ASK DR NOVOA – What are your thoughts on VBACs?

My thoughts about VBAC or Vaginal Birth After Cesarean section is discussed in the following Youtube video.

6 Comments

Filed under Blog, Obstetrics, Questions of the Day

6 responses to “ASK DR NOVOA – What are your thoughts on VBACs?

  1. Cant figure out how to ask a question so I will leave it as a comment. I had preeclampsia which caused me to need a c section at 33 weeks but otherwise healthy. Will these cause me to not be a candidate for a vbac? I really want a water birth after my nightmare last time.

    • Hello Brunette2blondie2005,

      I would like to break down your question into parts and then answer each accordingly.

      First, there is no contraindication to attempting a VBAC with a previous history of preeclampsia. Further, if you were to develop Chronic Hypertension, Gestational Hypertension or Mild Preeclampsia during your pregnancy, you would still be a candidate for a VBAC as long as there are no other medical issues which would raise your risk of potential complications.

      The risk of developing preeclampsia again are depend on multiple factors. The greatest risk is based on the fact that you already had preeclampsia. In other words, the fact that you had preeclampsia in a previous pregnancy predisposes you to have an increased risk with all furture pregnancies.

      Some studies also suggest that there is a paternal (father of the baby) component to the risk of developing preeclampsia. In some cases, having a baby with a different father may reduce your risk of developing preeclampsia since the genetic makeup of the babies are different based on the genetic information given from two different fathers.

      Second, having had a C/S at 33 weeks does not specifically prevent you from attempting a VBAC. What is important to have asked is why you were not allowed to attempt a vaginal delivery with your first baby even though you had preeclampsia? I often allow my mild preeclampic patients to attempt a vaginal delivery and have also allowed severely preeclampic patients to try as long as I felt the time period from induction of labor to the estimated time of the vaginal delivery was reasonable. Some of my colleagues disagree, and will recommend or insist on a C/S rather than recommend allowing for the vaginal delivery.

      Third, what type of C/S did you have? You will need to review the Operative Report from your C/S. If it was a Lower Segment Transverse Cesarean Section (LSTCS), your risk will be between 0.47-1% of having a uterine rupture with your VBAC. If, however, it is a Classical C/S (Vertical Midline on the Uterine), the risk of uterine rupture can be higher than 5% and most doctors will not recommend you try a VBAC. Despite the relatively low risk, I do not perform VBAC on patients with Classical C/S scars. However, Classical C/S scars are uncommon with greater than 90% of all scars associated with LSTCS incisions.

      Fourth, there is no contraindication to attempting a water birth delivery or Water Birth After Cesarean Section (WBAC). The risks and complications are estimated to be the same as with standard VBAC attempts. However, based on potential risks, benefits, complications and delayed response time to complications, I do not perform WBAC. Although there are plenty of advocates for home birth VBACs or Home Birth After C/S (HBAC) and despite the fact that data does not show a significant difference with risks vs. benefit with HBAC, WBAC and standard VBAC, I recommend the following protocol for my VBACs.

      1. All VBAC patients must attempt their vaginal deliveries in a hospital.

      2. All VBAC patients must be prepared for an emergency Repeat C/S.

      3. All VBAC patients must sign consent forms for both a Repeat C/S and VBAC.

      4. All VBAC patients must have an IV line in place as well as an epidural line in place. (The patient does not have to receive the epidural medicine, but must have the line in place in case an epidural bolus is necessary for an emergency C/S.)

      With these things in place, a water birth is not possible. But, again, there are no contraindications to attempt a water birth. I simply have a high number of safety factors in place in case of emergency.

      I am happy to say that a good candidate for a VBAC has between a 60-74% chance of a successful VBAC. My success rate with VBAC is 90%.

      I hope this information helps. But please remember to discuss your concerns with your doctor and follow your doctor’s recommendations but continue to do your research on the subject of VBAC.

      Good Luck,

      Sincerely,

      Dr. Novoa

  2. Amina

    Hello dr,
    I am pregnant with my 4th baby and I want your opinion. I want to try vbacs but my doctor told me once a vbacs then I always have to have vbacs because I didn’t wait the time given (24month). What should I do?? Ok a little history on all my birth: my first baby( 4 yrs old) was a viginal birth, the second one (2and 1/2 yrs old)was emergance c-section ( the cord came out first), the third baby(1yrs and 4month old)was plannned c-section because they were too closer together. Now am pregnant with my fourth (us of today my youngest is 1yrs and 4month) 7 weeks pregnant I want to try vbacs is this possible? Both surgery were Lower Segment Transverse Cesarean Section.
    Thank you for taking your time to answer our questions!!!

    • Hello Amina,

      The Amerian College of Obsetrics and Gynecology (ACOG), the World Health Organziation (WHO), the Centers for Disease Control (CDC) and Health People 2012 all support allowing a patient to attempt a vaginal birth after 2 C/S (VBA2C)

      Based on your history, you have a 2% risk of uterine rupture as compared to 1% for C/S x1 or VBAC.

      The recommended interval between pregnancies is 24 months. The risk is 1% for c/s at 24 months, 2% for C/s when interval pregnancy of between 6-24 months and 3% for interval pregnancy of less than 6 months.

      Therefore, your overall risk is approximately 2-3% as compared to 1% for VBAC x 1 and 24 months.

      Based on the aforementioned information, I would recommend a repeat C/S but would also allow you to attempt a VBAC if you were sure that you want to try for the VBAC.

      Please go to vbacelpaso.com more information regarding VBAC.

      Sincerely,

      Dr. Novoa

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