What is VBAC? All About Vaginal Birth After C-Section

Many parents who've experienced a C-section enter subsequent pregnancies hoping to avoid the procedure again. But due to the increased possibility of uterine rupture, a vaginal birth after cesarean (VBAC) is often considered high risk by doctors. Read these important facts, and discuss your concerns and wishes with your obstetrician.

VBAC Success Rate

Many people have a VBAC without any problems. "A VBAC is a very safe option for many women who have had one previous C-section and who have been identified as low risk—and that is the majority of women," says Nancy Petit, M.D., chief of the division of obstetrics at St. Francis Hospital in Wilmington, Delaware.

In fact, for those who've been screened properly and deemed fit for a VBAC, the success rate is between 50 and 80%, according to the American College of Obstetricians and Gynecologists (ACOG).

Benefits of VBAC Birth

You might want to try vaginal birth after a C-section for several reasons; some want to experience a vaginal birth, while others choose it for the following medical reasons:

• Elimination of the need for abdominal surgery, which has inherent risks like infection, hemorrhage, and anesthesia-related complications
• Reduction of the risk for possible blood transfusions, which also lowers the risk of a blood-borne disease
• Decreased length of hospital stay
• Shorter recovery time

According to a Cochran Review of data, there appears to be no statistical difference in outcomes from planned c-sections and VBACs, meaning they may each carry the same risks and benefits.

VBAC Risks and Uterine Rupture

Along with the benefits of vaginal birth after cesarean, there are also a handful of risks. VBAC can lead to uterine rupture, a dangerous tearing of the uterine muscle, or a past C-section scar.

"Uterine rupture can be catastrophic for the baby and may be life-threatening to the mother," says Marilynn Frederiksen, M.D., an associate professor of clinical obstetrics and gynecology at the Feinberg Medical School of Northwestern University and a member of a panel of childbirth experts convened by the NIH.

If a uterine rupture results in excessive bleeding, a patient may have to undergo a blood transfusion or an emergency hysterectomy, explains William Grobman, M.D., associate professor of obstetrics and gynecology at Northwestern University's Feinberg School of Medicine, in Chicago. However, the incidence of uterine rupture is low—less than 1 %—and it's riskier if you need to be induced.

The ACOG also reports a greater risk of infection for the parent and baby in cases of attempted vaginal birth after a C-section. Nevertheless, if you're going to have a VBAC, you should give birth in a facility that's equipped to do emergency cesareans, should the need for one arise.

Do All Hospitals Offer Vaginal Birth After C-Section?

Thirty to 45% of OB-GYNs no longer offer VBACs, and some hospitals offer it only with strict stipulations, such as going into labor spontaneously before your due date. (A VBAC should never be attempted if labor has been induced.)

Fear of litigation drives much of the reluctance to allow VBACs. "Lots of providers and hospitals refuse to offer women the option because they fear getting sued if something goes wrong," says Amy Romano, C.N.M., a nurse-midwife in Connecticut and author of Lamaze International's Science & Sensibility blog. Even some midwives have stopped offering VBACs because of liability issues.

Budget cuts and lack of funding may prevent some hospitals from having the necessary personnel for a VBAC, and money may also be at play.

Recommendations from ACOG require anesthesiologists and OB-GYNs to remain in the hospital for the entirety of a VBAC. And according to Marra Francis, OB-GYN and author of The Mommy MD Guide to Pregnancy and Birth, they cannot bill for their time in doing this. "Hospitals can choose to reimburse physicians for the time they are at the hospital providing care, or they can decline to reimburse them," says Dr. Francis.

Is VBAC Delivery Right For Me?

Before determining whether you can try for a VBAC, your doctor will carefully consider your case. One important factor: the reasoning behind your previous C-section. If it resulted from something that isn't likely to recur, such as a breech baby, your chances of being able to attempt a VBAC are higher than if your C-section was due to an issue that could reemerge, such as not dilating.

Ultimately, it's up to your physician to decide what's right for you. VBAC tends to be safest for those who:

• Have had at least one vaginal delivery. If you've given birth twice, but only the second was a VBAC, you have a lower risk for uterine rupture, says Brian Mercer, M.D., professor of obstetrics and gynecology at Case Western Reserve University School of Medicine in Cleveland. Why? "Your body has demonstrated that it can complete labor," says Dr. Mercer. Therefore you're more likely to be able to do it again.
• Have had only one previous C-section. The risk of uterine rupture increases with each C-section performed.
• Had a low-transverse incision—a horizontal cut low in the uterus—during their previous C-section. If you had a high vertical or "classical" cesarean, made by cutting vertically in the upper uterus, your risk of uterine rupture is greater.
• Have a history of low-risk pregnancies.
• Are delivering only one baby who is a reasonable size.
• Do not have certain health conditions, including high blood pressure, diabetes (pre-existing or gestational), or active genital herpes.
• Have no history of uterine surgery or other uterine problems.
• Conceived longer than nine months after C-section since your body will have had more time to recover.
• Don't have placenta previa (low-lying placenta) or abruption placenta (placental separation).
• Want more than three kids. Having more than two cesareans may be riskier than attempting a VBAC, as the chance of surgical complications increases with the number of C-sections a person has. The most serious risk: placenta accreta, where the placenta abnormally adheres to the lining of the uterus. This can lead to uncontrollable bleeding and might require a hysterectomy.
• Are younger than 35. Though doctors aren't sure why older patients have a lower chance of having a successful VBAC than younger ones. There are many theories about this, says David Stamilio, M.D., associate professor of obstetrics and gynecology at Washington University School of Medicine in St. Louis: "It could be that as women age, they tend to have larger babies, or their muscles are not as conditioned. No one really knows."
• Maintain a healthy weight—if you were slim when you became pregnant and haven't gained much weight since then, your chances of a problem-free VBAC are higher. "Being overweight doesn't rule one out, but the increase of soft tissue around the pelvis may make it harder for a baby to come through the birth canal," says Dr. Mercer.

When determining if you're a candidate for vaginal birth after cesarean, your doctor will also consider the baby's size relative to the size of your pelvis. If the baby can't fit, your uterus may be subject to prolonged stress in a delivery that won't progress properly.

Also, there may be factors that could signal possible complications during the baby's delivery (for example, breech presentation), which, coupled with the other risk factors of prior cesarean, might make VBAC too risky.

In the long run, most of these factors can be identified prior to the delivery. So you should be able to discuss your options and wishes at length with your health care provider.

Preparing for a Vaginal Birth After C-Section

If you want to try a vaginal birth after a C-section and are a good candidate, start researching your options early in pregnancy. If your doctor or hospital doesn't allow VBACs, consider other providers. For example, a major medical center with a level-3 NICU (neonatal intensive-care unit) and round-the-clock staffing by anesthesiologists is more likely to offer the option than a small community hospital.

Also, follow the experts' advice: Take childbirth classes that address vaginal birth after C-section, and read as much about the process as possible.

Support and information can come from childbirth educators, doulas, midwives, and women online and in other communities who have had a VBAC. "Making a choice that is not considered mainstream, even when research supports its safety, can be very difficult," says nurse-midwife Romano. "So the more support a woman has, the better."

Regardless of your approach, focus on the fundamental goal. Iffath Hoskins, M.D., chair of obstetrics and gynecology at Lutheran Medical Center in Brooklyn, New York, reminds all her VBAC patients about what really matters: "A successful birth means a healthy woman and a healthy baby, regardless of the route of delivery."