VBAC: natural delivery after having a cesarean

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Philippe Gloaguen
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Natural childbirth after a cesarean

Generally we use a new cesarean section (CT) after a precedent mainly due to an assumed risk of rupture of the uterus due to a dissection of the scar, which is very rare. The previous caesarean section therefore does not seem to represent in itself an adequate indication for a new CT, nor does it prohibit the possibility of having a natural birth. US studies indicate that in women with a previous CT scan it is recommended to carry out the so-called trial labor since in over 50% of cases, delivery takes place successfully vaginally. It defines itself trial labor verifying the possibility of vaginal delivery in a woman who has previously undergone a CT scan. We talk about VBAC (vaginal birth after cesarean), natural birth after caesarean. Let's see under what circumstances it is indicated and how it works.





All pregnant women with a previous CT can face the labor in the following birth, except for those few who have to do the caesarean regardless, or those who have had previous surgical interventions on the uterus, such as removal of fibroids (metroplastic or myomectomies) of the muscular wall (called intramural) or of the sub-mucosal area important in terms of the extent of the uterine scar.

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Llabor assistance women who have had a previous transverse incision of the lower uterine segment (the one that is now most commonly practiced in caesareans) should not differ from that given to any spontaneous labor. The hospital resources needed to follow a trial labor after CT are the same that should be available to all women in labor, regardless of their previous obstetric history. Any obstetric ward able to intervene on complications, such as placenta previa, placental abruption, cord prolapse, or acute fetal distress should be able to manage trial labor after CT with equal confidence.



Natural childbirth after a caesarean, risks

First let's talk about the risks of caesarean section.

The risks for women are related to the surgical technique and the use ofanesthesia and they can cause a more or less serious morbid state up, in rare cases, to death. They are in order of frequency:

  • endometritis (infection of the uterine tissue), puerperium febrile complications, urinary tract infections, laparotomic wound infections, paralytic ileus, pulmonary embolism, deep vein thrombosis, damage to ureters, bladder and bowel, peripheral anesthesia risks, complications in intubation.
  • Additionally, increased risks of developing have been reported in women undergoing CT previous placenta in subsequent pregnancies and their fertility undergoes a reduction. The risk of maternal mortality in CT is two to seven times higher than the risk in spontaneous birth

I risks for the child They include

  • neonatal respiratory distress due to the possible aspiration of amniotic fluid by the newborn who does not undergo the normal chest compression that occurs during the passage into the birth canal) and therefore an altered reabsorption of alveolar fluid, with the risk of pulmonary hypertension that can occur in the newborn;
  • iatrogenic prematurity (due to medical interventions) or linked to a too early and decided transition by doctors to extrauterine life (timing of birth) with respect to the risks related to it including hyaline membrane disease or RDS (respiratory stress syndrome linked to lack of production of the surfactant factor produced by the fetus only in the last weeks before delivery);
  • neonatal depression resulting from pharmacological substances used for anesthesia; obstetric trauma resulting from the extraction of the child, greater difficulty in extrauterine adaptation.

According to the ISTAT data of 2002, in the country the 67,7% of all the women had a spontaneous birth and 29,8% a CT, a much too high percentage. CT is in fact an intervention deemed appropriate only in particular clinical conditions that do not involve the motivation of a previous intervention: the maximum quota according to the indications of the WHO (World Health Organization) should not exceed the 10-15% of all parts. When labor begins spontaneously in the second pregnancy of women with a previous CT, according to research about 70% of women in labor will be able to give birth vaginally; this percentage increases up to 90% if the first CT scan was performed at a cervical dilation greater than 7 cm. There complication of uterus rupture it concerns a percentage that varies between 0,09% and 0,02% of cases. Therefore a systematic intervention on all women is not justifiable.

If it is necessary to induce labor, research indicates that judicious use of prostaglandins it is compatible with a good maternal-neonatal outcome. The management of labor is identical to that of a non-pre-caesarized parturient, except for the following aspects: monitoring of the child throughout labor is recommended; the Kristeller maneuver is contraindicated.

Since research indicates a desirable trial labor, it is important to inform the woman about the benefits of spontaneous birth and to support her in labor. The birth preparation courses represent a protective factor with respect to the possibility of having a caesarean section, probably because the women who take part in them are already a selected group that is characterized by a greater orientation towards demedicalization, but also because they increase the skills of the women to participate in the decisions to be made at the time of childbirth (women empowerment).

L'midwife can offer you the opportunity to access correct information, supported by scientific research about the real risks and benefits of surgery, which allow you to face conscious choices, free from affected influences. If you have already had a cesarean and are going to your midwife for a second birth, you want a figure who gives you ongoing assistance, trust and the opportunity to share your concerns and doubts with her. Maybe you also hope to suffer less or no kind of intervention. You feel that if an additional caesarean is needed, it will happen out of real necessity, not because of excessive intervention. You want to be given the maximum opportunity. The midwife takes into account the rationale behind your decision; the degree of associated risk; local assistance protocols and any degree of challenge; of one's attitude towards spontaneous vaginal birth.

Natural childbirth after caesarean, testimonies

Su forum we can find many stories of women who have decided to give birth spontaneously after a caesarean. From these experiences  we can draw some tips.

What can you do

  • you can prepare for a spontaneous birth
  • you can elaborate on your previous experience of a caesarean, by talking to a midwife or other professional and with other women who have elaborated their experience
  • you can understand your specific needs and prepare resources to address them
  • you can find out about hospital procedures and choose a place for your birth where VBAC is practiced
  • you can choose the support people who will accompany you in your childbirth experience
  • you can talk to your baby and try to connect with him
Read also: How to avoid caesarean delivery

What your partner can do

The support of the partner both in the choice to face the experience of labor and spontaneous birth after a previous CT scan, and during the various stages of labor, is a very important element. The possibility of the partner's presence at the time of labor and delivery is underlined both by the WHO guidelines. Birth recommendations drafted by WHO in 1985 support the importance of psychological support for women at the time of childbirth and speak of free access by a trusted person in the delivery room as a determining factor for the reduction of negative outcomes.

What are the questions to ask

  • Could an arbitrary CT scan pose any risk to me and the baby?
  • What happens when a baby is not given the opportunity to experience labor?
  • Are there any differences between babies born from spontaneous birth and those born from CT? If yes, what are they?
  • Can all women with previous CT be able to try to labor, or is a selection still made?
  • What are the specific risks in my case if I give birth spontaneously?
  • What are the attentions to keep?
  • Can I choose the type of anesthesia?
  • Can I keep my baby with me right away, just born?
  • Can my husband see the baby right away and hold him?
  • Can you expect to cut the cord to the end of the pulse?

What are your rights

  • You have the right to give or deny consent to a repeat cesarean and to choose the place for your birth.
  • You are entitled to receive your baby immediately in case of epidural anesthesia.

Natural childbirth after a cesarean how much time must pass

Many women wonder after how long can they do a Vbac. Well recent studies show that already after 12 months from cesarean delivery, the probability of serious complications with a natural birth is 4,8%, a figure that drops down to 0,2% after 3 years. This means, of course, that more time passes between a previous cesarean and the next vaginal delivery the lower the risk rupture of the uterus or other problems, but also that after 24 months the percentage of ischium is comparable to that of a healthy uterus.

Natural childbirth after an emergency caesarean section

Can the second child be given birth after an emergency first caesarean section? The advice is always to rely on your own gynecologist of trust that he will know well the reasons for which urgent action was needed the first time and what are the possible risks to be encountered. Even if she will invite you to abandon the idea of ​​a natural birth the second time, do not be discouraged and always and only think about your own good and that of your child: a good mother cannot be seen from the way she gave birth to her baby. !

Natural delivery after two caesareans

After having two caesareans, are you advocating in your mind the desire to try natural childbirth? It is not forbidden a priori. Talk to your doctor, prepare carefully for the moment of birth by attending a preparation course, make peace with yourself and with the idea that in the end it could all end with a third caesarean. A trial labor it's always possible, even after two caesareans: the most recent el paesene guidelines say so, which have been drawn up after carefully examining dozens of international studies.

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