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Share Ask the midwife: Vaginal delivery after cesarean section (VBAC)

Mireia Long

As every Friday comes our section: Ask the midwife . In it the midwife Marina Fernández each week will answer a question that our readers have left for her.

This week we have chosen a question that, for women who have had a cesarean section and are going to have a second child, is important, because we are going to assess the possibility of a vaginal birth, its advantages and possible problems.


Marina Fernández is a midwife, specialized in home birth, lactation consultant and expert in complementary therapies. She is a member of the Professional Association Nacer en Casa and a partner-founder of Multilacta.

Each week she will collaborate with Bebés and more by answering a question from our readers. You can get to know her better on her Marina Matrona page.

The question that we have selected is that of Nene-nenita, to which Marina has already responded in her first part, it is about this:

Two questions that worry me because I am almost fulfilled: If you break the bag, do you go to the hospital immediately? I understand that if you do not give birth in 12 hours you induce labor ... :( And another ... I have been told that I have a risk of uterine rupture because my previous pregnancy ended at 26 weeks in emergency caesarean section. I will try natural childbirth, some advice, recommendation? How do I know if the break is occurring?

Matron Marina Fernandez responds to the second question this week, which refers to a vaginal delivery after cesarean section:

"According to the Ministry of Health publication of 2010 on" Assistance to the delivery of healthy women, study of variability and systematic review. "Says:

"With the caesarean data that account, with 22.2% in centers of public ownership, Spain is well above the 15% of cesareans recommended by the WHO, a percentage that increases even more if we take into account the cesarean sections performed in private centers so that it is established around 33% "

Until very recently, one reason to indicate a cesarean section was the previous caesarean section. And unfortunately, in some hospitals it is still one of the criteria for recommending a cesarean section. For this reason the Spanish Society of Obstetrics and Gynecology (SEGO), recommends that it is the woman, once informed, who decides if she wants to try a vaginal delivery or not. This information must be clear, objective, and with scientific evidence in hand so that the woman is free to decide what is best for her and her baby.

Given this situation we find that a high percentage of women have had a cesarean and want to consider a vaginal delivery. When a cesarean section has been performed, there is a scar in the uterus that should be "pampered" as much as possible to minimize the risks of suffering the much feared "uterine rupture" during the birth process. The way to "pamper" a scar is to treat it with care and softness, that is, not to force it at any time with inductions, oxytocin, forced postures, haste, fears, judgments, orders, etc. The way to care for the next birth process is to RESPECT the physiological conditions of childbirth and the decisions of the woman who will give birth.

Studies published on the subject, give results of risk of uterine rupture between 0.2-1%, without induction of the next delivery. If this is done, the risk rises to 6%. On the contrary, if the intervention is diminished, and other parameters are taken care of such as free posture, sufficient waiting time for the body to do its work without haste, emotional environment appropriate to that woman's labor, etc. The risk decreases to 0.02%, of uterine rupture, in home births. Today, cesareans are performed with a horizontal incision, which carries less risk of dehiscence of the scar, than the vertical incisions that were previously made.

In the event that this happens, the risk to the mother is of hemorrhage and, in very few cases, a hysterectomy, but a higher associated mortality has not been described, not being so for the baby, who suffers a risk of fetal death in a 5 '5% of uterine rupture.

However, all the studies conclude that the risk of a cesarean is greater with respect to the attempt of vaginal delivery after caesarean section. Caesarean section implies an associated risk of increased maternal morbidity and mortality, increased neonatal morbidity and mortality, greater complications for women's reproductive health, etc.

The success rates of the attempt of vaginal delivery after caesarean section are around 70-80% in a hospital delivery with little interventionism and of 90% of deliveries at home. This success rate is very similar to that of vaginal delivery without previous cesarean section, since we have previously commented on the percentage of cesarean sections that are currently in Spain. We must also take into account the emotional issue, the success of seeing that your body works properly, the satisfaction of giving birth without the need for outside help as female mammals that we are and are ready to give birth.

For this success to be greater, we must bear in mind that it is convenient to wait at least 1 year until the beginning of the next pregnancy, so that the uterine contractions of the next delivery, occur after almost 24 months and the previous incision is well healed. In the case of occurring in pregnancy sooner than expected, nothing should be done differently and the option of vaginal delivery is still recommended in the first place.

If you already have two caesarean sections, the risk of uterine rupture does not increase significantly in the studies, but it does increase the risk of a new scar in the uterus, with another major surgery, anesthesia, etc. So in all cases, we must assess the possibility of attempting a vaginal delivery after a previous cesarean section.

SEGO only contraindicates a vaginal delivery in the following cases:

  • If the incision of the previous caesarean section was made in the upper part of the uterus.
  • If a uterine rupture occurred previously.
  • If in an operation to eliminate a myoma the uterine cavity was opened.
  • Without there are three or more caesarean sections.

You can get more information about these studies, and other articles related to the topic, as well as experiences of women who have had a VBAC in "Blog El Parto es Nuestro", and at www.doctorsantos.com.

To finish I would like to say, that I also have a cesarean at my first delivery and then I have had two wonderful vaginal births without any problem and therefore I encourage the women who are in this situation to try it. I have attended many births in these circumstances and above all the emotional satisfaction of being able to achieve it is immense. "

We hope that the response of midwife Marina Fernández will be useful and serve to clear your doubts. Remember that every Friday we will choose a question so she can answer it, so if you are pregnant, you can leave your question here.

In Babies and more | Stories of natural births after one (or two) caesarean sections, Ask the midwife: a girl who comes from the buttocks, Ask the midwife Marina Fernández Martín: leave us your doubts and she will answer them, The home birth explained by Marina Fernández and Emilio Santos

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