By Dr. Marlene Lidkea previously published in Birth Issues Winter 2010

Why is this an issue?

Not everyone who had a cesarean section with the first pregnancy needs a section with the subsequent pregnancies. Not everyone who would like to have a vaginal birth after cesarean section feels that the “medical establishment” supports her. There is criticism by some members of the public that the “medical establishment” is not doing enough to prevent cesarean sections in the first place.

Prevention, prevention, and prevention

Prevention is the first step in decreasing the controversy around the vaginal birth after a cesearean (VBAC) issue. Many cesareans are being done that arguably may not be necessary. If you have been told that you need a cesearean, how can you be sure that it is necessary? For example, for years we (doctors) have been told that if your baby is in a breech position, the only option is to offer you a cesarean section. The 2006 Premoda study1has shown us that this is not true. The Society of Obstetricians and Gynecologists revised their clinical practice guidelines in June 2009 to reflect this information and encourage doctors to offer patients the option of a vaginal birth.2 If your physician suggests a cesaream section ask him or her if there are any other options. Also do your own research and ask questions.

How did this become a problem?

There are many contributing factors. Physicians base many of their decision about care on the degree of risk of a bad outcome. Particulars about a woman and her pregnancy that increase this risk level make physicians and mothers nervous. No one wants a bad outcome. Some doctors and mothers look at a cesarean section as the solution to increased risk. Unfortunately a cesarean section is not without its own risk levels – including the risk it puts on further pregnancies. Subsequent babies are more likely to die or experience damage due to miscarriage, placenta previa, abruption placenta and uterine scar rupture simply because the previous pregnancy ended in a cesarean section.3

When is it not regarded as safe?

Not everyone should attempt VBAC. Some contraindications to VBAC are – placenta previa (placenta covering the cervix), footling breech (one or two feet coming into the vagina before the buttock), transverse lie (baby lying sideways), and classical scar (up and down incision on the uterus). These are outlined in the updated SOGC guidelines.4

Who is a good candidate?

If you do not have one of the above conditions you may be a candidate for VBAC. But that is not the only determinant. You also need to be educated about the risks and benefits. You especially need to be motivated and have good support. You are most likely to be successful if you have had a previous labour, you go into labour spontaneously (not induced) and you have an otherwise low risk pregnancy.

What will interfere with success?

Everything that can complicate a first labour or birth may complicate a second labour or birth. Check out the “decision tool” developed in the United States for women to help them understand risk and make an informed choice for their birth. Remember educate yourself and get lots of support. There are many doctors who support you in your choice of having a vaginal birth after a cesarean. Look for us.

Dr. Lidkea was a family physician is St. Albert, Alberta, who always loved attending births. She encouraged natural births when ever the patient wished. She practiced according to “Centering Model of Care” which offered a fun, interactive holistic approach to pregnancy care. She passed away suddenly and the Edmonton area community greatly misses her.

Editorial notes:

1. Goffinet F, Carayol M, Foidart JM, Alexander S, Uzan S, Subtil D, et al. “PREMODA Study Group. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium.” American Journal of Obstetrics and Gynecology 194 (2006): 1002–1011.

2. Kotaska A, Menticoglou S, Gagnon R. “Vaginal delivery of breech presentation. SOGC Clinical Practice Guideline. No. 226, June 2009.” Journal of Obstetrics and Gynaecology Canada. Vol 31, no 6 (2009): 557–566.

3. Galyean AM, Lagrew DC, Bush MC, Kurtzman JT. “Previous cesarean section and the risk of postpartum maternal complications and adverse neonatal outcomes in future pregnancies.” Journal of Perinatology. Vol 29, no 11 (2009): 726-730.

4. SOGC. “Guidelines for vaginal birth after previous caesarean birth. SOGC clinical practice guidelines.” International Journal of Gynaecology and Obstetrics. Vol 89, no 3 (2005): 319-331.

5. Trial of labour after cesarean form. TOLAC. Copyright, 2005, American Academy of Family Physicians.