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Everything You Need to Know About VBAC

If you’ve had a c-section in the past, you’re probably wondering what you need to know about VBAC vaginal birth after cesarean. Well, I’ve got the answers you’ve been looking for. Here is everything you need to know about VBAC, including the benefits, risks, how to increase your chances of success, and a word of encouragement from a fellow c-section mama.

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If you’ve given birth by c-section, you may wonder what your options are if you want to have another baby. Let me assure you: like all things, you have options and you get to choose. 

Except in rare cases, a woman who has had a previous c-section has two options for her next birth when it comes to “mode of delivery” as they call it: 1) another c-section or 2) a vaginal birth, which we call a “VBAC,” or vaginal birth after cesarean.

You can head over to my blog post about c-sections to learn more about those, including the risks of repeat c-sections. But in this article, we’re going to cover everything you need to know about VBAC.

What is a VBAC?

Let’s start with the basics. A VBAC is a vaginal birth after cesarean, and it’s exactly what it sounds like – when a woman who has had a c-section before gives birth vaginally.

Technically, a birth is not a VBAC until the baby has been born. That’s because of the possibility of another c-section, even if a repeat c-section wasn’t the plan. Until a vaginal birth has actually happened, the woman’s experience in labor is referred to as a “TOLAC,” or a trial of labor after cesarean. 

Benefits of a VBAC

Trying for a VBAC has many benefits, both for mom and baby. Overall, VBAC is associated with lower rates of death and fewer complications. And if you successfully have a VBAC, you are much more likely to have more vaginal births in the future!

To be more specific, VBAC is beneficial for mom because…

  • Risks of surgery are avoided (higher blood loss, damage to organs, possible infection, longer recovery);
  • There’s a decreased chance of placental problems in future pregnancies (which means it will be safer to have lots of kids, if that’s what you want); and 
  • You get to experience vaginal birth.

A VBAC is good for baby because…

  • He or she experiences the fetal heimlich maneuver which expels amniotic fluid from airways (which means fewer breathing problems); 
  • Vaginal birth exposes him or her to healthy bacteria in the vagina that improves their overall health; 
  • They experience the normal hormonal surges that happen during labor; and 
  • Vaginal birth usually means higher rates of successful long-term breastfeeding.

Risks of a VBAC

Clearly, vaginal birth has lots of benefits, even after a previous c-section. As would be expected, there are also some risks. Gratefully, these risks are relatively rare. And, as I’ll explain, the risks most often cited aren’t all that they initially appear.

Uterine Rupture

The main risk of a VBAC is uterine rupture. Uterine rupture is when the uterus tears open spontaneously. It most often happens along the line of an incision from a previous c-section. It sounds scary and it is dangerous but, thankfully, it is rare.

Uterine rupture happens in just 0.07% of pregnancies. (That’s 70 out of 100,000 births.)

If a uterine rupture were to occur during a TOLAC (remember, that’s a “trial of labor after cesarean”), an emergency c-section would happen immediately and most of the time, both mom and baby would be alright.

Complications from an Unplanned Repeat C-section

Another risk you’ll hear about has to do with an unplanned repeat c-section after a trial of labor. A successful VBAC is almost always better than an elective repeat c-section. That said, a TOLAC that ends in an unplanned c-section may have more risks than an elective repeat c-section.

This claim is true from one standpoint: an emergency c-section often is more dangerous than a planned c-section.

If you and your baby need an emergency c-section, whether it’s your first child or your fifth, time is likely of the essence. The rush to get you and your baby out of danger can lead to severe hemorrhage, complications from rapidly administered anesthesia, and accidental injury to you or your baby.

That said, an emergency c-section is unlikely. In the case of a VBAC, a trial of labor is successful about 60-80% of the time.

The reason I take issue with the claim that a TOLAC is more dangerous than a repeat c-section is because the argument is based on a misrepresentation of the numbers.

I’ll talk more about that in a moment.

Hysterectomy

Another risk of a VBAC is the possibility of needing a hysterectomy. A hysterectomy is a surgery to remove a woman’s uterus. It is sometimes necessary in cases of heaving bleeding or severe damage to the uterus.

Yet again, this risk is not exactly what it seems.

A TOLAC doesn’t directly increase your risk of hysterectomy. A TOLAC increases your risk (slightly) of uterine rupture and uterine rupture is a risk factor for hysterectomy. That means that attempting a VBAC only indirectly increases your chance of hysterectomy.

And, again, it is unlikely. If you were to be one of those 0.07% of cases of uterine rupture, you would still only have a roughly 10% chance of needing a hysterectomy.

Finally, studies have found that hysterectomy and blood transfusion are no more likely for a woman trying for a VBAC than a woman having an elective repeat c-section. 

The Hidden Truth About VBACs

I mentioned a moment ago that I don’t like when people say that a TOLAC is more dangerous than a repeat c-section. Now I want to explain why in more detail – with an analogy.

An Analogy: To Bike or Not to Bike?

Let’s say you have a family party to go to a few miles away. You’re excited to go. It’s a nice sunny day and the roads are good the whole way there, so you’re trying to decide if you want to bike or drive.

Because you are such a logical thinker, you want to do whatever makes the most sense statistically. 

You know that driving a car makes it more likely that you’ll get in an accident – 1 in 63 people will get in a car accident any given time they drive a car. But you also know that only 1 in 147 accidents is fatal. That means if you drive a car you have a 0.01% chance of dying. 

If you take your bike, on the other hand, it’s quite unlikely that you’ll get hit – 1 in 83,333 people will get hit by a car while riding their bike. Yet you also know that if you are one of those unfortunate people who do get hit, your chances of surviving are worse – 1 in 65 accidents is fatal.

That means if you take your bike you have a 0.000018% chance of dying.

In short, bike accidents are less common but more fatal than car accidents, and car accidents are more common but less fatal than bike accidents. That means your chance of dying is actually higher in a car than on a bike.

In other words, there are two necessary factors: how bad an accident could be AND how likely that accident is. Leaving out one paints an incorrect picture. 

Applying the Analogy

It’s the same with repeat c-sections and VBACs. A repeat c-section is like driving your car. A VBAC is like taking your bike.

Your chance of dying if you experience uterine rupture is 10.5%. But a uterine rupture only happens 0.07% of the time. That means your risk of dying from a TOLAC that ends in uterine rupture is actually only 0.0074%. That’s only 7 out of 100,000.

According to one study, your risk might actually be as low as 0.0038% – about 4 out of 100,000. 

On the other hand, if you choose a repeat c-section without laboring first, your risk of dying is 0.0134%. That’s 13 per 100,000 births – almost twice what it is for a TOLAC.

And YOU GET TO CHOOSE how common this one is. If you don’t choose to schedule a c-section, you avoid this risk completely!

So next time someone tries to tell you that it’s safer to schedule a repeat c-section than to try for a VBAC…tell them you prefer to ride your bike.

How to Increase Your Chances of a Successful VBAC

Now that you understand the benefits and risks of a VBAC, let’s talk about what you can do to prepare for one. There are things you can do now to increase your likelihood of a successful VBAC.

Before we get to those, I do want to point out that if you’ve given birth vaginally before (that is, before you had a c-section), a VBAC is more likely to be successful for you. It’s not something you can do at this point, but it is a factor so I wanted to make sure you knew.

Now let’s get to what you can do.

Eat well during pregnancy.

First and foremost, eat well. Good nutrition during pregnancy is important for lots of reasons. One of those is that a nutrient-dense diet supplies your muscles and tissues with the things they need to be healthy, flexible, and ready to give birth to a baby.

And the more ready your body is, the better labor will be able to proceed like it’s meant to and without injury.

I recommend The Brewer Diet. You can learn all about it in The Brewer Diet: What, Why, and How (+ free checklist).

Exercise regularly throughout pregnancy.

Exercising during pregnancy also has many benefits. When it comes to preparing for a VBAC, exercise is beneficial because it can reduce your risk of developing fibroids. Fibroids are non-cancerous growths in the uterus.

They can cause problems during labor and are a risk factor for hysterectomy so it’s a good idea to avoid them.

But beyond that, if something lessens your chance of developing fibroids, that probably means that same something is keeping your uterus healthy. So if exercise helps you avoid fibroids, it likely also reduces your risk of uterine rupture.

RELATED >> The Best At-Home Pregnancy Workouts

Choose a labor support person who can be with you through all of labor.

Having a familiar, trusted person with you continually during labor has lots of benefits no matter what your birth history is. Those positive effects include better chance of a vaginal birth and less likelihood of a c-section.

That sounds like exactly what a woman trying for a VBAC needs.

A doula is likely going to help you achieve the best outcomes, but anyone – your husband, your best friend, your mom – can be your support person.

Stay home until active labor begins.

Even if you plan to give birth in the hospital, labor at home as long as you can. Learn the signs of the different stages of labor so you know when you are in active labor and you can avoid going to the hospital too soon.

Home is the ideal place for early labor because at home you are more relaxed, you can move around more, and you can eat and drink whatever you want. Each of those things will help you to labor more effectively and more comfortably.

Plus, the longer you stay home, the shorter amount of time you’ll be in a situation where interventions and medications are common (both of which can negatively affect your labor and make a c-section more likely).

Work through your fears about birth.

In 1933, Dr. Grantly Dick-Read, an obstetrician and natural birth advocate, introduced a concept that we now call the “fear-tension-pain cycle.” In short, his belief was that a woman who was afraid to give birth would hold that fear as tension in her body.

That tension would prevent her from relaxing and therefore make contractions more painful. The more pain the woman experienced, the more scared she would get and the cycle would continue.

That cycle is the idea behind the many childbirth methods that emphasize relaxation, hypnosis, and breathing techniques. Beyond relaxation, though, if a woman can address her fears before going into labor, she has a much higher chance of a successful, comfortable vaginal birth.

Why? Because emotions affect our body. If we are scared, we naturally hold back or tense up and that makes labor harder and more painful and it makes injury (like uterine rupture) more likely.

Ask questions when your doctor recommends anything.

As much as I wish I could teach you everything you need to know to have a wonderful birth experience, I don’t know your care provider and I won’t know every situation you’ll be in. That’s why it’s so important for you to ask questions any time your care provider recommends something.

Especially when planning a VBAC, small things can have big consequences (like getting induced, which we’ll talk about in a second). Do everything you can to make sure you’re getting all the information. 

To make sure you’re truly informed, you can use the acronym BRAIN.

Using BRAIN to Get Informed

B is for benefits. Anytime a procedure or intervention is suggested, ask what the benefits are to you and your baby.

R is for risks. You also want to make sure to ask what any and all risks are that are associated with whatever your care provider is recommending. Make sure to ask about risks to both you and your baby, short-term and long-term.

A is for alternatives. After understanding the pros and cons, ask what possible alternatives exist.

I is for intuition. Once you have all the information, trust your intuition. Some people call it a gut feeling. Some people call it inspiration from God. Whatever it is to you, trust that.

N is for nothing (or for “natural” or “normal”). Your care provider may make lots of suggestions, but that doesn’t mean you have to do any of it. Birth is a normal, natural process that usually proceeds without complications. Remember that doing none of what is recommended is an option, too.

Things That Decrease Your Chances of a Successful VBAC

In addition to understanding what you can do to improve your chances of a successful VBAC, it’s important that you know what can decrease your likelihood of a VBAC, or, said a different way, what can increase your likelihood of a repeat c-section.

Factors that can negatively influence your chance of a successful VBAC include:

  • Where you give birth
  • How many c-sections you’ve already had
  • The kind of incision made for previous c-section(s)
  • How long it’s been since your last birth
  • Medications and other interventions during labor (including induction)
  • Carrying multiples (twins or more)
  • Unideal positioning of the baby
  • Maternal age
  • Being overweight
  • Pre-existing conditions (like heart disease)

Let’s look at those in a bit more detail.

Where You Give Birth

Your birth location is probably the biggest factor in whether or not you have the VBAC you’re hoping for. Choosing a hospital instead of a home birth or a birth center will affect your chances simply because doctors are more likely and more able to move you to the operating room at the first sign of distress.

Surprisingly though, which hospital you go to matters too. Some OBGYNs will be more comfortable with VBACs than others. Some hospitals may not be equipped to handle the possible uterine rupture and emergency surgery so they won’t even allow a TOLAC.

And it’s not only that. One study found that your chance of a c-section may increase by more than nine times depending on which hospital you go to. Though that study wasn’t specifically about repeat c-sections, second- and third-time c-sections are certainly part of those rates.

The point is that you should ask your doctor and your hospital what their c-section rates are and if they’re not satisfactory, find a different doctor and hospital! (Or just hire a midwife.)

Number of C-sections

While it’s true that VBACs can be low-risk and safe for the majority of women, the more c-sections you’ve had, the more risky each birth gets. For some women, multiple c-sections could safely be followed by a VBAC.

For others, scarring or placenta problems could make anything but another c-section dangerous.

Usually, if you’ve had 3 or more c-sections, doctors will not allow you to try for a VBAC. Some midwives may allow for a VBAC after several c-sections, after checking for health concerns and risk factors.

Incision Type

The kind of incision you’ve had matters because a vertical incision is far more likely to tear open than a horizontal one. The good news is that horizontal incisions are used the majority of the time, so you likely won’t have to worry about it.

Time Between Births

As for the length of time between births, it’s been found that the shorter the period of time between your last c-section and your next birth, the more likely it is that you’ll experience uterine rupture. And uterine rupture always leads to a c-section.

Generally, it’s recommended that you wait at least 18 months after a c-section before trying for a VBAC.

Getting Induced and Other Medical Intervention

As I alluded to earlier, induction can increase your risk of uterine rupture and a failed VBAC. No matter what induction method is used, it increases stress on the uterine muscles making rupture more likely.

This also applies to any use of synthetic oxytocin (or Pitocin) during labor. One study found that using synthetic oxytocin during labor decreased the likelihood of VBAC from nearly 75% to about 60% and increased the risk of uterine rupture from 0.7% to 2.2%. 

Multiples (Twins or More)

OBGYNs will perform a c-section for twins most of the time, even if it’s a mother’s first birth. When a woman has already had a c-section, a doctor is likely to be even more hesitant about a vaginal birth. 

In addition to that, twins are going to put more pressure on a mother’s uterus, especially if she carries them to full term. And more pressure makes rupture more likely.

Unideal Positioning of Baby

Like with multiples, an OBGYN is likely to perform a c-section if your baby is breech (butt or feet down) or transverse (horizontal in the uterus). If you’ve already had one c-section, that’s even more likely.

Maternal Age and Being Overweight

A mother’s age and weight are tricky subjects when it comes to the possibility of increasing risk. Though older women and women who are overweight do tend to have more c-sections, it may not be true to say that these factors always increase your risk.

A 37-year-old woman may be in far better shape – and therefore much more prepared for a vaginal birth – than a 20-year-old woman. 

And a mother who has an average weight may have other complications that make it more likely that she’ll have a c-section than a mother with an otherwise healthy pregnancy who is overweight.

So while it’s a good idea to be aware of age and weight as factors in the likelihood of a VBAC, know that there are likely things that have a far greater effect on your outcomes.

Pre-existing Conditions

Certain medical conditions that existed before pregnancy may make it unsafe to go through labor or birth a baby vaginally. This list is shorter than many people believe, though.

If you have an active HIV or herpes infection in your vagina, giving birth vaginally will likely pass that on to your baby. That is usually a good reason for a c-section.

Heart conditions may also make it unsafe for you to get pregnant and give birth. Even then, though, many times vaginal birth can still be safely attempted.

Circumstances like having diabetes or uterine fibroids can increase your need for a c-section but don’t necessarily require one.

When NOT to Try for a VBAC

Though VBAC is a good option for most women most of the time, like most things, there are exceptions. You cannot have a VBAC if…

  • You’ve experienced uterine rupture before
  • Your incision is vertical instead of horizontal (usually)
  • You have major placenta previa and the placenta doesn’t move on its own
  • You’ve had other surgeries on your uterus, such as fibroid removal
  • You have certain health conditions that make it unsafe (e.g. heart disease or herpes)
  • You’re pregnant with triplets or more (usually)
  • You’ve had 3 or more c-sections (usually)

If you fit in one of the above categories, don’t despair. A c-section is still a valid way to give birth and you and your baby will likely be okay.

Now, I have something I want you to hear.

A Word of Encouragement

Whether you’ve had a c-section in the past or you are pregnant now and know you will need one for this coming birth, I have a bit of encouragement for you. Straight from the mouth of a family member of mine who had a traumatic c-section with her first baby, here’s what I want you to hear:

“You are not a bad mom. You didn’t take the easy way out. Your birth story is still valid. You are still a mom – a good mom. There is value in every story and every experience. Healing IS possible and available. You’ve got this!”

Summary: Birth Is Beautiful

To sum up, most women will be able to try for a VBAC, and most who do will do so successfully.

Vaginal birth provides benefits to both mom and baby that c-sections don’t, such as less chance of breathing problems, hemorrhage, and infection and more chance of breastfeeding, long-term health, and satisfaction with the birth experience.

VBAC does present risks, but the main risk is uterine rupture, which is rare.

Claims that a trial of labor is more risky than an elective repeat c-section don’t hold up. And most other complications, such as hysterectomy, happen equally as often whether a woman chooses a VBAC or a repeat c-section.

You can do things during pregnancy (like eating healthy) to improve your chance of a successful VBAC. And there are things that decrease your chances of a VBAC, such as getting induced.

Occasionally, a woman will not be eligible to try for a VBAC because of circumstances such as previous uterine surgery or placental problems. 

But above all that, what I want you to remember is this: your body was created to give birth. And it will do so safely and effectively most of the time.

In reality, neither a VBAC nor a repeat c-section is life-threatening the overwhelming majority of the time. All the factors we talked about are the exceptions.

So don’t be afraid. Birth is supposed to happen. And it’s supposed to be beautiful. Let’s do what we can to keep it that way.

Until next time,

Allison

READ MORE:

C-sections: Why and How to Avoid Having One

Birth Center vs Hospital: What They’re Like and Factors to Consider

Are Home Births Safe?

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