VBAC: Taking Back Your Birth

Medical Experts: Katherine Economy, MD; Cecilia Jevitt, RM, CNM, ARNP, PhD, FACNM; Hiba Mustafa, MD, FACOG, FAIUM, FOMA; Lorene Temming, MD

When I was expecting my first child, I read every pregnancy book I could get my hands on to prepare myself for a smooth delivery. When I went into labor one day after my due date, I was feeling confident that all would go according to plan. But after 12 hours of labor, I was whisked away for an emergency cesarean section (C-section) because my baby’s heart rate dropped as my labor progressed. Despite the unforeseen complications, my son was born beautiful and healthy. 

Still, a part of me was devastated—this was not the birth experience I had hoped for. I was unprepared for the physical recovery of a C-section, and I couldn’t reconcile the feelings of failure that lingered for months after my baby’s birth. Before long, I became determined that my next delivery would be different.

The Rise of C-Sections 

Cesarean deliveries account for a little more than 22% of all births, according to the Centers for Disease Control and Prevention (CDC). There are a variety of reasons an OB-GYN might want to do a C-section such as when labor has stalled, when the baby is in a position that makes vaginal delivery difficult or life-threatening, or when there are indications that your little one isn’t getting enough oxygen (based on a lack of movement, an abnormal heart rate, or a bowel movement in utero).

Anastasia Leyden, a mom in Melrose, Massachusetts, had planned for an intervention-free birth but after enduring 36 hours of early labor, was labeled with “failure to progress,” resulting in her delivering via C-section. 

“The word ‘failure’ captures my dismay,” says Leyden. “I was not prepared for the very sterile and impersonal nature of the birth.”

Despite feelings of regret, when baby or Mom is truly at risk, a C-section can be a lifesaving choice. Romiya Barry, a mom in Groton, Massachusetts, found herself facing an early induction because of potential intrauterine growth restriction. When her baby began to show signs of distress during labor, she was taken for an emergency C-section. 

Barry is thankful that her daughter, born six weeks premature, is alive and well. Still, she says, “I felt that everything was rushed and that there was little time for me to process it. Even though I was physically present, I missed out on my daughter’s birth. I felt robbed.”

After having a cesarean delivery, mothers often assume that any future pregnancies will end in the operating room—and many medical professionals follow that protocol. “The number one reason for C-sections is a repeat C-section,” says Katherine Economy, MD, a maternal-fetal medicine specialist at Brigham and Women’s Hospital in Boston and instructor at Harvard Medical School.

However, a repeat C-section isn’t the only option. Many women are good candidates for a vaginal birth after cesarean (VBAC).

What Is a VBAC?

While “VBAC” is the more commonly used acronym for this birth plan, Lorene Temming, MD, an OB-GYN at Atrium Health in Charlotte, North Carolina, notes that it is not the clinical term. “What patients need to request is actually a ‘TOLAC’—a trial of labor after cesarean—which means attempting vaginal [delivery].” VBAC and TOLAC are different terms that describe the same thing, but while a patient may wish to have a vaginal delivery, it doesn’t always work that way.

That being said, many birthing parents are eligible for VBAC, according to Hiba Mustafa, MD, FACOG, FAIUM, FOMA, a specialist in maternal-fetal medicine and fetal intervention and surgery at Riley Children’s Health in Indianapolis, Indiana. “The success rate for women who underwent trial of labor after cesarean section after one prior section in the United States was 60-80%,” she says. 

Aside from the emotional benefits many birthing parents will experience with a VBAC, there are physical advantages to a vaginal delivery compared to a C-section as well. 

“There are many pros for VBAC including avoiding complications related to surgery, shorter hospital stay, faster recovery and return to usual activities, and for [parents] considering future pregnancies, it decreases the rates of complications related to multiple cesarean sections, such as abnormal placentation,” explains Dr. Mustafa. 

Given that the odds are in their favor, why aren’t more birthing parents attempting a TOLAC? “As with any pregnancy, there is always a chance that surgery will become necessary, and some women don’t want to labor only to end up in the OR again,” says Cecilia Jevitt, RM, CNM, ARNP, PhD, FACNM, an associate professor and director of the midwifery program at the University of British Columbia. 

Health care access also plays a huge part. Smaller hospitals often require repeat C-sections because they don’t have round-the-clock resources to handle an urgent surgical delivery should complications occur. Many women would rather schedule a repeat section than switch to a new provider or hospital, explains Dr. Economy.

Who is a Good Candidate for a VBAC?

Not every patient is a good candidate for TOLAC, so whether or not you can have one is not always a matter of choice. 

“The best candidates for TOLAC are [patients] who have had a vaginal delivery before their cesarean delivery, as they are more likely to be successful,” says Dr. Temming. “Additionally, if their first cesarean delivery was for a reason other than a failed induction, or arrest of dilation or descent, they are more likely to be successful.”

That being said, determining if a patient is or is not a candidate for VBAC still isn’t black and white. “There are many factors that affect eligibility,” explains Dr. Mustafa, noting that scientists are routinely making attempts to calculate patient success rates for a VBAC. Some factors that she says are considered include: 

• The type of uterine incision used in the prior C-section. Most cesarean sections use a low uterine transverse incision. Patients who have had a low transverse or low vertical incision are usually VBAC candidates. While, for patients with a prior high vertical (classical) incision, VBAC is not recommended due to the increased risk of uterine rupture.
• Prior uterine surgeries, such as fibroid removal (myomectomy). VBAC is not recommended due to the increased risk of uterine rupture. 
• Indications for prior C-section. Indications such as malpresentation (for example, a breech presentation) are good candidates for VBAC. Indications such as labor dystocia including arrest of the active stage of labor or arrest of descent following cervical dilation of 10 centimeters have been shown to reduce the success rate.
• Number of prior C-sections. Many obstetricians do not offer VBAC for patients who had two or more prior C-sections.
• Time between prior C-section and current delivery date. Many obstetricians do not offer VBAC if it has been less than 18 months since prior C-section due to the increased risk of uterine rupture.
• Maternal or fetal conditions in which cesarean section is recommended such as abnormal placentation.
• Other factors that might reduce success rate, such as obesity with a Body Mass Index (BMI) of 30 or more, expected birth weight above 8.8 pounds, and induction of labor versus labor that begins spontaneously.  

Dr. Temming further explains that in many cases, the circumstances that caused the prior C-section are unlikely to change. For instance, a patient “who got to 10 centimeters, pushed for several hours, and had to have a C-section, or a patient whose labor stalled out after a certain point … it is more likely there are individual factors, such as the shape of their pelvis, that led to the first C-section. Since these sorts of factors don’t change between deliveries, it is more likely that a TOLAC would be unsuccessful.” 

VBAC Risks and Safety

As with any delivery, VBACs aren’t entirely risk-free. The main complication that worries both parents and providers is uterine rupture. This happens when there’s a tear in the wall of the uterus, often at the site of a scar from a previous C-section incision. 

“Although the risk is only about 0.5-1% in women who are good candidates for VBAC, it can be catastrophic when it happens,” says Dr. Economy. When the uterus ruptures, the baby is deprived of oxygen and has to be immediately delivered surgically to prevent brain damage. Additionally, birthing parents can face significant blood loss or require a hysterectomy. Uterine rupture is rare, but when it occurs, both the birthing parent’s and baby’s lives are in danger.

Because of this potential risk, Dr. Temming says, “Patients undergoing TOLAC must deliver at a hospital with immediate access to an obstetrician and anesthesia so that if they need something emergently it can be handled.” 

Of course C-sections, like any major surgery, are not without inherent risks, but they also have long-term effects as far as future pregnancies are concerned. For example, placental abnormalities, like placenta previa (where the placenta is too close to the mother’s cervix) and placenta accreta (where the placenta attaches to the wall of the uterus), are more likely to occur. Plus, the risk increases with each additional C-section. 

Is VBAC Right For You? 

If you’re interested in a TOLAC, Dr. Temming suggests speaking directly with your provider. “Some providers are more comfortable with allowing TOLACs than others—and this is true for a variety of reasons, including but not limited to the provider’s experience, resources available in a hospital, and liability rules and regulations wherever the provider is practicing.” 

Once you’re in the throes of labor, there will be a few differences for TOLAC parents, however, Dr. Economy notes that most providers will monitor the baby more closely, as fetal distress can be an early indicator of uterine rupture. They’ll also watch for “loss of station” (when baby’s head has migrated out of the pelvis) and signs of internal bleeding in the birthing parent.

Your perspective and involvement can make the entire process a lot easier. “If you want a VBAC, you have to be motivated and engaged,” says Dr. Economy. “Make sure you’re a good candidate, understand the risk and that there are no guarantees, and be patient with the process.”

Ultimately, a healthy baby and parent are what matter. If a VBAC doesn’t work out, it’s not a failure. It’s just another path to bringing your baby into the world. 

Although Leyden had hoped for a VBAC, she agreed to a second C-section after finding out her daughter was transverse (sideways) and measuring large, but she credits her VBAC prep with helping her stay calm and present during the procedure. “Whether you have a vaginal birth or an elective or emergency C-section is not a reflection on your character or abilities as a mother,” she says.

As for me, almost 23 months after the birth of our son, we welcomed our daughter through a successful VBAC. Throughout my pregnancy, my OB was supportive, answering questions and explaining the risks and benefits. During labor, my husband, the terrific nursing staff, and the on-call doctor helped me remain calm and confident. The birth was a healing and rewarding experience that I wish any parent who desires a vaginal birth could have. But looking at my children today, no one can tell that they came into the world with such different deliveries—because they are both healthy, happy, and abundantly loved.

This article was originally written by Julie Roy and has been updated by Ashley Ziegler.