Vaginal Birth After Cesarean (VBAC)

Risks of VBAC and Cesarean Deliveries

Whether you deliver vaginally or by cesarean section, you are unlikely to have serious complications. Overall, a routine vaginal delivery is less risky than a routine cesarean, which is a major surgery. But pregnant women who have a cesarean scar on the uterus have a slight risk of the scar breaking open during labor. This is called uterine rupture.

Although rare, uterine rupture can be life-threatening for both mother and baby. So women with risk factors for uterine rupture should not attempt a vaginal birth after cesarean (VBAC).

Risks of VBAC

The risks of VBAC include:

• An unsuccessful trial of labor that ends with a cesarean delivery (most common complication). Up to 40% of women who attempt VBAC develop a problem that requires a cesarean delivery.¹ Stalled labor (called dystocia) or fetal distress are common examples of problems that require a cesarean. A cesarean after a trial of labor increases the risk of infection for both the mother and baby.¹
• A slight separation of an existing cesarean scar (called dehiscence). This usually causes no problems and in some cases is not even detected. The separation usually heals on its own.
• A slight risk of uterine rupture, which can be life-threatening for the mother and the baby. A uterine rupture is very rare yet very serious. If the rupture cannot be repaired quickly, removal of the uterus (hysterectomy) may be necessary to prevent severe blood loss.

The possibility of uterine rupture is influenced by the:

• Type of incision used for the previous cesarean. Scarring above the thinner, lower uterus is more likely to rupture. A low, side-to-side (transverse) incision is least likely to rupture. About 5 out of 1,000 women (0.5%) with one low, transverse incision scar have a uterine rupture during labor when the labor starts on its own without medicine.² It is likely that these women have other risk factors that raise their chances of having this complication.
• Number of surgical uterine scars a woman has, especially if the cervix is not softened and opening (dilating). The risk of rupture increases with each additional cesarean scar.
• Use of medicine to start (induce) labor. Among women who are otherwise good candidates for VBAC, the greatest risk factor for rupture is the use of misoprostol (Cytotec) to start (induce) or strengthen labor.^{2, 1} Aiding a slow labor (augmentation) with careful use of oxytocin (Pitocin) has rarely been linked to uterine rupture.⁶

Should I have a VBAC trial of labor after a previous cesarean?

Risks of any cesarean

The risks of any cesarean delivery include:

• Infection, which may develop in the incision.
• Blood clots (a risk with any surgery). This is rare but can be dangerous.
• Fetal injury during the delivery. The injury usually is not serious.
• Breathing problems (respiratory distress syndrome) for the baby after birth if the due date has been miscalculated and a cesarean is done before the fetus's lungs are fully developed.

To lower your risk of serious complications, arrange to deliver in a hospital that has the staff and facilities to handle an emergency cesarean delivery. A doctor must be immediately available to perform an emergency cesarean if one is needed.

Future risks. With each surgery on the uterus, more scar tissue forms. If you are planning on a pregnancy after this one, scarring is an important thing to think about. After you have two scars, each additional scar in the uterus raises the risk of placenta problems in a later pregnancy, such as placenta previa or placenta accreta. These problems raise not only the risks for a fetus but also your risk of needing a hysterectomy to stop bleeding.⁷

For more information about cesarean risks, see the topic Cesarean Section.

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Author:	Sandy Jocoy, RN	Last Updated: April 17, 2009
Medical Review:	Sarah Marshall, MD - Family Medicine Kirtly Jones, MD - Obstetrics and Gynecology
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