Safety of Vaginal Delivery After Cesarean Section

Q:  I keep hearing different information on whether it is safe for a woman to have a vaginal delivery after a cesarean section. For sometime, I thought that this was the recommendation of most physicians. Yet new reports suggest that it may not be such a good idea after all. What’s the safest alternative?

A:  The overall cesarean section rate in the U.S. ranges from 18-24% depending on the hospital setting with the highest rates in community hospitals and the lowest rates in academic medical centers. Although a generally safe procedure, C-sections are not without complications for moms and babies and almost always lead to a longer hospital stay and a slower recovery. Consequently, vaginal birth after c-section (VBAC) seemed a potentially healthy and more economical course to pursue. This was in contrast to the previous adage of once a c-section, always a c-section.

Complications that may occur during a VBAC include; uterine rupture, injury to the urinary tract, a need for blood transfusion, and maternal complications including coma and death.

The most recent study focused on the likelihood of uterine rupture and found that rates of this complication varied from 1.6/1000 to 24.5/1000 births. Those at the highest risk were women for whom labor was induced with prostaglandins while risk levels of 5.2/1000 and 7.7/1000 occurred for women with a spontaneous onset of labor and those induced without prostaglandins.

The relatively high level of rupture associated with the risk of prostaglandins is of significant concern and I would suspect is enough for some physicians to reconsider their actions. The rest of the information needs to be factored in by the physician and patient in the process of determining the safest alternative following a previous c-section.

One should also keep in mind that the United States has one of the higher c-section rates in the western world and yet ranks about 15th in perinatal child mortality statistics which seems to imply that our c-section rate does not translate into healthier babies. In a larger context, we ought to be doing all we can to strive for a vaginal delivery at the time of the first pregnancy, making the question of a VBAC less of an issue.

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