction of labor, whenever possible: Experts disagree about some common reasons given for induction (for example, the pregnancy has gone beyond 41 weeks), and others are not supported by research (for example, induction for suspected big baby). Some inductions may be recommended for non-medical reasons, such as your convenience or that of your caregivers. Because induction agents may increase risk of scar rupture and do increase the likelihood that the labor will end with a c-section, it is best to limit induction to situations where there is a clear, compelling, and well-supported reason. Should the question of induction arise, discuss the trade-offs with your caregiver of awaiting labor, having the induction, or scheduling a c-section. In many cases, awaiting labor is the safest option. (See making informed decisions for tips on how to discuss your options with your caregivers.)
• If you are having labor induction, avoid cervical ripening agents: Available research on the role of cervical ripening agents is hard to interpret but suggests caution. Dinoprostone, also called prostaglandin E2, the agent found in Prepidil and Cervidil, may increase the likelihood of scar rupture, especially in combination with synthetic oxytocin (Pitocin or "Pit"). Misoprostol, also called prostaglandin E1, the agent found in Cytotec, may increase the chance of scar rupture. Please note: although a recent independent review concluded that evidence about impact of labor induction on VBAC labors is unclear at this time, the manufacturer of Cytotec includes a warning on the official Food and Drug Administration (FDA) "label" that use of this product for induction increases risk for uterine rupture, which is higher for women with a previous cesarean (see references for Searle and Guise, McDonagh and colleagues).
• Avoid use of synthetic oxytocin (Pitocin or "Pit") early in labor: Available research suggests caution about synthetic oxytocin in early labor. However, synthetic oxytocin given once labor is well underway doesn't seem to cause a problem. This may be because more forceful contractions over a longer period are needed to get labor going than to help it along once it is in progress.

Are there some practices used in VBAC labors that I might want to avoid?

• internal monitoring of contraction pressures (as opposed to internal monitoring of the baby's heart rate): The theory is that should the scar give way, internal contraction monitoring will pick up a drop in contraction pressure, but studies have not found this to be the case. Meanwhile, internal monitoring increases the risk of uterine infection and limits mobility.
• prohibition of eating and drinking in labor: The fear is that in the event of general anesthesia, the woman may risk serious infection by vomiting and inhaling the vomit into her lungs. But cesareans are rarely performed under general anesthesia. When general anesthesia is used, a tube is inserted to protect the airway. If hospital staff are unwilling to permit solid food, a compromise is frequent sips of clear fluids, which are rapidly absorbed into the bloodstream.
• routine intravenous (IV) drip: If the hospital will not agree to forgo an IV line, a good compromise is a heparin or saline lock. The IV needle is inserted with a short piece of attached tubing, and heparin or saline keep the needle from clogging. In an emergency, an IV bag can be connected immediately.
• routine internal examination of the uterine scar after vaginal birth: This is extremely painful for a woman who doesn't have an epidural, it could introduce infection, and it could convert a small, harmless gap in the scar into a problem.

If my goal is VBAC, how can I increase the likelihood of giving birth vaginally?

• Choose a doctor or midwife who favors VBAC: Unfortunately, with changing cultural views of c-section, VBAC and vaginal birth, and fears of legal claims and lawsuits, caregivers who offer you the option of VBAC are becoming more difficult to find. Discuss your goals and preferences with potential caregivers, and find out how they will work with you to meet your objectives. If their response does not satisfy you, and you have other options, seek a better match.
  
  A pro-VBAC caregiver:
  • believes that women should labor unless there is a new reason for cesarean or a compelling reason not to labor. Even in these cases, the caregiver respects a woman's right to make the ultimate decision.
  • does not have policies that discourage VBAC but are not supported by sound research. Examples of unnecessary barriers would be caregivers who refuse VBAC for women thought to be having a big baby, for women with "gestational diabetes," or when the pregnancy goes past 40 weeks. (To learn more about what such policies might be, see Options: VBAC or Repeat C-Section.)
  • has a VBAC rate (proportion having a vaginal birth among those who plan VBAC) of 70% or more. Dozens of studies involving tens of thousands of women have shown that a VBAC rate this high or higher is an achievable goal.
• Hire a doula (trained labor support specialist): Because your prior labor ended in a cesarean (or if you haven't experienced labor), and there is growing bias against VBAC, you and your partner may feel heightened anxiety and doubts during a VBAC labor. The continuous presence of a trained, experienced woman can help you deal with this. She will know ways to help you relax, ease pain, and promote progress.
• Work with your caregivers to delay hospital admission until your cervix is beginning to open: Women who are admitted to the hospital before their uterine contractions are well-established are less likely to have VBAC.
• Avoid labor induction procedures, when possible: when caregivers use drugs or other techniques to try to start labor artificially, a woman's risk for c-section goes up
• Commit yourself to vaginal birth: If you ask for a cesarean in a weak moment, your request is likely to be granted.
• Avoid epidural and spinal analgesia: Although these generally provide excellent pain relief, they have many drawbacks. One in particular is important to VBAC labors: a common side effect is slowing of the baby's heart rate. As a drop in the fetal heart rate is also the most reliable symptom that the uterine scar has given way and is causing problems, this side effect could lead your caregivers to push for an urgent c-section. If you wish to avoid this "regional" analgesia, be sure to learn about the wide variety of comfort measures and other strategies, including continuous labor support, that can help you cope effectively with labor pain. (See Options: Labor Pain for more information on epidurals and other methods of coping with labor pain.)
  
  One factor that need not enter into the epidural decision is the concern that having an epidural could mask the pain of the scar giving way. Pain has not been shown to be a reliable symptom. Experts agree that women should not be denied an epidural for this reason.

What are some tips I can use to reduce my risk of having an unnecessary repeat cesarean?

• If a c-section is proposed and you're not in an emergency situation: Ask about (1) why it's being recommended, (2) the benefits and risks of surgery, (3) other possible solutions to the problem, including just waiting longer, and (4) the benefits and risks of those. If you aren't in labor at the time the issue arises, you should have time to do your own research and talk things over with your partner and caregivers before making a decision. (See making informed decisions for more information on this topic and Options: VBAC or Repeat C-Section for information on reasons that may given for a c-section.)
• If your baby is in a buttocks- or feet-first position (breech): Very few caregivers will agree to vaginal birth with a breech baby. Ask your caregiver about having an external cephalic version (a doctor turns the baby to a head-first position by manipulating your belly) if your baby is still breech when you reach "term" (about the 37th week of pregnancy). You may need to search to find a caregiver who has skills and experience with this technique. We do not have much research on external version in women with prior cesareans, but what little we have has not found extra problems. See more on breech position and external version on the Cesarean Section page in Resources A-Z.

What if I have unresolved emotional issues?

Consider, too, what you will need during this birth to feel safe and well-cared for. If you were dissatisfied with your previous care, you will want to pinpoint the sources of your dissatisfaction and plan to do things differently this time.

What if I can't find a hospital and caregiver who will support my wish for VBAC?

It may be possible in some communities to find a practitioner willing to take on a VBAC client who wishes to give birth outside of the hospital at home or in a birth center. You should know, however, that while many birth center and home birth practitioners have had good success with helping women who plan VBAC achieve vaginal birth, a national study of VBAC in birth centers concluded that risks of laboring with a scarred uterus warrant hospital care.

WHEN HAVING A REPEAT C-SECTION, what are some tips for having a safer delivery?

• Schedule the c-section after the 38th week of pregnancy if there is no urgent reason to deliver the baby sooner: Babies born before the 39th week of pregnancy are more likely to have breathing problems.
• Use epidural or spinal anesthesia: Regional anesthesia (you are numbed from your ribs down) is safer for you and your baby than general anesthesia (being "put to sleep").
• Request antibiotics at the time of the cesarean: Antibiotics reduce the chance of infection. You do not need them afterwards unless you develop an infection.
• Ask for your uterus to be closed in two layers of stitching (double-layer uterine suturing): In recent years, many doctors have begun closing the uterus with one layer of stitches instead of two. Some studies suggest that this may lead to the scar giving way more often during a future labor. Research that established that there was a very low likelihood of the scar opening during labor was done when double-layer stitching was the norm. Until this controversy is resolved, it may be wise to request the older technique.
• Request care after the surgery to reduce the chance of blood clots: Depending on how likely you are to have this problem, preventive care may include getting you up and walking soon after the operation, having you wear elastic support stockings, or giving you medication for this purpose.

What are some tips for having a satisfying cesarean birth experience?

Some of these options may be readily available; others may require some effort on your part. Still others may not be available at all. In that case, you will have to decide whether they are important enough to you to seek care elsewhere. You may wish to choose a doctor and/or hospital based on your preferences.

• Participate fully in decisions about the birth: The difficulty or ease of the birth and whether the baby was born vaginally or by cesarean have little to do with how women feel about the birth. Women are most likely to feel satisfied with their births when they feel a sense of accomplishment and personal control and when they have a good relationship with caregivers. A good relationship includes such elements as being treated with kindness and respect, getting good information, and having the opportunity to participate in decisions about care.
• Have an epidural or spinal anesthesia (regional anesthesia): Epidural or spinal anesthesia allows you to be awake and aware to greet your baby and to hold and breastfeed your baby in the recovery area.
• Have the bladder catheter inserted after the epidural or spinal is administered: Then you will be numb for this somewhat uncomfortable procedure.
• Keep your partner and any labor companions with you throughout: You can benefit from the support of your partner and any other labor companions during what may be an anxious and stressful time. This is particularly true during preparation for surgery and administration of the epidural or spinal anesthesia, which many women find more stressful than the surgery itself. Your partner and support team will also have the opportunity to share in moment of birth and to greet the baby.
• Keep your baby with you after the birth, in skin-to-skin contact: Unless your baby has problems at the birth that require care in the nursery — and few babies do — there is no reason not to keep your baby with you so that you and your partner can enjoy and begin to get to know your baby, and you and your baby can get breastfeeding off to a good start. Skin-to-skin contact can contribute to breastfeeding success and your early relationship.
• Work with your caregivers to carry out your preferences: For example, you may wish to:
  • videotape the birth or the time just after the birth
  • play the music of your choice
  • not have your arms strapped down
  • have the drape that screens your view of the surgery placed low enough that the baby can be laid on your chest; if your arms are free, you can hold and touch your baby.
  • have a doctor or nurse explain what is happening throughout
  • have the drape lowered or have a mirror at the time of the delivery (your belly will be covered so you will see your baby lifted out of an opening in the sheet)
  • announce or have your partner announce the sex of the baby or be the first to speak to the baby (versus a member of the care team doing these things)
  • take the placenta home (some people bury the placenta and plant a tree or bush over the site; if of interest, bring a sealable container to contain the blood and ease the staff in this time of HIV/AIDS)
• Have a narcotic (opioid) medication injected into the epidural tube at the end of the operation: This provides sufficient pain relief for you to feel comfortable enough to hold and breastfeed your baby in the first hours after the surgery.
• Have your baby and your labor companions with you in the recovery area: Holding and breastfeeding your baby soon after delivery helps both you and your baby get started on the right foot and may avoid problems with breastfeeding.
• Have your partner able to be with your baby in the nursery: This includes the newborn intensive care nursery. If your baby must be separated from you because of concerns about the baby's health, it will be comforting to know that your partner can provide a reassuring presence and can bring you word of your baby's condition.
• Control your pain medication: A new alternative is patient-controlled analgesia (PCA). With this technique, you can give yourself a small dose of medication through the intravenous (IV) line when you need it by pushing a button. A lockout mechanism keeps you from going beyond a preset dose. Since narcotics can make you feel sleepy and nauseous, you may wish to combine narcotic with non-narcotic pain medications. This can reduce or even eliminate your need for narcotics.
• Begin drinking and eating again when you feel ready: Access to food and drink when you feel ready will help you feel more normal and can avoid hunger and thirst.
• Get help with breastfeeding: Breastfeeding can be more difficult right after surgery and while your incision is healing. A knowledgeable person can help you find ways to be more comfortable during breastfeeding sessions. Your partner or others can help with switching sides, burping, and diaper changing.
• Get plenty of help at home: You will be recovering from major surgery with all that entails in terms of how you may feel, as well as restrictions on lifting and driving. At the same time, unlike the usual experience of recovering surgical patients, you will have the demands of caring for a newborn and one or more older children. The VBAC or Repeat C-Section Resources page can lead you to detailed help with cesarean recovery.