It used to be a given: Women who had a baby by cesarean section only had the option of delivering any following pregnancy by C-section.
However, that’s no longer the case.
Vaginal birth is now an option for many expectant mothers with a prior C-section. In fact, international medical specialty groups, including the American College of Obstetricians and Gynecologists, have developed expert recommendations regarding VBAC as an alternative for women who’ve had previous C-sections.
Vaginal birth after cesarean, also referred to as VBAC, is recommended when possible, depending on individual circumstances of the pregnancy, mother and baby. As a result, rates are slowly rising. In the U.S., VBAC rates increased from 12.4% to 14.2% between 2016 and 2021, according to a summary data report from the March of Dimes Perinatal Data Center.
If you’re considering VBAC delivery, here’s what maternal-fetal health experts want you to know.
[SEE: What to Pack in Your Hospital Bag When You’re Expecting.]
What Is a VBAC?
VBAC is a vaginal birth after previously delivering by C-section.
When you work with your doctor to develop a birth plan, they’ll take many benefits and risks into consideration and will help you decide which course is right for you.
To find high-performing maternity care near you, look through U.S. News Maternity Care ratings, which highlight key factors of care for uncomplicated pregnancies. If yours is a complicated or high-risk pregnancy requiring more intensive care, see the Best Hospitals for Neonatology rankings for care of a high-risk newborn.
Differences between VBAC and TOLAC
Although the terms VBAC and TOLAC are often used interchangeably, there is a difference as defined by the ACOG:
— TOLAC (trial of labor after cesarean delivery). This is a planned VBAC delivery attempt, regardless of outcome. (In some cases, if the TOLAC is not successful, doctors will require a repeat C-section.)
— VBAC (vaginal birth after cesarean delivery). When TOLAC is successful, it becomes a VBAC.
In short, TOLAC includes the entire process of labor and refers to the attempt, whereas VBAC refers to a successful completion of vaginal delivery.
[See: 11 Things Your OB-GYN Wants You to Know.]
Should You Consider a VBAC?
Different considerations can factor into an expectant mother’s decision to attempt a vaginal delivery instead of planning another C-section.
[Related:How to Get Pregnant Fast]
Minimizing risks
There are a couple reasons to consider undergoing a trial of labor to have a VBAC.
With a repeat C-section and subsequent C-sections, the recovery period is typically longer, and there’s an increased chance of health risks for the mother.
“It’s a big operation,” says Dr. Julia Cormano, an OB-GYN and assistant professor of obstetrics, gynecology and reproductive sciences with UC San Diego Health System. “When you compare a major abdominal surgery with a successful vaginal delivery, the risk of death is slightly higher for the mom (with the surgery).”
She adds that with a major abdominal surgery, the need for blood transfusions and risk of infections are slightly higher than vaginal delivery.
“Certainly, the risks in future pregnancies start to go up significantly,” she adds.
Health advantages
Vaginal birth may offer health advantages to the newborn, as well as the mother.
“Babies that are born by C-section often require a little extra transitioning time because they don’t have the squeezing process they go through in the birth canal, where the fluid gets pushed out of their lungs,” says Dr. Katherine Economy, a maternal-fetal medicine specialist with Brigham and Women’s Hospital and an assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School in Boston.
In addition, babies born vaginally may have a slightly lower rate of respiratory distress, and cutting-edge research is now being done to evaluate the advantage of the baby being exposed to the mother’s vaginal microbiome during birth. This normal bacteria may help form the baby’s immune system in later life and play a role in future health outcomes.
Family planning
Women need to discuss their wishes and preferences with doctors in the shared decision-making process.
“Part of counseling when a woman comes to me is to try to understand: What is her life plan?” Cormano says. “Does she want five kids? She’s had prior C-sections, and she’s looking forward at her family size. The larger family size that’s desired, the more important it might be to try for a VBAC to reduce those risks.”
Prior C-sections
Your doctor will likely assess:
— How many C-sections you’ve had.
— The type of closure you’ve had.
“If they’ve had one or two (C-sections), it’s reasonable,” says Dr. Teresa Hubka, a dual board-certified OB-GYN in private practice in Chicago and president-elect of the American Osteopathic Association.
However, health risks increase after each C-section.
“Every time you cut into the uterus, you’re making that muscle weak,” Hubka says, adding that the way the uterus is stitched closed after each procedure — whether it’s a single layer or double layer uterine closure — affects the strength of the uterus.
Emotional factors
Giving birth is an emotional choice and major life event.
“Birth is very different from other medical sorts of experiences,” Economy says. “There’s nothing like it, really. Birth, of course, is weighted with centuries of human emotion, and that’s important to acknowledge.”
Perspectives on type of delivery vary among expectant mothers.
“Some women very much feel that having the opportunity to labor and having that vaginal birth is a part of the narrative that they want for their pregnancy,” Economy says. “Other women are not as attached to that narrative.”
Who Should Avoid VBACs
There are several reasons why a C-section might be recommended or medically necessary, including:
— Complications during labor, such as if the baby is too large for the pelvis or there isn’t enough contraction power.
— Fetal distress, like an abnormal heart rate.
— If the baby is breech, meaning the bottom is down instead of headfirst.
— Placenta previa, which is when the placenta is partially or completely covering the mother’s cervix.
— Multiple births, such as twins or triplets.
There are many reasons why a woman may be guided away from a VBAC, Cormano points out, but it’s important to remember that C-sections are primarily done for the safety of the mom and baby.
“The trial of labor in general is a higher-risk event for the baby in an effort to get a safer outcome for the mom,” Cormano says. “Somebody who’s being guided toward a repeat C-section is probably being guided there with the hope of minimizing risk to the baby because the baby’s the one who’s at most risk in the situation of uterine rupture.” (This can be a TOLAC complication.)
Sometimes, women simply prefer to have a C-section, known as cesarean delivery by maternal request.
“There are women who just choose to have a cesarean delivery in the first place,” Economy says. However, “some women may really feel like they want the opportunity to try to have a vaginal birth afterward.”
VBAC Benefits
According to ACOG, delivery by VBAC may help avoid health problems linked to multiple C-sections for women who want to have more children. Reducing the risk of bowel or bladder injury, as well as hysterectomy and placenta problems in future pregnancies — problems associated with multiple C-sections — are reasons for some women to consider VBAC/TOLAC.
Further motivations for considering a VBAC/TOLAC include:
— Reduced risk of bleeding.
— Reduces recurrent C-sections in the future.
— Shorter recovery time.
— No surgery required.
— More cost-effective than C-section.
VBAC Risks
Because VBAC/TOLAC comes with risks of its own, careful consideration goes into recommending and choosing between vaginal delivery and another C-section.
Risks involved with a VBAC/TOLAC may include:
— Uterine rupture, most often occurring from separation of the surgical scar that resulted from the mother’s previous C-section.
— Complications during labor, leading to emergency C-section.
— Risk of infection or blood loss.
— Maternal or fetal injury or death.
“When there’s a scar on the uterus, there is some increased risk for the scar opening during labor,” Economy says.
Although the phrase “uterine rupture” is commonly used for this event, she tries to avoid that terminology when referring to surgical scar separation.
“That imagery can be very upsetting,” Economy says. “In counseling women, I really try to reflect more that sometimes the scar opens. Frankly, the scar can open and women can be totally asymptomatic. Or, the scar can open and it can be quite dramatic. There can be bleeding and both the mother and the baby’s life can be at risk in that situation. Those are rare events, but women need to hear about it. They need to make the decision with all the available information.”
The type of uterine scar a woman has can contribute to having a higher risk of rupture during VBAC.
“For instance, if a woman has an up-and-down scar on her uterus, not her abdomen, we really discourage labor because the uterine rupture or scar separation rate is much higher,” Economy explains.
With induced labor, medications or other methods are used to stimulate contractions instead of waiting for labor to begin on its own. With TOLAC, induced labor slightly raises the risk of scar separation.
“We prefer women to go into spontaneous labor,” Economy says. “Their chance of success is higher, their risk of uterine rupture is lower.”
VBAC Success Factors
VBAC may be more successful for some women than others. A predictor of success is if they’ve already had a vaginal delivery.
A woman who has a history of one or more successful vaginal births after C-section deliveries is a really good candidate, Cormano says.
“Her body knows how to do this and has shown that a baby can fit through her pelvis,” she adds. “Especially if she goes to term, has a normal-size baby and had good recovery time, she has a high chance of successful delivery.”
An analysis for estimating the chance of a vaginal birth after cesarean delivery, published in the December 2021 American Journal of Obstetrics and Gynecology, included registry data on more than 11,500 women who had delivered a single baby at 37 weeks or more, had a previous C-section with a horizontal incision in the uterus and had a TOLAC.
Of these women, nearly 75% experienced VBAC, and researchers found these significant variables:
— Women who were taller and had a previous vaginal birth, particularly if they had occurred after a previous C-section, were more likely to have VBAC.
— Older women, heavier women, those whose previous C-section was related to delivery problems with dilation or fetal descent or were treated with medication for chronic hypertension were less likely to have VBAC.
In some cases, VBAC may be possible even after two previous C-sections. However, the risk for uterine rupture increases. If both of the mother’s C-sections were for failed labor, for instance, in which the baby didn’t descend to the pelvis either time, “the chances for her having a successful vaginal delivery really are much, much lower,” Cormano says. “That risk-benefit decision-making changes, and that might be somebody who is better guided toward a repeat C-section.”
How to Prepare for a VBAC
With all the health and safety considerations involved and the need to understand and carefully weigh risks and benefits, it’s essential for women to receive counseling from their maternal health providers before deciding whether to move forward with VBAC.
The patient-physician relationship is really important, particularly to help the patient to feel empowered to make decisions, Hubka emphasizes.
“Communication is huge,” she adds. “We’re there to counsel them.”
Considering such factors in the context of a woman’s obstetric history, overall health and personal preferences help expectant parents arrive at an informed decision regarding delivery.
“For women who have a prior cesarean delivery, it requires a more balanced and nuanced conversation,” Economy says. “I always need to hear from them: What’s the thing that you most value in this process? Understanding, of course, that everybody wants to be healthy and have their baby be healthy. That’s a foregone conclusion.”
Where Can You Get a VBAC?
The facility where the woman intends to go for maternity care is another key factor in the VBAC choice. Because a VBAC attempt could necessitate a C-section, and with the low — but real — risk of a scar separation emergency, it’s imperative for mothers to be in an environment that can promptly respond, around the clock, in any delivery scenario that arises, with anesthesiologists, the blood bank and the neonatal intensive care unit available 24/7.
“In our institution, women who are undergoing TOLAC have to be continuously monitored,” Economy says. “You have to have monitors on the baby and monitors on the uterus all the time.”
Not every maternity facility allows VBAC as a choice or can handle a TOLAC/VBAC delivery. The hospital may not have the resources needed, such as the staff or facilities to quickly get the patient back for an emergency C-section, Hubka says.
Additionally, facilities may not offer TOLAC because they have obstetricians who are available to respond to medical emergencies but aren’t physically present in the hospital or clinic, so a provider may not be immediately available.
“Women who are considering this option need to do their research and pick a hospital that’s very comfortable and experienced with offering TOLAC,” Economy says.
Cormano also urges people in this situation not to plan for a home birth, which can result in “really tragic and preventable outcomes.”
By going to the right place, mothers are supported for vaginal delivery after C-section, when it’s indicated. As mentioned, the U.S. News Maternity Care ratings and Best Hospitals for Neonatology rankings can help you find the right hospital for you.
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Vaginal Birth After Cesarean (VBAC): Benefits and Risks originally appeared on usnews.com
Update 11/28/23: The story was previously published at an earlier date and has been updated with new information.
