Two or more previous caesareans?

(Vaginal birth after two caesareans is sometimes abbreviated to VBA2C. Vaginal birth after three caesareans is VBA3C, and so on.)

Many women have had successful vaginal births, both at home and in hospital, after two or more prior caesareans. For example, see birth stories from Bernadette (two prior caesareans), Amy (three caesareans), Karen (two caesareans), Kathy (three caesareans) and Alicia (two caesareans). However, you will still find some pregnancy books which suggest that your only option after two caesareans is a repeat section. This view is not supported by either the evidence, or by expert opinion, as we are about to see...

'A Guide to Effective Care in Pregnancy and Childbirth', which is a well-respected summary of evidence-based practice, says:

"The available data show that among [women who have had more than one previous caesarean] the overall vaginal birth rate is little different from that seen in women who have had only one previous cesarean section. Successful trials of labor have been carried out on women who have had three or more previous caesarean sections."

"The rate of uterine dehiscence in women who have had more than one previous cesarean section is slightly higher than the dehiscence rate in women with only one previous cesarean, but dehiscences in the reported series tend to be asymptomatic and without serious sequelae. No data have been reported on other maternal or infant morbidity specifically associated with multiple previous cesarean sections."

"While the number of cases reported is still small, the available evidence does not suggest that a woman who has had more than one previous cesarean section should be treated any differently from the woman who has had only one cesarean section."

- From 'A Guide to Effective Care in Pregnancy and Childbirth' 3rd edition, by Enkin, Keirse et al, Oxford University Press, 2000 (p363-4)

A report from an obstetrician of a client who had a successful vaginal birth after five prior caesareans is reproduced on this page, along with accompanying discussions from an obstetricians' forum, including another's experience with a client who had a VBA4C.

A very comprehensive website, written by a VBAC mother, is dedicated to this subject: vaginal birth after two or more caesareans, by KMom (www.plus-size-pregnancy.org/CSANDVBAC/vbac_after_2_cs.htm). There is also a page full of birth stories from women who have had two or more sections - VBA2C birth stories (www.plus-size-pregnancy.org/CSANDVBAC/VBA2Cstories.htm).

Despite the expert opinions quoted above from the leading the 'best practice' guide, it still seems to be harder for mothers who have had two or more previous caesareans to arrange a VBAC. Of course, her first caesarean might have been for one reason - such as a breech baby - and her second an elective repeat, before the idea of a VBAC was acceptable to her or her doctor/midwife. So the fact that a woman has had two or more previous caesareans does not necessarily imply that there is anything preventing her body from giving birth vaginally, although in some cases this might apply.

The lower success rate for VBACs after two caesareans may be due in part to a lack of confidence on the part of the health professionals and/or the mother. Each woman is an individual and many women have easy VBACs after two or more prior caesareans, so you do not need to be put off by statistics.

Some inspiring stories of women who have had vaginal birth after multiple caesareans are included in Midwifery Today e-News, 29 May 2002. One mother had a VBAC after seven caesareans. You can read them online - scroll down to "Question of the Week Responses". Don't get confused by the title of the issue, which is about breastfeeding and HIV!

New Report on VBA3C

The British Journal of Obstetrics and Gynaecology recently published a case history of a woman who had a vaginal birth following three previous sections:

Sharma S, Thorpe-Beeston JG.
Trial of vaginal delivery following three previous caesarean sections.
BJOG. 2002 Mar;109(3):350-1

The full text is currently available online (www.elsevier.com/gej-ng/10/12/39/55/34/46/main.pdf).

The woman in this case study had never had a vaginal birth - her first CS was for failure to progress, second elective CS due to hospital policy, third she wanted a VBAC but baby was breech and unfavourable pelvimetry. Fourth baby, mother was determined to have a trial of labour, but agreed with the docs that no induction or oxytocin augmentation of labour would be used. She went into spontaneous labour at 40 weeks, had a 5 hour first stage and 57 minute second stage, gave birth to a boy weighing 3.88 Kg.

The authors mention Miller et al (1994) who found, among 241 women with three or more previous caesareans, a 79% vaginal birth rate. I think this must be from the full text as it is not mentioned in the abstract, below. The authors say: "Miller et al concludes that although a trial of labour is reasonable following two or more caesarean sections, it is best reserved for motivated women who understand and accept the increased risk of uterine rupture and the decreased likelihood of success. In another series of 115 women with two caesarean sections... 89% delivered vaginally, but of these 80% had a previous vaginal delivery"

Other Studies on VBAC after Multiple Caesareans

Here are some abstracts which I have found on the issue. All suggest that the risk of uterine rupture is increased, and the risk of ending up with a repeat caesarean is also increased. This may reflect concerns or lack of confidence on the part of caregivers as well as genuine medical reasons for a repeat caesarean.

The study by Asakura and Myers, below, refers to would separations rather than true ruptures, and for women attempting a vaginal birth, such separations occurred in 2.0% of women with two or more prior caesareans, compared to 1.1% of women with just one prior caesarean. Overall, the authors found that "Important adverse outcomes were infrequent and not related to the number of previous cesareans."

More than one previous cesarean delivery: a 5-year experience with 435 patients.

Obstet Gynecol 1995 Jun;85(6):924-9
Asakura H, Myers SA
Department of Obstetrics and Gynecology, Mount Sinai Hospital Medical Center, Chicago Medical School, Illinois, USA.

Uterine wound separation occurred in nine of 435 patients with more than one previous cesarean compared with 16 of 1206 with a single previous cesarean (2.1 versus 1.3%, not significant). Of those undergoing a trial of labor, separations occurred in six of 302 and 12 of 1110 patients with more than one and a single previous operation, respectively (2.0 versus 1.1%, not significant). Vaginal birth after cesarean was successful less often in women with more than one previous cesarean than in those with one previous operation (64 versus 77%, P < .05). Important adverse outcomes were infrequent and not related to the number of previous cesareans.

CONCLUSION: Our findings support allowing a trial of labor for patients with more than one previous cesarean delivery under conditions that permit prompt recognition and treatment of emergencies.

Medline abstract: Asakura and Myers, 1995

The most recent study of vaginal birth after two sections had reassuring results:

Vaginal birth following two previous cesarean sections

Bretelle F, Cravello L, Shojai R, Roger V, D'ercole C, Blanc B.
Eur J Obstet Gynecol Reprod Biol 2001 Jan;94(1):23-6

The study considered 96 women who who attempted VBAC after two prior caesareans, and who for this pregnancy had cephalic presentation and "normal pelvic dimensions". Over 65% gave birth vaginally, many of them to babies heavier than their previous caesarean-born babies. There were three dehiscences of uterine scars, and one of these mothers had a hysterectomy after she haemorrhaged, suggesting that this dehiscence extended into a true rupture. Outcome for all the babies was good. The authors concluded that:

"Trial of labor following two previous cesarean sections is acceptable in the majority of cases. It leads to a high vaginal delivery rate and low maternal and fetal morbidity"

Medline abstract: Bretelle et al (2001)

Vaginal birth after cesarean: a 10-year experience.

Miller DA, Diaz FG, Paul RH.
Department of Obstetrics and Gynecology, University of Southern California, Los Angeles County.

Obstet Gynecol 1994 Aug;84(2):255-8

OBJECTIVE: To report the changing incidence of previous cesarean delivery, and the increasing use and success of a trial of labor and its effect on the repeat cesarean rate.
METHODS: Between 1983-1992, there were 164,815 deliveries at Los Angeles County+University of Southern California Women's Hospital, of which 17,322 (10.5%) were to women with at least one previous cesarean delivery. Data were gathered on an ongoing basis from delivery logs and patient charts.
RESULTS: Women with at least one previous cesarean accounted for 8.1% of all deliveries in 1983, increasing to 14.1% by 1992. Trial of labor was used in 80% of women with one previous cesarean, in 54% with two, and in 30% with three or more. The success rate was significantly higher with one previous cesarean (83%) than with two or more (75.3%). Furthermore, uterine rupture was three times more common with two or more previous cesareans. Compared to a policy of routine repeat cesarean, trial of labor yielded a 6.4% lower cesarean delivery rate. The majority of this benefit (5.5%) was derived by women with one previous cesarean. Among women undergoing a trial of labor, there were three rupture-related perinatal deaths and a single rupture-related maternal death.
CONCLUSION: Substantial reduction in the cesarean rate is achieved safely and efficiently by encouraging a trial of labor in women with a single previous cesarean delivery.

PMID: 8041542 [PubMed - indexed for MEDLINE]

Ob-Gyn Forum thread on VBA5C

The Ob-Gyn Forum is a message board for obstetricians and gynaecologists. Although anyone can read the messages, only ob-gyns and professionals in related fields may post messages or respond to them. In 1996 there was a discussion about a woman who wanted to try for a vaginal birth after five prior caesareans. All messages from the thread which I could find are copied below.

It is interesting to see that some of the responding obstetricians were not aware of any risk involved in inducing or augmenting labour in women with prior caesareans. This may be because much of the research on this matter had not been published in 1996. See VBAC and Induction for more information.

To find this thread on the forum, go to the last message on the ob-gyn forum, and work backwards.

Key to abbreviations and terms used in the posts:

pt - patient
G6P5 - gravida 6, parity 5 , ie sixth pregnancy, five children already born
CPD - cephalo-pelvic disproportion, ie baby supposedly too big to be born
Dx - decelerations
OP - occiput posterior position, ie baby facing mother's tummy rather than her back. See "Get your baby lined up" for more information.
ROM - rupture of membranes, ie waters broken
TOL - Trial of Labour


Would be interested in response from the list to a request presented to me last week. The pt is 37 y.o. G6 P5 with five prior low-transverse c/s.

1st section done for "CPD" with delivery of 4 lb infant. 2nd section "elective" repeat. 3rd section "elective" repeat. 4th section after failed VBAC. c/s performed after 45' in second stage with final Dx of "fetal heart rate abnormality and persistent OP" 5th section performed after pt had experienced 24 hr of ROM (rupture of membranes, ie waters broken) without labor (records indicated hesitancy to attempt induction with four prior uterine incisions)

She is VERY motivated to attempt VBAC. My inclination is to go for it, but I'm not sure about augmentation (even with IUPC - intrauterine pressure monitor) if failure to progress occurred.

I'll be anxious to hear your opinions.

Terri Rosenbaum, M.D.


Terri: I would let her attempt a VBAC, and I would augment her if necessary. I don't know anything about your hospital and facilities, but the usual VBAC guidelines apply.

I have always thought that most ruptures occur during the 2nd. stage of labor. In addition, she could have a uterine rupture with augmentation as a G5, regardless of the prior C/S history.

Patrick S. Pevoto, M.D., FACOG


A contraindication to pitocin is a contraindication to contractions. If you are willing to allow spontaneous contractions, then what is wrong with oxytocin induced contractions ? A contraction is a contraction. The only diference is that you are doing something to bring about the contraction with the oxytocin. If properly administered and watched, there should be no more problem with pitocin induced contractions. With this patient, if I were to allow her to labor or to be augmented, I would be there with my hand on her abdomen and probably watching the Intrauterine pressure monitor as well..

R.Daniel Braun,MD Clinical Professor Indiana U. School of Medicine


>>A contraindication to pitocin is a contraindication to contractions. If you are willing to allow spontaneous contractions, then what is wrong with oxytocin induced contractions ? A contraction is a contraction. The only diference is that you are doing something to bring about the contraction with the oxytocin. If properly administered and watched, there should be no more problem with pitocin induced contractions.

But you are interfering with the normal course of events and then if somethign goes wrong you have to accept responsibility.

>With this patient, if I were to allow her to labor or to be augmented, I would be there with my hand on her abdomen and probably watching the Intrauterine pressure monitor as well..

I notice that you didn't write how you would deliver.

Here she would get an elective Vaginal Bypass and we'd really strongly try and convince her to sign for T/L (I think this means Tubal Ligation, ie sterilisation).

Dr. Eberhard W. Lisse


I would not offer this patient a trial of labor for many reasons including liability concern.
Douglas Krell MD


I do a lot of VBAC yet without any data to back me, I would recommend repeat C/S in this case. She's already had a failed VBAC as well as her fifth C/S where someone told her it was best to not labor. There's a good chance you could prove that MD wrong, but there is also a chance you could prove him right. Chances are she'd do fine with a VBAC, but I think you are out on a limb if something bad happens, and bad things do happen. Be happy with a healthy baby and do the safe thing. If you do elect to proceed with TOL, I would give her a real TOL with pit and all. Watch closely, stay in the hospital, probably in the room. Good luck.
Mitch Nudelman


I would be hesitant to offer VBAC, but if pt. insisted I would do it under double setup conditions. Pitocin question same as VBAC question- a "mild" trial of labor without pitocin if needed might not as well even be started. A recent USC study proved VBAC after greater than 1 previous C/S to be MORE dangerous than VBAC after one C/S (2% rupture rate). I've heard that those at USC no longer allow VBAC after greater than one C/S. Is this true? Any trojans out there?

Roland, M.D. Bemidi, MN, U.S.A.


>I would give her her trial - it's so rare to see someone motivated after so many repeat cesareans. I would use epidural and oxytocin as indicated. Good Luck!

I agree with Dr. Nagey. I admit, however, that there are no good data to support either decision. When confronted with similar patients, I discuss the benefit of VBAC with regards to 1 or 2 prior c/sections, and tell the patient that there really are no data with this many c/sections. We discuss the risk:benefit profile, and I'll do whatever she wants. In this situation, I can't argue with her choice for a repeat c/section, and I likewise can't argue if she wants a VBAC.

I would consider a pressure monitor if you use oxytocin, and if I saw bradycardia (slowing foetal heart rate) or significant variables (variable decelerations in foetal heart rate?) I admit that I would probably head for the OR (operating room). Please let us know how things turn out.

Ashley Hill D. Ashley Hill, M.D.


I did a VBAC on a patient with only 4 prior cesarean sections. After getting the records to show that they were low transverse cesarean sections, I let her labor (she was in favor of VBAC - I would not have pressed her to have a VBAC if she did not want to try labor). The first cesarean was done for failure to progress, the second for a breech, the third and fourth done because her last doctor insisted. She delivered without difficulty. This is anecdotal, of course, but in a closely monitored situation with the patient's informed consent and desire to attempt vaginal birth, I do not feel it is unreasonable medically or legally to attempt VBAC after multiple low transverse cesareans.

Paul D. Burstein, MD FACOG Clinical Assoc. Professor Univ. of Wisconsin Milwaukee Clinical Campus


Fri, 12 Apr 1996 00:25:59 -1000

Geoff Klein reminded me I had not provided outcome data on the patient requesting VBAC after c/s x5. A few days ago, after a 45' second stage,a successful VBAC was accomplished. She was VERY proud of herself, and rightfully so! I'm sure the successful outcome wouldn't have been possible without such a motivated patient.

I appreciated the input of the list, especially the obvious polarity of the replies.

Terri Rosenbaum

from http://forums.obgyn.net/ob-gyn-l/OBGYNL.9604/0185.html


This page last updated 6 June 2002


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