The VBAC Choice: Weighing the Risks and Benefits

Considering a VBAC for your next birth? You’re not alone, and the good news is—there are options! Whether you’re exploring the benefits, wanting to understand the risks, or wondering how to prepare, this guide will give you the facts you need to make the best decision for your body and your baby.

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If you’ve had a c-section, you might be wondering about your options for your next birth. The good news? You do have options, and you get to decide what feels right for you.

In most cases, there are two paths forward: another c-section or a vaginal birth, often called VBAC—short for vaginal birth after cesarean.

If you’re curious about repeat c-sections, I’ve got you covered in another blog post where I break down the risks and considerations. But for now, let’s dive into what you need to know about VBAC—because having the right information can make all the difference.

What is a VBAC?

Let’s start with the basics: a VBAC, or vaginal birth after cesarean, is exactly what it sounds like—when a woman who’s had a c-section gives birth vaginally.

Technically, it’s only called a VBAC once the baby is born. Because of the possibility of a repeat c-section, doctors may refer to the process as a “TOLAC,” or a trial of labor after cesarean.

Benefits of a VBAC

Planning a VBAC offers significant benefits for both you and your baby. Overall, VBAC is linked to fewer complications and lower mortality rates compared to repeat c-sections. Plus, if you have a successful VBAC, your chances of having vaginal births in the future increase significantly!

Here’s how VBAC can benefit you:

You avoid the risks of surgery, like higher blood loss, organ damage, infection, and a longer recovery.
There’s a reduced risk of placental complications in future pregnancies, making it safer if you plan to have more children.
You get to experience the process of vaginal birth, which many women find empowering and rewarding.

And for your baby, the benefits include:

A natural “fetal Heimlich maneuver” during birth, which helps clear amniotic fluid from their airways and reduces breathing problems.
Exposure to beneficial vaginal bacteria, which can boost their overall health and immune system.
Experiencing the hormonal surges that occur during labor, which support their transition to life outside the womb.
Higher likelihood of successful, long-term breastfeeding.

Risks of a VBAC

While VBAC has many benefits, it’s natural to want to understand the risks as well. Thankfully, these risks are relatively rare, and some are often misunderstood. Let’s break them down.

Uterine Rupture

The main risk associated with VBAC is uterine rupture, which occurs when the uterus tears along the scar from a previous c-section. While this sounds alarming, it’s essential to put it in perspective.

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

If a rupture happens during a trial of labor (TOLAC), emergency care is available and, in most cases, an immediate c-section ensures that both mom and baby are safe.

Unplanned Repeat C-section

Another risk often discussed is the possibility of needing an unplanned repeat c-section during a TOLAC.

It’s true that an emergency c-section can carry more risks than a planned one, such as heavier bleeding, anesthesia complications, or accidental injury. (This is the case whether you’re having your first child or your fifth.)

However, a trial of labor is successful 60–80% of the time, making an emergency c-section unlikely for most women.

And while the numbers may suggest higher risks with an unplanned c-section, they often don’t account for the overall lower risks of complications when VBAC is successful. (We’ll talk more about that in a moment.)

Hysterectomy

The possibility of needing a hysterectomy—a surgery to remove the uterus—is another risk sometimes associated with VBAC. Here are a few things to know about this risk:

A TOLAC doesn’t directly increase your risk of hysterectomy. Instead, the connection comes indirectly, from the rare occurrence of uterine rupture, which is a risk factor for hysterectomy.
Even in the rare case of uterine rupture (0.07%), only about 10% of those cases result in a hysterectomy.
Studies suggest that the likelihood of needing a hysterectomy or blood transfusion is no higher for women planning a VBAC than for those having a planned repeat c-section.

Rethinking the Risks: VBAC vs. Repeat C-section

Earlier, I mentioned that I take issue with the idea that a trial of labor after cesarean (TOLAC) is more dangerous than a repeat c-section. Let me explain why, with an analogy that might help clarify the concept.

An Analogy: To Bike or Not to Bike?

Imagine you’re heading to a family party a few miles away. It’s a sunny day, the roads are clear, and you’re deciding whether to bike or drive. You want to make a choice based on the statistics—what makes the most sense logically?

Driving a car means you’re statistically more likely to get in an accident—about 1 in 63 drivers will experience an accident at some point. However, only 1 in 147 accidents are fatal, so your chance of dying in a car crash is 0.01%.
Biking, on the other hand, has a much lower risk of getting hit. Only 1 in 83,333 cyclists will be involved in an accident. However, bike accidents tend to be more serious, with 1 in 65 accidents being fatal. That means your risk of dying while biking is about 0.000018%.

So, while bike accidents are less common, they’re more likely to be fatal. Car accidents are more frequent but less likely to result in death. In other words, we need to consider both the likelihood of an event and the severity of the outcome to get a complete picture.

Applying the Analogy: VBAC vs. Repeat C-section

Now, let’s translate that analogy to VBAC vs. repeat c-section:

A repeat c-section is like driving your car. In the US hospital system, you are more likely to have a c-section (higher frequency) but the most common risks are generally lower in terms of severity.
A VBAC is like taking your bike. You’re less likely to experience a uterine rupture (lower frequency), but if you do, the potential risks are higher in severity.

Let’s break it down with the actual numbers:

Your risk of uterine rupture with a TOLAC is 0.07% (that’s 7 out of 10,000). If uterine rupture occurs, the chance of death is 10.5%. This results in an overall risk of 0.0074% (7 out of 100,000). Some studies suggest the risk could even be as low as 0.0038%, or about 4 out of 100,000.
On the other hand, the risk of death from a repeat c-section is 0.0134%, or 13 out of 100,000—almost twice as high as the risk of a TOLAC. And, importantly, you get to decide whether or not you even want to schedule a repeat c-section, which would avoid that risk entirely.

So next time someone says a repeat c-section is safer than a VBAC, you can confidently tell them, “I prefer to ride my bike.”

Preparing for a Successful VBAC

Now that we’ve covered the benefits and risks of a VBAC, let’s talk about how you can increase your chances of having a successful one. There are several things you can do now to help set yourself up for success.

Previous Vaginal Birth? You’re More Likely to Succeed with a VBAC

If you’ve had a vaginal birth before, even if it was prior to your c-section, your chances of a successful VBAC are higher. While it’s not something you can change now, it’s worth knowing that this factor plays a role in your outcome.

Knowing that, let’s jump into things you can do.

Eat Well During Pregnancy

Good nutrition is essential for many reasons during pregnancy, and it’s especially important when preparing for a VBAC. A nutrient-dense diet supports your muscles and tissues, helping your body stay healthy, flexible, and ready for labor. The more prepared your body is, the better your labor is likely to go.

I recommend following The Brewer Diet, which focuses on balanced nutrition during pregnancy. You can learn more about it in my guide The Brewer Diet: What, Why, and How (+ free checklist).

Stay Active with Regular Exercise

Exercising during pregnancy also has many benefits, including reducing the risk of fibroids (non-cancerous growths in the uterus that can complicate labor). Plus, regular exercise promotes overall uterine health, setting the stage for a smoother and more effective labor.

Choose the Right Support for Your Birth

Having a familiar, trusted person with you throughout labor can make a huge difference, whether it’s your husband or partner, a friend, or a doula. This continuous support has been shown to increase the likelihood of a vaginal birth and lower the chance of needing a c-section.

A doula, in particular, is trained to guide you through labor and provide invaluable emotional and physical support.

Labor at Home as Long as Possible

Even if you plan to give birth in the hospital, it’s a good idea to stay home during early labor. You’ll be more relaxed, free to move around, and able to eat and drink as you like.

Staying home longer can help labor progress naturally, reducing the need for interventions that could increase your risk of a c-section. Plus, the longer you stay at home, the less time you’ll spend in a hospital setting, where unnecessary interventions and medications are more common.

Address Your Fears About Birth

The “fear-tension-pain cycle” is a concept first introduced by Dr. Grantly Dick-Read, which explains how fear can lead to physical tension and make contractions more painful. This tension can also increase the risk of complications, including uterine rupture.

By addressing your fears ahead of time, you can help your body stay relaxed and avoid getting stuck in this cycle. Techniques like relaxation, breathing exercises, or simply talking through your concerns can go a long way in preparing you for a smoother, more comfortable birth.

Be Your Own Advocate: Ask Questions

It’s essential to ask questions and gather as much information as possible when planning a VBAC. Even though I can provide general advice, I don’t know your unique situation, so you need to be proactive about understanding your options.

To ensure you’re truly informed, use the BRAIN acronym:

B is for benefits. What are the benefits (to you and your baby) of a proposed intervention or procedure?
R is for risks. What risks are involved, both for you and your baby, both short- and long-term?
A is for alternatives. What other options are available?
I is for intuition. Trust your gut. After gathering all the facts, listen to your intuition.
N is for nothing: You always have the option to choose “nothing” or to let birth unfold naturally.

By using BRAIN, you empower yourself to make decisions that are in line with your values, comfort, and the experience you want to have.

Factors That Can Decrease Your Chances of a Successful VBAC

While there’s a lot you can do to increase your chances of a successful VBAC, it’s just as important to be aware of the factors that might decrease those chances. In other words, what might increase the likelihood of needing a repeat c-section?

Here are some of the key factors that could affect your chances of a successful VBAC:

Where You Give Birth

Your birth location is one of the most significant factors in determining whether you’ll have a successful VBAC. Hospitals tend to have higher c-section rates than home births or birth centers, largely because doctors have more resources and more inclination to intervene at the first sign of trouble.

Surprisingly, which hospital you choose can make a big difference. Some hospitals may not even allow VBACs, while others might have doctors who are more supportive of them. Research your hospital’s c-section rates and be proactive about finding a provider and location that aligns with your birth goals.

Number of Previous C-sections

The more c-sections you’ve had, the more complicated your next birth may become. Multiple c-sections can lead to increased scarring and placental problems, which could complicate a VBAC. Even in hospitals supportive of VBACs, for women who’ve had 3 or more c-sections, VBAC may not be an option.

Some midwives may still support a VBAC after multiple c-sections, but this depends on individual health and risk factors.

Type of Incision

The type of incision made during your previous c-section plays a crucial role. A vertical incision is more likely to rupture than a horizontal one. Thankfully, most c-sections are done with a horizontal incision, so this is something you likely won’t need to worry about.

Time Between Births

A shorter time between your previous c-section and your planned VBAC can increase the risk of uterine rupture, which can lead to a c-section. It’s generally recommended to wait at least 18 months before attempting a VBAC to give your body ample time to heal.

Induction and Other Medical Interventions

Induction can significantly increase the risk of uterine rupture and a failed VBAC. Whether you’re induced with Pitocin or other methods, the stress on your uterus can make rupture more likely.

Studies have shown that using synthetic oxytocin (Pitocin) can drop your chances of a successful VBAC from 75% to 60% and increase the risk of uterine rupture (from 0.7% to 2.2%).

Other interventions, such as epidurals or fetal monitoring, can also raise the likelihood of needing a repeat c-section for the same reasons they contributed to your first c-section. For more on this, check out The Cascade of Interventions [Explained].

Carrying Multiples (Twins or More)

Carrying twins or more increases the likelihood of a c-section, whether it’s your first birth or a VBAC. The additional pressure on your uterus makes rupture more likely, and most OBGYNs will opt for a c-section when multiple babies are involved, especially if you’ve already had a c-section.

Baby’s Position

If your baby is in a breech (butt or feet down) or transverse (horizontal) position, a c-section is typically the preferred option. This is especially true if you’ve had a previous c-section, as trying to turn a baby in these positions with a previous scar can increase the risk of complications.

Breech is unique in that some midwives are happy to attend a breech birth, in certain circumstances. To learn more about breech birth options, see my blog post here.

Maternal Age and Weight

Age and weight can influence the likelihood of a successful VBAC, though they don’t always correlate with increased risk. A 37-year-old woman in excellent health may be better prepared for a VBAC than a younger woman with other complications.

Similarly, a woman with a higher weight may have fewer complications than someone with other health conditions. So, while it’s important to consider age and weight, other factors are often more significant in determining your chances of success.

Pre-existing Conditions

Certain pre-existing health conditions can impact whether a vaginal birth is safe. For instance, active infections like HIV or herpes in the vagina may necessitate a c-section to prevent passing the infection to your baby.

Heart conditions might also affect your ability to safely give birth, though many women with heart conditions can still attempt a vaginal birth. Conditions like diabetes or uterine fibroids may increase your likelihood of needing a c-section but don’t necessarily rule out a VBAC.

When a VBAC May Not Be the Best Option

Though VBAC is a great option for most women, it’s important to recognize that there are certain situations where it may not be recommended. Here are some circumstances where planning a VBAC might not be the best choice:

You’ve experienced uterine rupture before
Your incision is vertical instead of horizontal (usually)
You have major placenta previa and the placenta hasn’t moved 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 any of the above apply to you, please don’t feel discouraged. A c-section is still a valid way to give birth, and you and your baby will likely be just fine.

A Word of Encouragement

Whether you’ve had a c-section in the past or you’re pregnant now and know you’ll need one for this upcoming birth, I want to share some encouragement with you. This message comes straight from a family member who had a traumatic c-section with her first baby:

“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!”

Wrapping It Up

To sum it all up: Most women can safely plan a VBAC, and most who do will be successful.

Vaginal birth offers several benefits for both mom and baby that a c-section simply can’t provide—things like a lower chance of breathing problems, hemorrhage, and infection, as well as better chances for breastfeeding success, long-term health, and satisfaction with the birth experience.

While VBAC does come with risks, the main one—uterine rupture—is rare. Claims that a trial of labor is riskier than a repeat c-section simply don’t hold up. In fact, complications like hysterectomy happen at similar rates for both VBAC and repeat c-section.

There are things you can do during pregnancy—like eating well—to improve your chances of a successful VBAC, and things that may decrease your chances, like getting induced.

In some cases, a woman might not be eligible for a VBAC, due to factors like previous uterine surgery or placental issues. In those situations, know that a repeat c-section is still a good option.

Above all, I want you to remember this: Your body was created to give birth. It is perfectly capable of doing so safely and effectively, most of the time. And in reality, neither a VBAC nor a repeat c-section is life-threatening for the overwhelming majority of women. Most of what we discussed are the exceptions, not the rule.

So, don’t be afraid. Birth is meant to happen. And it is meant to be beautiful. Let’s do what we can to make sure it stays that way.

Until next time,

Allison

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The VBAC Choice: Weighing the Risks and Benefits

What is a VBAC?

Benefits of a VBAC