- ATHENS OFFICE MED4WOMAN ATHENS
- VOLOS OFFICE MED4WOMAN VOLOS
Obstetrician-Gynecologist
PhD, University of Athens Medical School
Obstetrician-gynecologist Panagiotis Polyzos practices at the Institute of Life, the IVF Unit of IASO Maternity Hospital.
Vaginal birth after cesarean delivery (VBAC) is becoming increasingly common. The long-held belief “once a cesarean, always a cesarean” no longer applies today. This viewpoint originated from a time when the uterine incision during cesarean delivery was typically made vertically. Since the early 1970s, with the routine use of a lower transverse uterine incision, the risk of uterine rupture has been minimized (less than 0.5%).
In most developed countries, a previous cesarean delivery is not an absolute indication for a repeat cesarean in the next pregnancy. The alternative option is VBAC (vaginal birth after cesarean).
Many women who initially desired a vaginal delivery but ultimately required a cesarean wish to give birth vaginally to their second baby. However, certain criteria must be met for a VBAC to be considered safe. Most women with one prior cesarean and no additional risk factors are candidates for VBAC. A planned vaginal birth after a previous cesarean has a success rate of 60–80%, which is fully comparable to the success rate of vaginal deliveries in first-time mothers. If a woman has had a previous vaginal delivery before the cesarean, the success rate rises to 87–90%.
The main advantages and benefits of a vaginal birth after cesarean section are that the mother recovers faster, her hospital stay is shorter, and she avoids infections, injuries (to the bowel, bladder, etc.), blood loss, blood clots and postoperative complications. The mother takes a more active role in caring for the newborn in its first hours of life. Finally, it keeps the door open to more future pregnancies, because multiple cesarean sections carry risks related to the strength of the uterus, injury to neighboring organs (bowel and bladder), and the position and attachment of the placenta (risk of placenta previa and/or placenta accreta). There are certainly benefits for the baby too, such as avoiding iatrogenic prematurity and fewer cases of persistent pulmonary hypertension. Vaginal birth always prepares the baby for life outside the womb.
Certain requirements must be defined to ensure the successful outcome of a vaginal birth. Some of the basic prerequisites include selecting an obstetrician who has experience with similar cases, ensuring that the maternity hospital and delivery room are fully equipped, and confirming that there is the capability for an immediate cesarean section if and when needed.
Additionally, from the early stages of pregnancy through to the last month, weekly fetal ultrasound scans (including Doppler) are required, and from week 32 of pregnancy onwards the fetus should be checked regularly with cardiotocography (NST), while labor is induced only when there is a clear indication and with caution, preferring mechanical methods (a balloon catheter) to prostaglandins, because the latter increase the risk of uterine rupture. During labor, continuous cardiotocographic monitoring is used, as it is the most reliable way to recognize a rupture early.
It is very important to know the exact reason for the previous cesarean section. If the previous cesarean was due to fetal malposition or breech presentation, the woman may attempt a vaginal birth with a high likelihood of success. The same applies when the reason for the cesarean section was fetal heart rate abnormalities due to umbilical cord compression. There are, of course, contraindications, mainly related to the type of the uterine incision, which must definitely be a low transverse incision. Any other type of uterine incision, a previous uterine rupture, or a previous myomectomy involving entry into the uterine cavity are significant contraindications. Also, at least one year must have passed since the last cesarean delivery so that the probability of a successful vaginal birth is not reduced. The labor must be planned around the 38th week of pregnancy. Epidural anesthesia significantly assists the entire process because it allows the woman to relax and also facilitates cervical dilation.
Attempting a vaginal birth after cesarean (VBAC) is not unrealistic. If the above requirements are met, the probability of a successful vaginal delivery is around 60%. The main reason is the exceptionally strong feeling of satisfaction and accomplishment associated with achieving a vaginal birth after a cesarean section. The woman feels she has achieved what she originally wanted when she first became pregnant. It allows her to feel optimistic that future births may also be vaginal. Finally, it enables the husband to participate actively in the vaginal birth process alongside his partner and their doctor, something that strengthens the couple’s and the family’s sense of fulfillment.
After one cesarean section, you have two safe options: a trial of labor or a planned repeat cesarean. Neither is free of risk. The decision is yours, once you are well informed.
If you plan to have more children, this last factor carries particular weight in the decision.
The chances of a vaginal birth after cesarean are not the same for everyone. Some factors improve them significantly:
Other factors lower the chances, without ruling out a trial of labor:
The estimated weight comes from the third-trimester ultrasound, as described on the page about obstetric ultrasound, with a margin of error that must be taken into account.
Uterine rupture is rare, but serious. That’s why a VBAC labor is carried out with continuous cardiotocographic monitoring. The first and most common sign is usually a change in the baby's heart rate. Other signs looked for are:
An epidural does not “mask” a rupture, as was once believed, because the key sign is the cardiotocograph. When a rupture is suspected, an immediate cesarean follows. That’s why a VBAC is attempted only in a maternity hospital with an operating room, an anesthesiologist and a blood bank available around the clock.
Labor starting on its own gives the best chances for a VBAC. If you reach your due date without contractions, the options are discussed again:
Bring the discharge summary or surgical notes from your previous cesarean to your first appointment. It is the most useful document for planning your next birth.
After a successful vaginal birth, recovery is like that of any vaginal birth. Most women get up and walk within a few hours, care for the baby without restrictions and go home sooner than after a cesarean. Breastfeeding usually gets off to an easier start, because there is no postoperative abdominal pain.
The scar from the previous cesarean needs no special care. However, if you develop a fever, severe abdominal pain or bleeding that increases over the following days, contact your doctor. A successful VBAC significantly increases the chances of a vaginal birth in future pregnancies as well.
The answers to these questions turn a general discussion into a personalized plan you can trust on the day of the birth.
About 60 to 80% of women who try give birth vaginally. The chances are higher if you have had a previous vaginal birth.
With one previous low transverse incision, about 0.5 to 1%. That’s why the birth takes place in a maternity hospital where an immediate cesarean is possible.
Ideally at least 18 months between the two births.
Yes, epidural pain relief can be used as usual.
In selected cases and after a detailed discussion, since the risk is slightly higher.
It is not recommended. If the uterus ruptures, a cesarean is needed within minutes, which is only possible in a maternity hospital with an operating room and an anesthesiologist on standby.
The discussion ideally starts in the first half of pregnancy, and the final decision is usually made around week 36, when the baby's position and estimated weight are known. You can change your mind right up until labor starts.
Mild discomfort or twinges around the scar are common as the belly stretches. Severe or persistent pain, especially with contractions or bleeding, needs immediate assessment, like any abdominal pain during pregnancy that does not go away.
