What is VBAC? All About Vaginal Birth After Cesarean
Many moms who've experienced a C-section enter subsequent pregnancies with the hope of avoiding 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 women 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 women who've been screened properly and deemed fit for a VBAC, the success rate is between 60 and 80 percent, according to the American College of Obstetricians and Gynecologists (ACOG).
Benefits of VBAC Birth
There are several reasons why you might want to try VBAC. Some women simply want to experience 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 blood-borne disease
- Decreased length of hospital stay
- Shorter recovery time
All in all, a National Institutes of Health (NIH) panel found that repeat C-sections expose women to greater risk of death than VBACs. This means VBACs may be the safer option.
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 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 woman 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 percent—and it’s more of a risk if you need to be induced.
The ACOG also reports there's a greater risk of infection for mother and baby in cases of attempted vaginal birth after cesarean. 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 VBAC?
Thirty to 45 percent 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 are not able to 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.
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Is VBAC Delivery Right For Me?
Before determining whether you can try for a VBAC, your doctor will give your case careful consideration. 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 women 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 cesarean performed.
- 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 abruptio 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 woman 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 women. There are lots of 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 a lot of weight since, 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 VBAC, your doctor will also consider the size of the baby 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. Ultimately, 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 VBAC
If you would like to try a VBAC 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 VBAC, 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.”
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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 mother and a healthy baby, regardless of the route of delivery."