Vaginal delivery after cesarean section

cesarean section scar

Modern women giving birth after a previous cesarean section more often have a choice of repeated cesarean section or natural vaginal delivery. When choosing natural birth after cesarean section, it must be remembered that this has its limitations and particularities.
According to the statistics, up to 60-80% of those who decided on vaginal birth after cesarean section go through it successfully. The conditions for success include:

  • minimal transverse scar on the uterus and other scars associated with cesarean delivery;
  • normal pregnancy course;
  • good state of health of both pregnant woman and fetus;
  • correct position of the fetus;
  • placental location closer to the posterior wall of the uterus towards the bottom;
  • the absence of factors that led to performing the previous caesarean section;
  • onset of labor in time;
  • successful natural childbirth in the past (before the previous cesarean section).

What are the features of vaginal birth after cesarean section?
The main difference resides in the level of monitoring of the expectant mother and her baby during childbirth. In vaginal delivery after cesarean section a continuous electronic fetal monitoring is performed, involving a control of the fetal heart rate and of uterine contractions.
Many women successfully go through natural birth after cesarean section without any complications. However, with such deliveries there is always a risk (though very small) of uterine rupture on the site of the scar left after the previous cesarean section.

vaginal birthStatistics show that uterine rupture occurs in 1 out of 200 cases. Although the risk is small, the medical team monitors the entire birth process very carefully. An early sign of possible problems with the scar is the pathological change of the baby’s pulse on the monitor.

In case of patients requiring anesthesia during vaginal birth after cesarean delivery, they will be proposed the epidural kind. In European clinics, patients may be offered to use maternity pools so as to ease contractions. Selecting the method of anesthesia mostly depends on the reason for the performance of cesarean section the previous time. Doctors will find out how the previous pregnancy proceeded.
What is the alternative to natural childbirth after cesarean section?
Another possible delivery option for women that already had a C-section is to perform another repeated planned operation. In this case, the C-section is usually carried out seven days before the expected date of delivery (EDD), unless an earlier date is not due to medical conditions. In general, both methods – vaginal delivery and repeated cesarean section – are quite safe.
The woman will have plenty of time to carefully consider all advantages and disadvantages before choosing one or the other method. Talking to her obstetrician about her previous deliveries would do her good by helping decide on the new ones. Such a decision should be made before the 36th week.

What are the advantages of vaginal birth after cesarean section?
The main advantage of vaginal birth after cesarean delivery is that of women giving birth vaginally, thus avoiding the risks associated with C-section. The post-partum period is much less painful, and the time of hospitalization in the postpartum unit of the clinic is also reduced.
Besides the above, there is a slightly reduced risk of breathing problems in the newborn, although this risk is not so high. If choosing a cesarean section has not met a woman’s expectations the previous time, then a subsequent natural birth may be considered as a personal achievement. Finally, a successful attempt may inspire her to try again.
What are the disadvantages of natural birth after cesarean section?
In essence, the disadvantages of natural birth after cesarean section are the same as those of normal vaginal delivery:

  • Pain in the perineum (perineal pain), and, possibly, the necessity of suturing;
  • Urinary incontinence during the first three months after delivery;
  • Possibility of future uterine prolapse (lowering) through the vagina is not excluded. This event – the so-called prolapsed uterus – usually occurs after menopause, being found in only five percent of women who gave birth. However, in case of vaginal birth, the probability is increased almost by half. To prevent uterine prolapse, it is recommended to perform certain exercises that strengthen the pelvic muscles on a constant/ lifelong basis.

Compared to the C-section, natural childbirth poses a relatively greater risk of leading to complications. However, their probability is extremely low. Such possible complications include:

  • the need for blood transfusion;
  • getting an uterine infection after childbirth;
  • uterine rupture – in rare cases.

What else should be known before giving birth naturally after cesarean section?
Any delivery is an unpredictable process. Therefore, there is always the possibility that, for some reason, the woman will be refused a natural birth after cesarean section. A quarter of all women planning vaginal births are eventually forced to being submitted to cesarean section. This usually occurs due to the critical slowing down of the delivery, or because of concerns regarding the child’s condition. However, if estimating the probability of having to perform a cesarean section in case of vaginal birth after cesarean, it is only slightly higher than at first delivery. This is a purely personal decision. Taking such decision may be difficult, therefore it is preferred to thoroughly discuss it with the doctor and midwife, as well as with the family.
What are the chances of natural childbirth after cesarean section?
The chances of success are quite high. They, however, largely depend on the reason why the woman has previously had a cesarean section and on the progress of the current pregnancy. If the reason for choosing cesarean section the last time still exists (e.g. “narrow pelvis”), then, most likely, another cesarean section will follow. On the other hand, if the reason for surgery was just some characteristics of the previous pregnancy, such as, for example, breech presentation, or placenta previa, then there is a good chance to give birth naturally. In order to be well informed, the woman should probably see the statistics. The chances of successful vaginal delivery are:

  • From 87% to 90%, if the woman already had at least one child born vaginally, especially as a result of natural birth after cesarean section;
  • From 72% to 76%, if she had a C-section in the past;
  • From 70% to 75% if she had two cesarean sections in the past.

The probability of a successful vaginal delivery is reduced if the woman:

  • Resorts to the induction of labor, especially with the use of prostaglandins. Prostaglandins are hormone-like substances that stimulate uterine contractions. Using stimulation greatly increases the load on the scar, therefore the probability of uterine rupture increases by 2-3 times compared to natural childbirth;
  • Gave birth only by caesarean section;
  • The reason for the previous C-section was that the child was “stuck” in the birth canal;
  • Has a significant excess body weight and her body mass index (BMI) before pregnancy was more than 30;
  • If the woman has all four of the above factors at the same time, her chances for a successful vaginal delivery are reduced to 40%. Repeated cesarean section is also safer than vaginal delivery when the birth of a very large baby is expected (macrosomia).

Can natural birth after cesarean delivery be performed at home?
Home births may be an option for women opting for natural childbirth. In this case, however, they cannot seek any professional health care or hope for any monitoring of the state of the uterus and of the child’s pulse; in the case of emergency admissions to the hospital, they will be taken to the maternity hospital’s infectious department. Their doctors, and any other person with a medical degree, will try to talk her out of this decision. The fact is that the conduct of home births attended by certified physicians is an illegal practice in many countries. Besides, in natural birth after cesarean section there is a risk of uterine rupture. Conducting a natural birth in the hospital ensures that, if the worst scenario happens (e.g. rupture of the scar), the mother will be provided with emergency assistance. Cesarean section should be performed no later than 30 minutes after occurrence of the indications for its urgent performance. The time needed for emergency hospitalization from home could be calculcated if this necessity occurs.
Conducting a natural birth after cesarean section is associated with a small risk of uterine rupture. Opting for natural birth after cesarean section can be a difficult choice. Natural childbirth is worth considering, although it differs significantly from C-section. If women decide on vaginal birth, they should discuss this decision with their doctor. In any case, they should be fully informed about all its advantages and disadvantages.

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