Answer
When making the choice to have a trial of labor after cesarean, it is
important to weigh the risks versus the benefit.
There is less maternal morbidity in women having a vaginal delivery
after a cesarean, provided the services are performed in a hospital
with appropriate facilities, the previous uterine incision is known to
be a low transverse scar, and there are no confounding contraindication
such as maternal illness or malpresentation.
Studies by Phelan etal (1987) and Lawson (1987) show that the overall
success rate for vaginal deliveries after 2 or more cesareans varies
little from women with one previous cesarean (58%-81%). The rate of
uterine dehiscence is slightly higher in women having more than one
previous cesarean (0-3.8% for 2 or more cesarean and 0.4-2.8% with 1
previous cesarean). These dehiscence were all asymptomatic without
serious sequelae and no maternal or perinatal mortality was associated
with the labor trials of women who had more than one cesarean.
The conclusion of these studies was that though the number of cases is
still small the available evidence does not suggest that the 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.
Nurse-midwives, working in collaboration with physicians, provide care
to women seeking a vaginal delivery after cesarean. Not all physicians
and nurse-midwives will feel equally comfortable with providing this
service. You are still early in your pregnancy, so you have some time
to interview providers. I would recommend you interview the
nurse-midwife first and specifically discuss with her what sort of
success she has had with vaginal trial of labor. I would also recommend
that you openly discuss with her your previous birthing experiences so
that she may become aware of any features that may contribute to or
prevent potential success in your trial.
It is important that she have a good consulting relationship with a
physician. Once you have chosen a nurse-midwife provider, I would also
recommend you request to speak with her physician consultant and share
with the physician your commitment to a vaginal trial of labor.
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