VBAC: Risky after repeated cesareans?

I have had three children -- all born by cesarean. I want to have another baby, vaginally, but my obstetrician advises against it. She said that the risk of uterine rupture is higher because of my previous cesareans. I was wondering if the odds of uterine rupture are associated with every birth after multiple c-sections?

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Peg Plumbo CNM

Peg Plumbo has been a certified nurse-midwife (CNM) since 1976. She has assisted at over 1,000 births and currently teaches in the... Read more

The simple answer to how many cesarean births a woman can have is "we just don't know." We need to look at each case individually.

Several large research studies have been published recently that look into possible risks of VBAC. For example, a large study in Nova Scotia addressed the risks associated with labor in women who had previously undergone cesarean section. The outcome in 3249 women who chose vaginal labor was compared to 2889 women who chose repeated cesarean sections. Though none of the women died, those who chose labor were twice as likely to have major complications (1.6 percent versus 0.8 percent), such as uterine rupture, the need for hysterectomy, or operative injury.

Although the difference in overall perinatal mortality between the groups was not statistically significant, there were ten uterine ruptures and two infant deaths in the group of women undergoing VBAC, as compared with only one uterine rupture without serious consequences in the group undergoing repeated cesarean section.

There is no accepted protocol or published guidelines which can definitively answer your question. Considerations should include the extent and condition of the scar, past complications, birth weights of past babies, physical health of the mother, type of past labors she had, position and presentation of the baby, fetal condition, and quality of labor.

Many obstetrical care providers are fearful of the catastrophic complication of uterine rupture. Even in a modern obstetric unit, uterine rupture is associated with substantial maternal and fetal mortality and morbidity. Although maternal death is thankfully uncommon, uterine rupture is also associated with a high incidence of major blood transfusion and hysterectomy.

If you are considering another cesarean, it is important for you to make a well-informed decision. You may want to seek another opinion just to make sure that you are getting all the facts. Have a copy of your surgical reports sent ahead for the physician to evaluate.

It is important to note that the risk of uterine rupture is not just a consideration in the VBAC. There is also a risk of spontaneous rupture prior to labor. Much of the risk depends on the uterus and the scar.

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