One of the more common questions that women asked when they come up to my clinic is that whether they could have a vaginal delivery after a Cesarean section. The answer of this question is not entirely straightforward as one need to take into consideration of a few factors, including what has happened in previous pregnancies, how things are with this pregnancy, and your own feelings about how you want to give birth to this baby. Therefore it is important that you, your doctor and midwife to discuss the advantages and disadvantages to you as an individual.

The general Cesarean rate of this country is about 20-25%. However, the rate may be increasing over the next few years with increasing safety of Caesarean sections and more evidence showing that Caesarean section may be beneficial in certain cases.

If you have had a Caesarean delivery for one birth and become pregnant again, you have two options:

Aim for a vaginal delivery. About 60-80% of women who choose this will be successful in giving birth to their babies vaginally. About 20-40% will need to have a further Caesarean section
The second option is to have a planned (elective) Caesarean section

Who are not suitable for a trial of vaginal birth after a Caesarean section?

About 90% of women who have had a Caesarean birth are suitable for a trial of vaginal birth. Factors which put a woman at high risk for trial of vaginal birth in this circumstance include:

Women who had a vertical uterine scar (classical incision) instead of low transverse (almost 95% of incisions are low transverse, therefore it is important that your obstetrician have a copy of your previous Caesarean delivery to be sure which type of incision was made on your uterus. Please note that the incision on your skin is not reflective of the type of incision on your uterus).

Women who have had more than 2 Caesarean deliveries are considered unsuitable for a trial of vaginal birth as the risk of uterine rupture is high. However, it is common that the obstetrician advise women with 2 previous Caesarean sections against a trial of vaginal birth.

Women with previous history of uterine rupture as the risk of recurrent rupture is unknown

In most studies, it has been shown that about 60-80% of women who have a previous Caesarean delivery can successfully give birth vaginally. Women who had previous vaginal births particularly those who have had delivered vaginally after a Caesarean delivery are known to be most likely to succeed (87-90%).

What are the risks if I aim for a vaginal delivery?

In the case of unsuccessful trial of vaginal birth due to slow cervical dilatation or your baby become distress during the process of labour, you will end up with an emergency Caesarean section. We know that there is a slightly higher chance of complications with an emergency Caesarean section compared to a planned (elective) Caesarean section.
One of the major concerns for women who have had a previous Caesarean birth is the risk of the scar on the womb opens up (uterine rupture) during a trial of vaginal birth. If you had a previous Caesarean section with low transverse incision, the risk is around 0.5%. This is if you go into labour on your own. If you required oxytocin to help to kick start your labour or make your contractions stronger, then the risk is quoted to be 0.8%. The risk of uterine rupture increases to 2.5% if your required prostaglandin to start off your labour.

Therefore, we need to take precaution steps to try to avoid it:

We would think carefully before inducing labour in a women with a previous Caesarean section

You are strongly recommended to have a trial of vaginal birth in a hospital setting for emergency Caesarean section

During labour, blood would be taken and a cannula inserted into your hand and arm so that we could quickly connect a drip if you need to go to the operating theatre quickly
The progress of your labour and the baby’s condition would be monitored closely. It is recommended we continuously monitor your baby’s heart rate with an electronic fetal monitoring machine following the onset of uterine contractions.

Comparing a Repeat Caesarean section to a VBAC (Vaginal Birth after Caesarean Section)

Repeat Caesarean Section	VBAC
Risk of Caesarean section (please refer to the topic what are the risk of Caesarean section )	0.5-1.0% risk of the scar on the womb opening up (uterine rupture). If this occur, it can cause serious internal bleeding and can be dangerous for both
Hospital stay of 2-3 days or even longer depending on the circumstances of your Caesarean section	Hospital stay of approximately 1-2 days
Increased risk of infection to the womb, bladder and skin	Risk of infection is higher if you ended up with an emergency Caesarean section
Injury to the internal organs such as bladder, bowel or adjacent organs	Risk of an episiotomy if you need one to deliver your baby
Risk of blood clot formation in the legs or lungs	Lower risk of blood clot formation in the legs or lungs
More pain relief required after the procedure	Lower requirement of pain relief
Risk of anaesthesia. However, with the development of modern anaesthesia technique such as epidural and spinal anaesthesia, the risk has been reduced remarkably
On-going pain due to scar tissue formation in abdomen	Short term pain and discomfort around vagina
Longer recovery	Shorter recovery
Higher cost	Lower cost
If you plan to have many more children, you need to take this into consideration as the risk of surgery increases with the number of surgery you have had. Therefore, a repeat Caesarean section may limit the number of children you could have
A small risk of baby having breathing difficulties upon delivery

Reference to Pitterpatter.com.my.