Vaginal Birth After Cesarean:

Is it Still an Option?

Howard Blanchette, M.D.

Professor & Chairman
Department of Obstetrics & Gynecology
New York Medical College
 VBAC Success Rate
66% to 85%

Minimal Neonatal or Maternal Morbidity

Blanchette et al. Is Vaginal Birth after Cesarean Safe? Experience at a Community Hospital. Am J Obstet Gynecol 2001; 6:1478-87
 Between 1970-1988 the Cesarean delivery rate in the United
States increased dramatically from 5% to 25%.

From 1989-1996 the Cesarean section rate decreased to 20.7%

while the VBAC rate increased from 18.9% to 28.3%.

Year C- Section Rate VBAC Rate

2002 26.1% 12.6%
2003 27.5% 10.6%
2004 29.1% 9.2%
2005 30.2%
Curtin SC. Rates of Cesarean Birth and Vaginal Birth After Previous Cesarean, 1991-95. Monthly Vital Statistics Report. Vol 45, No. 11, Suppl 3. Hyattsville
(MD): National Center for Health Statistics; 1997. (Level II-3)
Martin JA et al. Births: Final Data for 2002. Natl Vital StatRep 2003; 52 (10): 1-113. (Level II-3)
Martin JA et al. Preliminary Births for 2004: Infant and Maternal Health. Natl Vital Stat Rep 2004.
 Healthy People 2000

C-Section Rate 15%

Primary 12%
Repeat 3%

Healthy People 2010

Calls for a reduction in the rate of repeat Cesarean births from

72% in 1998 to a target of 63% in 2010.

Healthy People 2000. Washington: Public Health Service (US). Department of Health and Human Services (US); 1991.
Healthy People 2010. Washington: Public Health Service (US). Department of Health and Human Services (US); 2000.
 Uterine Rupture:
Uterine separation requiring emergency
laparotomy for a non-reassuring fetal heart
rate tracing or maternal hemorrhage

Uterine Rupture Rate

0.3% to 1.5%

Relative Safety of VBAC

Blanchette et al. Is Vaginal Birth after Cesarean Safe? Experience at a Community Hospital. Am J Obstet Gynecol 2001; 6:1478-87
 Risk of Perinatal Death
Mozurkewich et al.
Elective Repeat Cesarean Delivery versus Trial of
Labor: A Meta-analysis from 1989-1999.

TOLAC Repeat C-Section

38/19,842 10/13,292
(0.2%) (0.1%)
OR 2.05 (CI 1.17-3.57)

Although the risk of fetal or neonatal death is higher in women

attempting VBAC, the absolute risk is low.

*Mozurkewich et al. Elective Repeat Cesarean Delivery versus Trial of Labor: A Meta-analysis From 1989 to 1999. Am J Obstet Gynecol 2000; 11: 1187-97
Future Risk of Elective Repeat Cesarean Section
Placenta Previa
0 CD 1 CD 2 CD 3 CD
(0.26%) (0.65%) (1.8% ) (3%)
Placenta Acreta
0 CD 1 CD 2 CD 3 CD
(0.01%) (0.16%) (0.82%) (1.09%)
A woman with two prior Cesareans has a 2% incidence of
placenta previa; nearly half of these cases are associated with
placenta acreta.

Jackson et al. Physical Sequelae of Cesarean Section. Best Prac Res Clin Obstet Gynaecol 2001; 15: 49-61.
Clark et al. Placenta Previa/Acreta an Prior Cesarean Section. Obstet Gynecol 1985; 66: 88-92.
 Increased Maternal Morbidity Associated with the
Increasing Number of Cesarean Deliveries

Placenta Acreta

1 CD 2 CD 3 CD 4CD 5CD 6CD

0.24% 0.31% 0.57% 2.13% 2.33% 6.74%

Hysterectomy
1 CD 2 CD 3 CD 4CD 5CD 6CD
0.65% 0.42% 0.90% 2.41% 3.49% 8.99%
The authors concluded that because of serious maternal morbidity
increasing progressively with increasing numbers of cesarean deliveries,
the number of intended pregnancies should be considered during
counseling regarding elective repeat cesarean operation versus a trial of
labor, and when debating merits of elective primary cesarean delivery.

Silver et al. Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries. Obstet Gynecol 2006; 107: 1226-32
Complications With Cesarean Delivery vs.
Vaginal Delivery

Maternal death with Cesarean section 4/10,000

Maternal death with all vaginal births 1/10,000
Maternal death with elective Cesarean section 2/10,000
Maternal death with normal vaginal birth 0.5/10,000

Ob/Gyn Clinical Alert. October 2004; Vol. 21, No. 6, 43.

 ACOG Practice Bulletin (July 2004)
Summary of Recommendations
The following recommendations are based on good and consistent scientific evidence (Level A):
 Most women with one previous cesarean delivery with a low-transverse incision are candidates for
VBAC and should be counseled about VBAC and offered a trial of labor.
 Epidural anesthesia may be used for VBAC
The following recommendations are based on limited or inconsistent scientific evidence (Level B):
 Women with vertical incision with the lower uterine segment that does not extend into the fundus are
candidates for VBAC.
 The use of prostaglandins for cervical ripening or induction of labor in most women with a previous
cesarean delivery should be discouraged.
The following recommendations are based primarily on consensus and expert opinion (Level C):
 Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped
to respond to emergencies with physicians immediately available to provide emergency care.
 After thorough counseling that weighs the individuals benefits and risks of VBAC, the ultimate decision
to attempt this procedure or undergo a repeat cesarean delivery should be made by the patient and her
physician. This discussion should be documented in the medical record.
 Vaginal birth after a previous cesarean delivery is contraindicated in women with a previous classical
uterine incision or extensive transfundal uterine surgery.

ACOG Practice Bulletin N. 54. July 2004. Vaginal Birth After Previous Cesarean Delivery.
 Optimum TOLAC
1. One prior low transverse scar.
2. Clinically adequate pelvis.
3. High Bishop Score.
4. Prior NSVD.
5. Prior VBAC.
6. BMI <30 kg/m²
7. Fetal monitoring.
8. Induction of labor, only with prior NSVD.
9. Interdelivery interval of >18 months.
10. Double layer closure on uterus?
11. Lower uterine segment > 3.5 mm.
12. Immediate availability of OR, anesthesiologist, and obstetrician.
13. Informed consent.
To TOLAC or Not to TOLAC?
That is the Question!

∼ Howard Blanchette, M.D.