Considering Vaginal Birth After Cesarean
If you’re considering having a VBAC (vaginal birth after cesarean), you’re not alone. A national survey found that almost half of those with a previous cesarean were hoping for a VBAC for their current pregnancy. In spite of this, the United States VBAC rate was a mere 13% in 2018 according to the CDC.
Why don’t more families have the VBAC they tried to plan? Research shows that in most cases, a VBAC is safer than a repeat cesarean.
ACOG (The American College of Obstetricians and Gynecologists) recommends VBAC. Still, it’s often difficult to find support for a VBAC. Here’s what you need to know, and what you can do to prepare for your VBAC.
Why is VBAC Hard to Get?
Despite the research and the professional recommendations suggesting VBAC is a good idea in most cases, support is often hard to find. Many doctors will say they ‘do vbac,’ but have so many stipulations and rules that only a tiny percentage of people will ultimately qualify to have a vaginal delivery.
OB GYN’s and Midwives have concerns over litigation, face restrictive hospital policies on labor and delivery and insurance restrictions. Many are nervous about VBAC and have little trust or experience with vaginal birth after cesarean.
This lack of trust and experience leads to providers who are quick to intervention or swift to ‘give up’ and suggest repeat c section.
What are the Benefits of VBAC?
If you want to have a vaginal birth experience, it’s a legitimate desire. In most cases, it is what’s best for both the baby and the mother’s health.
Cesareans carry many risks, most of which are rarely talked about. Many of the risks compound the more cesareans you’ve had. So the first benefit of VBAC is avoiding of all the repeat cesarean risks.
Every time you have a cesarean birth, you are putting your next baby at increased risk. In many cases this is a small increase in risk, but if you plan to have a large family, avoiding cesarean is one of the best things you can do for you and your future pregnancies.
Each subsequent c-section delivery can become more difficult and increases the risk that your placenta will attach deeply onto your cesarean scar (defined as a form of placenta accreta). Placenta accreta can make it hard to get the placenta out after birth which can result in hemorrhage and damage to the uterus and ultimately result in a hysterectomy (removal of the uterus).
Simply planning a VBAC does not make you a super specialized case requiring all kinds of extra care and permissions and caution. If your provider treats you that way, you may want to find a new provider.
Is VBAC Safe? What are the Risks?
The main risk of a trial of labor after cesarean (TOLAC) is the risk of uterine rupture, or the possibility that the scar tissue on your uterus may tear. It can happen in pregnancy or during contractions in labor, and it compromises the placenta and baby’s oxygen when it does.
ACOG (The American College of Obstetricians and Gynecologists) recommends waiting at least 18 months between pregnancies. If you conceive 6 months or less after having a cesarean delivery, the risk of uterine rupture is higher.
When the uterus ruptures, a change is noted in the baby’s heart rate and an emergency c-section is required. A uterine rupture in a woman with a low-transverse scar from a prior caesarean is very rare, occurring in less than 1% of those laboring for a VBAC.
The NIH (National Institutes of Health) reports that women who attempt VBAC is slightly riskier for the baby than repeat cesarean, but the risk is approximately equivalent to the risk of a baby being born to someone who has never had a baby before. Since no one recommends universal cesareans for first births, we can assume babies who undergo a trial of labor after one cesarean are at significantly less risk than many clinicians would have us believe.
On the other hand, your risk of uterine rupture with a VBAC is slightly higher than your risk of a rupture with a planned repeat cesarean, according to the NIH statement — though the chance of this happening is low. If your uterus does rupture, you’ll need an emergency cesarean.
The NIH states that VBAC is a safe and prudent option for most people and that there is a 74% success rate for those who are given a chance to have a vaginal birth.
Am I a Candidate for Vaginal Birth After Cesarean?
Most providers who offer VBAC are comfortable with one (or maybe two) previous c-sections, as long as your uterine incision was low transverse. If you have had two or more cesareans, it’s still possible! Finding a provider can be much more difficult.
- You had a previous vaginal delivery (including a previously successful VBAC)
- Your incision (on the uterus) was low-transverse
- The reason for your first Cesarean Section is a factor too. Your VBAC success rate increases if your C-section was for a non-repetitive reason, meaning the cesarean surgery was performed due to the baby’s health (such as a breech baby), rather than the labor process
- You are younger than 35 – a 2007 study found that women under 35 years of age were more likely to have a successful VBAC and had fewer complications
When is VBAC Not Recommended?
- If your incision (on the uterus) was classical (high, vertical), VBAC will not be recommended.
- You are pregnant with multiples
- If your baby is in the breech position, you are not a VBAC candidate unless your baby rotates before labor (here is a post on breech babies and what you can do)
- You are considered high risk
How to Increase Chances of VBAC Success
The following suggestions will help you prepare for a successful VBAC.
1. Choose the Right Provider
If you don’t do anything else, this is the one you really need to pay attention to. Almost half of the people who would like a VBAC birth end up limited to repeat cesarean because their provider prefers it or scares them into it.
The choice is legally yours, not theirs. This doesn’t prevent manipulation of families leading to repeat cesareans.
A large national U.S. study found that, when talking about birth after cesarean delivery, 88% of obstetricians recommended repeat cesarean and only 37% spent some time talking about the benefits of VBAC. Scheduled repeat cesarean is much easier on the staff.
If you want a VBAC, you must find someone who regularly does VBAC. OB or Midwife is often the most important choice that many women desiring a VBAC have to make. Some providers are even excited to offer them! The midwifery model of care is often more supportive of VBAC. Not all Midwives support VBAC clients, but they’re much more likely to be supportive.
There’s a difference between VBAC Tolerant providers and those who are VBAC Friendly.
- Uses a VBAC calculator to predict your chance of successful VBAC
- Requires you to go into labor by 40/41 weeks
- Will not induce or augment labor
- Suggest your baby may be too big/require you to get a 3rd trimester ultrasound
- You must progress at X cm/hour during labor
- Require you to come to hospital early in labor
- Require epidural be placed just in case an emergency cesarean becomes necessary
- Internal fetal monitoring and/or intrauterine pressure catheter required
- Do not go over risks of repeat cesarean
- Is in a practice/shares call with an unsupportive provider and will not promise that he/she will attend your labor
- Do not place arbitrary restrictions on length of pregnancy
- Induction or augmentation are options if medically necessary
- Do not use baby weight estimate to discourage you from VBAC
- Will not place time limits on labor as long as mom and baby are doing well
- Encourage you to labor outside of hospital for a longer period of time in order to avoid unnecessary interventions
- Their statistics show low cesarean and high VBAC rates
- Go over both the risks of repeat cesarean and the risks of VBAC so you can make an informed decision
- Can promise that they or an equally VBAC supportive provider will be at your birth
Don’t Settle on a Doctor or Midwife until You Know:
- What is the practice’s or the provider’s VBAC rate?
- In what situations do they feel comfortable going forward with a trial of labor?
- What does a TOLAC (Trial of Labor After Cesarean) look like in their practice?
- What events will risk you out—during pregnancy and during labor?
It doesn’t matter how nice they are, or how many supportive things they say. If their statistics and policies don’t match VBAC Friendly requirements, you may be subject to a bait and switch.
2. Choose the Right Birth Place
A supportive and VBAC Friendly provider doesn’t benefit you much if the hospital where your birth takes place has restrictive rules that limit your provider’s decisions.
VBACs typically take place in a hospital, so finding a VBAC Friendly hospital is key. Some have even have VBAC bans and many are only VBAC tolerant. Along with your choice of provider, the hospital or birth center you choose is the biggest influence on whether or not you have a successful VBAC.
3. Take an Evidence Based Childbirth Class
It’s important to take a good, physiologic, evidence based childbirth class if you previously had a cesarean birth (c-section) and would like to have a vaginal birth after cesarean (VBAC) this time around.
Taking a good childbirth preparation class like the Beyond the Birth Plan will prepare you for the intensity of birth, make you aware of your available options and choices and help you understand how, when, and how often different medical interventions are used.
When planning a VBAC it’s even more important to be informed on how and when interventions should or should not be used during labor and birth. It may make all the difference in accomplishing a vaginal birth.
4. Hire a Doula
Research shows that cesareans are much less likely when a doula is present—anywhere from 25%-56%.
You can learn more about doulas and the benefits of hiring a doula here.
5. Join a Support Group
The International Cesarean Awareness Network (ICAN) supports families who have had cesareans, are planning cesareans, and especially those who want to deliver their babies vaginally after a cesarean. The people involved in your local ICAN chapter will know who the most VBAC Friendly providers are, which hospitals see the most VBACs, and which doulas know the ins and outs of supporting VBAC clients.
6. Consider Induction
Many providers have rules against induction for TOLAC patients. In general, letting baby choose his birth day is key to a lower intervention birth. More cesareans are done—VBAC or not—when your body is ‘forced’ into labor.
In general avoiding induction is a good goal. The problem is that if your doctor or midwife wants you to go into labor by week X and also won’t induce your labor, you’re more likely to end up with a repeat cesarean because you weren’t given a chance to labor.
So while induction itself leads to more cesareans, in the case of a labor deadline without tools to induce labor, you may not even have a chance.
Induction has been found to be safe and lead to vaginal birth in about two thirds of cases. Talk with a provider who is open to using some methods which are safe.
You may be able to bypass this problem by using some of the many methods for getting labor started outside the hospital—nipple stimulation, acupuncture, chiropractic care, regular consumption of dates, sexual intercourse.
Since you never know what’s going to help your body kick into labor, it’s better to have all the options. So if there’s a practice in your area that is open to induction for VBAC clients, a vaginal birth is more likely if you go there.
The ideal is a provider who is both open to induction and won’t require you to be in labor by 40 weeks.
7. Read Positive VBAC Birth Stories
Reading positive VBAC birthing stories can be very encouraging especially as you near your due date. Your mind plays a significant role in your overall labor experience. Following are links to several VBAC birth stories:
8. Ask the Right Questions
Questions to Ask Before VBAC:
How long can I push during a VBAC?
Limits on pushing times can mean the difference between another cesarean section and a vaginal birth. If both you and baby are doing fine, will limits be placed? And are they shorter time limits than those given to first time moms?
Will the provider encourage an epidural?
Who will actually be there on birth day? Will this person encourage the use of an epidural “just in case.”
When do I need to come to the hospital?
If the provider is nervous enough about labor with a uterine scar that they want you at the hospital immediately, that’s a red flag. Staying home until active labor is widely acknowledged to prevent intervention generally. Since in a majority of cases there is nothing about VBAC labors that differs from regular old labor, this also holds true, of course, for VBAC.
Will continuous fetal monitoring be required?
Constant monitoring is often required or encouraged for TOLAC. You may not be able to avoid this, but continuous monitoring is shown to increase cesarean rates and not outcomes when compared to intermittent monitoring.
Is there a limit to how long I can labor?
Arbitrary limits on labor duration obviously increase the incidence of cesarean. Ask if, as long as both baby and mom are doing well, labor can take its time.
Will you schedule a cesarean at 40 or 41 weeks?
If there’s a restriction on how long you’re “allowed” to be pregnant, and a cesarean is scheduled for a certain number of weeks, that really limits the faith in your body’s ability to birth the baby.
Can I try for a VBAC after 2 cesareans? After 3?
Many health care providers at least give lip service to vaginal birth after one cesarean. A good way to tell a VBAC Friendly provider from one who merely tolerates it is to ask if they work with people who have had 2 prior cesareans. A better measure is their VBAC rate, but that number is often harder to get. Cesarean rate in general is also a good measure of how quick they are to head to the operating room.
Will it Work? Can I Have a VBAC?
Birth is one of those things in life we have very little control over. The NIH reports that 74% of pregnant women who are given a chance do have a vaginal birth, so the statistics are good. (Nervous about labor? Read How Will Labor be for me?)
There are a number of things that impact where a trial of labor ends up, and some considerations that may constitute a “good sign.”
1. You have a VBAC Friendly provider.
2. The hospital or birth place is also VBAC Friendly and has good VBAC rates.
3. You have no other extenuating circumstances that make the provider nervous.
4. You labored with your first baby—your cesarean was not pre-labor.*
5. You breastfed for 6 months or more.*
6. You have a doula.
7. You both want and believe in your ability to have a safe vaginal birth.
* Numbers four and five have to do with the way the labor hormone oxytocin works in your body. If you’ve not labored or breastfed in the past, your oxytocin and the receptors are not as ‘practiced.’
Disclaimer: Pregnancy by Design’s information is not a substitute for professional medical advice or treatment. Always ask your healthcare provider about any health concerns you may have.
Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Listening to Mothers III: Pregnancy and Birth. New York: Childbirth Connection, May 2013.Retrieved from http://www.nationalpartnership.org/our-work/resources/health-care/maternity/listening-to-mothers-iii-major-findings.pdf
Hodnett, E. D., S. Gates, et al. (2012). “Continuous support for women during childbirth.” Cochrane Database of Systematic Reviews: CD003766.
Kozhimannil, K.B., R. R. Hardeman, et al. (2016). “Modeling the Cost-Effectiveness of Doula Care Associated with Reductions in Preterm Birth and Cesarean Delivery.” Birth, Volume 43, Issue 1.
National Institutes for Health (2010). National Consensus Development Conference Statement on Vaginal Birth After Cesarean: New Insights. Retrieved from https://consensus.nih.gov/2010/images/vbac/vbac_statement.pdf
National Institutes for Health. Induction of labor after a prior cesarean delivery: lessons from a population-based study.
Shatz L., Novack L., Mazor M., Weisel, R.B., Dukler, D., Rafaeli-Yehudai T., Israeli O, Erez O. (2013). Induction of labor after a prior cesarean delivery: lessons from a population-based study. J Perinat Med. 2013 Mar; 41(2): 171–179. doi: 10.1515/jpm-2012-0103
VBAC.com. What is a Uterine Rupture and How Often Does it Occur? Retrieved from https://www.vbac.com/what-is-a-uterine-rupture-and-how-often-does-it-occur/#.Xc8ghEVKjBJ
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