Having a cesarean section (c-section) is major abdominal surgery. It involves making incisions through the abdominal wall and uterus to deliver the baby. Recovering from one c-section can take weeks. Some risks also exist with undergoing the procedure. But what if you’ve had not just one, but two c-sections previously? Is attempting a vaginal birth after cesarean (VBAC) still possible?
What is VBAC?
A VBAC is when you labor and deliver vaginally after having had one or more previous c-sections. Vaginal birth has fewer complications associated with it compared to repeat c-section deliveries. It leads to shorter hospital stays and lower infection risks. VBAC also avoids major surgery and allows quicker recovery.
According to the American College of Obstetricians and Gynecologists (ACOG), 60-80% of women who attempt VBAC will deliver vaginally. This success rate is similar to women attempting vaginal delivery with no prior c-sections. However, the more c-sections a woman has undergone previously, the lower her chances of succeeding at VBAC.
Why is VBAC limited after multiple c-sections?
The uterine scar from a c-section poses risks during vaginal delivery in future pregnancies. As the uterus stretches and contracts during labor, it’s possible for the scar to rupture or open back up. A uterine rupture is rare but very dangerous for both mom and baby.
Having multiple repeat c-sections increases the risks of placental problems. But it also weakens the uterine wall more than a single c-section does. This exponentially heightens the chances of uterine rupture if a VBAC is attempted after multiple previous surgeries.
According to ACOG, the risks of uterine rupture during a VBAC attempt increase as follows:
- After 1 prior c-section: 0.7% risk
- After 2 prior c-sections: 0.9% risk
- After 3 prior c-sections: 2.7% risk
- After 4 prior c-sections: 2.7% risk
As the number of past c-sections increases, the uterine scar integrity worsens. This makes rupture much more likely. The risks to mom and baby are considered by most providers too dangerous to attempt VBAC after multiple repeat cesareans.
Risks of uterine rupture
Uterine rupture is an emergency situation requiring immediate c-section delivery. The severe abdominal pain and vaginal bleeding that accompany a rupture mean fast action is critical.
Consequences may include:
- Hysterectomy (removing the uterus)
- Blood transfusions
- Blood clots
- Injury to internal organs
If the uterus ruptures while the baby is still inside, oxygen supply is cut off. This can lead to brain damage or death of the baby if not delivered extremely quickly.
Success rates of VBAC after 2 c-sections
Limited research exists on VBAC success rates for women with more than one prior c-section. But here is what evidence does show:
- One study found a 60-80% VBAC success rate after 1 c-section, but only a 40-60% rate after 2 c-sections.
- A review of multiple studies estimated VBAC success around 51-57% for women with 2 previous c-sections.
Carrying a pregnancy to full term after 2 c-sections is also less likely. The risk of preterm birth before 37 weeks increases significantly.
VBAC success rates by number of prior c-sections:
|Number of prior c-sections||VBAC success rate|
|3+ c-sections||Less than 50%|
Even if VBAC is initially successful, an emergency c-section may still be required. The overall risk of uterine rupture, low fetal oxygen, and other complications rise as more cesareans have occurred.
Factors affecting VBAC success
Every woman’s situation is unique. Several factors may make VBAC more or less likely to be successful after 2 c-sections. These include:
- Method of previous incisions: Low vertical uterine incisions have higher rupture risks than low transverse incisions across the lower uterus.
- Time between pregnancies: At least 18 months between delivery and getting pregnant again allows more scar healing.
- Labor induction: Drugs to start labor increase chances of rupture.
- Gestational age: Delivering after 40 weeks raises risks.
- Baby’s size: Larger babies make vaginal delivery more difficult.
- Presence of obstetric complications: Issues like preeclampsia or gestational diabetes make c-section more likely.
Your provider can help evaluate if VBAC may be possible depending on your unique history and risk factors. Even then, preparations for emergency repeat cesarean are still recommended in case complications arise.
Weighing the risks and benefits
Women who have undergone more than one c-section have several important considerations if hoping to delivery vaginally again:
- The lower VBAC success rates after multiple prior surgeries
- Higher risks of uterine rupture and emergency complications
- Higher likelihood of needing an unplanned c-section anyway
These risks have to be carefully weighed against the possible benefits of avoiding repeat major surgery. Women desiring larger families should especially consider the implications of accumulating multiple repeat cesarean deliveries.
Ultimately whether to attempt VBAC is a personal choice that must balance your own health and safety along with your wishes for delivery. Some women are willing to accept greater risks for the chance at vaginal birth. Others decide the rupture risks outweigh the benefits after 2 or more c-sections.
Alternatives to consider
For women unable or unwilling to try VBAC after multiple cesareans, some alternatives exist:
- Vaginal birth after cesarean with a trial of labor: You labor with option of c-section if needed. No commitment to vaginal delivery.
- Planned repeat c-section: Scheduling the surgery for 38-39 weeks reduces risks of going into labor.
- Finding a provider open to VBA2C: Seek doctors comfortable attending vaginal birth after 2 cesareans.
Women who have had 2 c-sections already should start planning their options for subsequent births early. Discussing preferences with your healthcare provider before getting pregnant again is ideal.
Attempting VBAC after multiple repeat cesarean sections poses greater risks to both mother and baby. The likelihood of emergency complications and failed VBAC rise significantly compared to after just 1 c-section.
However, VBAC may still be possible depending on your unique medical history and risk factors. Women wishing to avoid additional surgeries may choose to accept the increased risks. But planning a scheduled repeat c-section is safest after 2 previous ones.
Careful thought should be given to the risks and benefits along with your own priorities. Review all available information and discuss options thoroughly with your provider to make the most informed decision.