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VBAC

While the large majority of repeat pregnancies where the prior pregnancy resulted in a cesarean section use the same method of delivery, it has become more common for mothers to attempt a trial of labor after a caesarian section (TOLAC) with the hope of accomplishing a vaginal birth. This is known as vaginal birth after caesarian, or VBAC. Optimal candidates for VBAC include women who have undergone one prior cesarean section that was performed using a transverse lower segment incision and who have been admitted to a hospital that is capable of monitoring labor while providing personnel who are available to perform an emergency cesarean section if necessary.  Women with preeclampsia or gestational diabetes, and women who are carrying twins or macrosomic babies (large babies over 8 pounds, 13 ounces), are not recommended for VBAC procedures.

While 60-80% of VBAC trials are successful these deliveries tend to have a greater risk for complications than an elective repeat cesarean section.  In particular, VBAC confers a higher risk mainly due to uterine rupture and perinatal death of the child.

Uterine rupture after VBAC may result in terrible consequences for a child. One such consequence is hypoxic-ischemic injury, which is associated with severe neonatal problems including seizures, trouble with feeding, poor muscle tone, respiratory distress, intracranial hemorrhages, and death. Long-term neonatal outcomes vary, depending on the physician’s response time to perform an immediate caesarian section.

Hypoxic-ischemic injury is often the result of a complete uterine rupture. Partial ruptures, in contrast, may or may not lead to a hypoxic-ischemic injury.  Unfortunately ruptures may be masked by epidurals.  Statistics show that only 26% of mothers experience pain with partial uterine ruptures.  In such situations, the fetal monitor may be the only evidence that a rupture is occurring, requiring that physicians and hospital staff stay vigilant in these cases.

Labor inductions or augmentations are also of particular risk in mothers who are attempting a VBAC. Uterine rupture due to VBAC alone occurs in 1 out of 100 trials of labor (1%). However, the use of Pitocin during VBAC introduces an increased risk of uterine rupture.

One other major risk factor associated with VBAC impacts mothers who carry macrosomic babies. These mothers are at risk for prolonged rupture of membranes and extended first and second stages of labor, which subsequently increase the chance of a uterine rupture.

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