Caesarean or Normal Delivery

More than one in five women (20%-25%) in the urban population in India currently give birth by caesarean delivery . After having  had a  caesarean delivery women often  think about how to give birth next time. Whether one  chooses  to have a vaginal birth( VBAC -Vaginal Birth After Caesarean )  or a caesarean delivery( Elective Repeat Caesarean Section) in next pregnancy, either choice is safe with different risks and benefits. Overall, both are safe choices with only very small risks.

While discussing with your Obstetrician you should tell the doctor about

• Why you had  the caesarean delivery
• the type of cut that was made in your uterus (womb)
• The recovery period after the operation and if there were any complications in this phase.

Across the globe  about  two to three out of four women (50-75%) attempting VBAC , with an uncomplicated pregnancy who go into labour give birth vaginally.

If one has had a vaginal birth, either before or after  caesarean delivery, about nine out of ten women (90%) have a vaginal birth.(RCOG , UK).

The other factors which have a positive impact on success of a VBAC include

• An uncomplicated pregnancy ( no medical problems in the mother with normal pattern of growth in the baby)
• Going into labour spontaneously. Inducing labours artificially reduces the success rate of attempted VBAC and may increase the risks associated with it.

There are certain factors which reduce the chances of a successful VBAC attempt.These are when

• One has never had a vaginal birth
• One needs to be induced for prolonged pregnancy or any complication in pregnancy
• the caesarean was performed last time because the woman did not make progress in labour( especially in second stage of labour)
• Woman  is  overweight – a body mass index (BMI) over 30 at booking.

 A successful VBAC means that one has avoided surgery. For most women it also results in shorter recovery period and hospital stay. There may be earlier resumption of normal activities and many women report better birth experience. It also increases the chances for vaginal birth in subsequent pregnancies.

There are  some  occasions when VBAC is not advisable and repeat caesarean delivery is a safer choice. These are when:

• Woman has had two – three or more previous caesarean deliveries
• the uterus has ruptured during a previous labour
• The uterus development has led to an altered shape of the uterus
• The woman has had a classical caesarean section performed with a high incision given in the uterus
• There are other pregnancy complications that require a caesarean delivery( example for women with baby in breech  position or women with placenta previa i.e. placenta attached to lower portion in the uterus)

A5  The greatest concern for women who have had a previous cesarean is the risk of uterine rupture during a vaginal birth.This occurs only in two to eight women in 1000(about 0.5%). Being induced increases the chance of this happening.(RCOG , UK).

I the group of carefully selected women the risks to the baby are minimal and are similar to those women who are in labour for the first time ( 0.2%) and should not deter women from opting for VBAC.

Many women opt for repeat caesarean section because they are not the right candidates for a safe VBAC.

The uncertainties involving the process of  attempted vaginal delivery may be unacceptable to many and this may be the reason why many women opt for elective repeat caesarean section.

The advantages of repeat caesarean section are virtually no risk of rupture of uterus  and avoids the risks to the baby (those which are associated with labour process).The main drawback is that it is a surgical procedure and the risks involved should be discussed with the obstetrician looking after the pregnant woman.

Final word – All women with previous caesarean sections should have a detailed discussion regarding their delivery choices with their doctors early on in pregnancy .Both choices (Vaginal Birth After Caesarean vs Elective Repeat Caesarean Section) are safe( Minimal risks)and decision making process should also take the woman’s preferences into account.