Neonatal-Perinatal Medicine Specialist Questions C-Section (Cesarean Birth)

Vaginal delivery after cesarean

I had 2 induced vaginal deliveries after a cesarean delivery. My daughter has had a cesarean delivery and her doctor refuses to allow her to have vaginal delivery now. Why is this? I know my deliveries were quite some time ago but what has changed?

10 Answers

Not all doctors are comfortable with a vaginal birth after a cesarean. There is a risk of uterine rupture. The candidate for a vaginal trial of labor after cesarean section should be chosen wisely so that mother and child are safe.
A trial of labor after cesarean (TOLAC) is certainly still attempted now as it has been in the past. Many factors play into why one may or may not attempt a trial of labor after a prior cesarean. These include but are not limited to: the type of incision she had on her uterus, the reason for her prior cesarean, how much time elapsed between her last surgery and her current pregnancy and the capability of the delivering hospital to perform an emergency cesarean should one be needed.

There are other factors involved in the decision making so ultimately, a discussion between her and her provider is necessary to determine whether she is a good candidate for TOLAC or not. Many women still attempt TOLACs and with great success so long as they are good candidates in a safe medical setting.
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It depends on the reason and the type of the previous cesarean section was done , It also depends on the comfort of the obstetrician and the hospital protocol
The initial discuss auto send my response prematurely...So let resume the discussion


Thank you for your question.In the current Obstetric community, efforts are being directed at reducing incidence and rate of cesarean deliveries due to its varied inherent comorbidities. The common feature I see in my practice is exactly this mother's stance...."I had a vaginal delivery after my cesarean delivery so why are you not giving my daughter the exact chance"  to paraphrase. Sure!There are circumstances that may preclude vaginal birth and may require a primary cesarean delivery such as extremely large fetus (macrosomy), inadequate pelvis , certain maternal medical condition- cardiac, fetal anomalies as well as in-labor indications such as fetal labor intolerance.

In subsequent pregnancies, options of mode of delivery should be discussed between patient and her obstetrician with the risks,benefits, alternative and indications well reviewed and documented. Much as some patient may desire vaginal birth after an initial cesarean delivery VBAC via trail of labor TOLAC , the decision will depend on various factors such as what type of incision  performed on the uterus at the cesarean delivery, how was this incision repaired, what were the reason for the primary cesarean delivery- was it maternal or fetal or a combination of both - which most often could be obtained  from a well documented operative report, as well as hospital policies that governs such deliveries to mention a few. And these decision must be adopted with safety of all parties well considered.

Remember the fact that I jumped off  the cliff and survived may not mean my daughter would survive if she takes the plunge.So kindly let your daughter have a candid discussion with her obstetrician to adopt the best option available to her.I hope this was helpful. I'm available to address any more concern. You may reach me at www.pineridgeobgyn.com.
Need to know the reason she had a CS. If it was due to CPD, chances are a vaginal delivery wouldn't be successful. If it was due to some other reason (failed induction for toxemia, stat CS for Fetal distress) might be able to deliver vaginally. Also depends on the incision.. if it was vertical, she will only be able to have CS's.

Jody
The doctor's advice on your daughter's delivery depends on her condition during the third stage of pregnancy. The type of delivery selected prevents danger to the newborn and the mother. Your daughter's and your delivery situations cannot be the same.
She may attempt a vaginal delivery depending on the circumstances. For instance, not all hospitals allow a trial of labor after a C-Section. Hospitals are supposed to have 24-hour anesthesia and obstetric services due to the risk involved. The kind of scar a person has on the uterus also determines who is and who is not a candidate. So she needs to discuss with her doctor why she is not a candidate, she more than likely has a good reason.

Hope this helps.
Yes, a lot has changed. A lot of hospitals have banned VBAC, due to liability and lack of resources to manage the complications.
Hi there,

When considering a patient for TOLAC, trial of labor after C-Section, many factors come into play, from both the mom's side and the baby's. For example, likelihood of a safe delivery depends on the reasons for the first C-Sec and if they are still present in the next case, then it does not look good. For example, I could imagine a mom having her first C-Sec for breech failed version, and the two subsequent babies who presented head down were delivered vaginally without incident. Then, her daughter, once grown up, had a large baby who arrested labor at 6 cm. In the daughter's second pregnancy, the doctor again sees excess maternal weight gain, a larger than average baby, and no descent into the pelvis near term. Those would not be good conditions in which to consider a TOLAC. This is just a hypothetical example, but there are an infinity of others which might cause a doctor to advise her against a TOLAC.

Your daughter is always welcomed to seek a second opinion. We encourage TOLAC in appropriate patients in centers that are equipped to handle it, with 24/7 anesthesia and Ob coverage.

Best of luck !
Dear Concerned Mom;

A vaginal birth after a cesarean delivery carries an increased risk of complications, the worst is a uterine rupture. A uterine rupture is where the scar separates, and can result in the expelling of the baby into the mother's abdomen. It is devastating for the baby, and many do not survive. Fortunately, it is a rare complication in women with a uterine incision in the lower part of the uterus and side-to-side. To clarify, the skin incision maybe side-to-side, but the uterine incision could be up-and-down, or an extension up the side of the uterus. Both carry an unacceptable risk for a rupture.

The risk of that complication increases if a mother has to be induced. The lowest risk occurs if a mother goes into labor on her own, not needing medication to open the cervix. Often doctors will schedule a repeat C-section at their due date, hoping the mother will go into labor on her own before that c-section.

Some physicians are uncomfortable allowing their patients to labor after uterine surgery, due to the increased risk. A few hospitals have strict guideline on allowing patients the option for a vaginal birth after a C-section; mostly due to the availability of other services, such as anesthesia and personnel in the laboring unit during the entire time a woman is in labor.

So it may not be just the OB not wanting to allow a patient the vaginal birth. I would discuss their wishes of a vaginal delivery with the physician, and if they are unable accommodate her ask to be referred to another Obstetrician that can provide that service.

Wishing you the best...