Vaginal Birth After Cesarean: Your VBAC questions answered
In the United States, 32 percent of babies are born via Cesarean Section, a surgical incision in the abdomen and uterus. 1
For the next pregnancy, those with a history of C-section have a difficult decision to make: schedule another C-Section or labor and have a Vaginal birth after Cesarean (VBAC) . Here are some common questions and answers about VBAC safety and practice to help you find your way!
Should I have a scheduled repeat C-Section or try for a Vaginal Birth After Cesarean (VBAC)?
In the past, the tagline “once a cesarean, always a cesarean” dictated our choices. Due to concern for uterine rupture, or a separation of the uterine muscle at the previous surgical scar, the recommendation was to deliver by C-Section every time to avoid labor. We now that for a good candidate, the risk of a complications of a repeat C-Section is about the same as the risk of complications from a VBAC. This means that either option could be a reasonable choice.
To make this choice, you need a provider who is willing to take the time to discuss each option in full, including what a complication might look like in either scenario to help you understand fully the decision ahead and pick the right option for you.
What risk is associated with VBAC vs. Repeat C-Section?
The risk of a VBAC is that the site of your previous surgery will open up while the uterus is contracting during labor, called a uterine rupture. This occurs during just under 1% of TOLACs when all conditions for safety are met (0.2-1.5%). This risk increases to 3.9% in the event of 2 previous cesareans.
Uterine rupture poses serious threat to the laboring person and baby. The body perfuses as much as 500mL to the laboring uterus and baby EVERY MINUTE, so excessive blood loss to both bodies can occur quickly. Blood transfusion, hysterectomy, and death are all possible complications. While maternal death from uterine rupture is rare, is does account for 5% of all pregnancy-related deaths each year. Neonatal mortality depends on the speed with which your team is able to execute surgical rescue. For people experiencing a uterine rupture, rates are approximately 2.6% in a center with surgical facilities readily available, but increases to 6% when rupture occurs at a site out of the hospital and transport to surgical care after diagnosis is attempted. 2
Risks of a repeat Cesarean section include surgical injuries to the bowel and bladder, longer hospital stay, infection in the uterus, bladder, or skin incision, blood clots in the legs or pelvis, increased pain after delivery, possible respiratory issues in the baby, and an exponentially increasing risk with each additional surgery. Depending on the severity of these complications, they can result in significant harm, morbidity, and mortality. 3
The American College of Obstetricians and Gynecologists (ACOG) has stated that VBAC is potentially safer than repeat Cesarean. With the likelihood of complications being rare and similar in each case, you are simply choosing the nature of the risk you are willing to take. While its hard to already be thinking about the next baby, consider future reproductive capacity in your decision making, as each additional C-Section becomes riskier.
What does TOLAC mean?
TOLAC stands for Trial of Labor After Cesarean. You may hear this term during your prenatal care or labor to mean that you will be attempting a VBAC instead of choosing to deliver with a repeat C-Section.
Trial of labor means watching closely as labor progresses to ensure that he laboring person and baby are tolerating labor well and to look out for any signs that the uterus and uterine scar may be under too much stress to tolerate the strong, frequent contractions needed to have a baby vaginally.
You may hear your labor referred to as ‘TOLAC’ before you have delivered and ‘VBAC’ after you have delivered vaginally.
Am I a good candidate for TOLAC/VBAC?
Candidacy for VBAC is first determined based on safety. You are safe to try a labor if:
Your first C/Section incision was made “low transverse”, or a single incision left to right along the bottom of your uterus. The way the incision on your belly looks may not be an indicator of the incision on your actual uterus. You will need a copy of the surgeon’s report to ensure you had the correct type of incision. “Classical” incisions, which are shaped like a T, or complications that caused your initial transverse incision to extend are a contraindication to TOLAC.
You have had one previous cesarean. (Some providers may consider after 2 previous cesareans, but the risk of uterine rupture is higher.) History of other surgeries or procedures on your uterus may also be a contraindication, as is a history of a uterine rupture.
You have a single baby in vertex, or head down, position
Your placenta has not implanted on top of your scar. This can cause the placenta to implant into scar tissue and have a difficult time disconnecting after your baby was born, which is a serious complication. You can discover your placenta’s position during your Anatomy Ultrasound in mid pregnancy.
Having had a previous vaginal delivery makes you a very good candidate for VBAC.
Next, you can discuss with your provider considerations for whether your are likely to have a successful VBAC. We can help evaluate this by considering the likelihood that the condition that resulted in your C-Section the first time around would occur again. Some examples of scenarios unlikely to occur again: breech or other malposition of the baby, a failed induction of labor (ex: I only ever got to 4 cm during my induction even though they tried all the medications), cord prolapse, or baby’s heart beat was concerning during labor. An indication more likely to occur again would be a failure of baby to descend through the pelvis after becoming completely dilated and pushing for many hours. If this is your story, this does NOT mean that it is impossible to have a successful VBAC, just that we can not preclude the possibility that there was a structural reason that baby was not able to enter the pelvis. While this is true for anyone who has never had a baby vaginally before, this story makes it a bit stronger of a possibility.
Every labor is different, and it is a delicate balance of the 5 P’s of labor: Passage, Passenger, Powers, Psyche, Partners. This means that the state of the vaginal canal (bones, soft tissue), the babies position and size, the strength, frequency and quality of your contractions, where you are in your mind and spirit, and the support of and attitude the people attending your labor all work together to create the birth scenario. If you have met the basic safety criteria for a trial of labor, none of the other factors are written in stone.
What are my chances of successful VBAC?
The overall rate of VBAC success is 74%. This means approximately 3 out of 4 trials of labor will end in vaginal delivery and 1 will result in a repeat C-Section. 3
What will my labor look like at the hospital?
Probably pretty similar to a typical labor in the hospital. You can be admitted when in active labor and use most of the tools available. The scope of available options for labor depends on your birthing location and their practice protocols. Most if not all hospital environments require continuous fetal monitoring- the monitors that measure baby heart rate and your contractions, and create the “strip” for your nurses and providers to monitor. This is to look out for signs of rupture at your scar site so that they can act quickly to prevent harm to you or your baby. Uterine rupture presents with a sudden drop in fetal heart rate as well as increased uterine tone. Continuous monitoring allows rupture to be diagnosed quickly and and immediately treated.
Some hospitals have monitors that are wireless for walking around or waterproof for getting into showers or tubs to make this monitoring requirement less restrictive to your labor. Ask your provider if this is available at their hospital!
You may choose to utilize all of the pain management options available or none at all. It was previously believed that it was not safe to have an epidural for fear that it would mask the signs of complication, but this recommendation has been reversed with the use of quality monitoring technology.
Can I have my baby at home?
Some providers may offer HBAC (home birth after cesarean) as an option for those who understand the increased risk. This is dependent upon provider comfort, whether or not they hold a license in their practice state, and if they are required to practice under state-mandated guidelines.
What if I need to be induced?
It is possible to induce your labor if there is a risk to your health or the babies health to remain pregnant. You can safely use the drug Pitocin to encourage contractions, but cervical ripening medications are contraindicated for those with a uterine scar. Because ripening medications (Cytotec, Cervidil) make induction more likely to be successful, strongly consider whether inductions for non-medical indications are necessary.
How do I pick a provider?
Try to find a provider that supports VBAC success! Ask lots of questions about their thoughts about and comfort with TOLAC clients.
What are your credentials? Where do you deliver?
What are your or your delivery site’s policies regarding VBAC? Do I have to have my baby by a certain time? What are my monitoring options in labor? What pain management options will be available to me at your site?
Do all the providers at your practice or delivery site support VBAC? Is there a scenario where I would not be able to try?
Will someone from your practice definitely be present during my labor or do you share call with other practices (a ‘laborist’ model).
Will you support a labor after 2 previous c-sections? (if applicable)
Remember, it is not informed decision making if you haven’t explored all the risks and benefits of ALL CHOICES AND ALTERNATIVES in a non-judgmental environment with lots of time and space to ask questions. If your provider seems like they always have one foot out the door and they are hoping you wont have any questions for them, they may not be the kind of provider who will be an advocate for you in the end.
For more information about Cesarean support, visit the International Cesarean Awareness Network at www.ican-online.org.
We hope this article has been helpful! Philadelphia Midwife Collective is located in Philadelphia, PA and offers VBAC after one cesarean at Einstein Medical Center Montgomery in East Norriton, PA.
Leave a comment or message us with your questions!
Toppenberg KS, Block, W.A. Uterine rupture: what family physicians need to know. Am Fam Physician. Sep 1;66(5):823-8, 2002.
. National Institutes of Health. NIH Consensus Development Conference Statement on Vaginal Birth After Cesarean: New Insights. March 8, 27(3) 2010