VBAC: Risks, benefits, and why it should be on the table

Once a cesarean, always a cesarean, or so the saying used to go. But thanks to the resurgence of evidence-based practices, one cesarean is no longer a certain sentence for moms and future births. After the first cesarean birth, many moms have two choices for birth number two (assuming all other factors point to a healthy, uncomplicated pregnancy): another cesarean or a VBAC (vaginal birth after cesarean). As with any decision made regarding birth and pregnancy, it is vital to educate yourself on the risks and benefits of both decisions. Every woman, birth and pregnancy are as unique as the child that enters the world through them; therefore, it is essential that parents explore their options from the perspective of their personal situation.

Unfortunately, many hospitals and doctors fail to offer a VBAC as an option once a cesarean has been performed. The main reason for this was the risk of uterine rupture due to the weakened scar tissue from the first cesarean delivery. In the case of a uterine rupture, both mom and baby are placed at significant risk of injury and death. 

Sounds serious, right? 

Right. Yes. Uterine rupture is no joke. 

But how many of these scar-laden uteruses actually rupture? Enough to merit a blanket policy as strong and absolute as “no VBACs, ever, no questions asked?”

In my humble, non-doctor/midwife/medically-trained-professional opinion, no. 

According to the American College of Obstetrics and Gynecology, previous cesarean section with low transverse incisions resulted in a .2-1.5% risk of uterine rupture during a vaginal birth.[i]  

Now, I’m no math genius, but that’s a pretty low risk. If I made decisions based on risks that low, I’d never get into a car, never climb a mountain, never go swimming, and never do much of anything.[ii] 

I am not trying to downplay the severity of uterine rupture. It is a real and substantial risk, and should definitely be a factor parents consider when electing the type of birth they want to attempt for bambino numero dos (or tres, etc.). However, to allow this risk to be the only factor to determine the fate of the next type of birth creates a painfully incomplete picture to consider. 

Because uterine rupture is the main concern with a VBAC, it’s important moms understand the following variables that can increase the risk of this rupture taking place[iii]:

1.       Labor is induced. Misoprostol, the drug often utilized the labor inductions, should not be utilized in a VBAC induction.

2.       Single-layer closures on prior cesarean scars – most are double layer, but some may be single layer to reduce time in the operating room, exposure to bacteria, etc. 

3.       Subsequent pregnancies/VBACs within 18-24 months of cesarean.

4.       Mom is over 30 years of age. 

5.       Maternal fever from prior cesarean. 

6.       Classical uterine incisions in prior cesarean (a “T” or “J” incision, as opposed to low transverse).

7.       Two+ previous cesareans.

8.       Laboring for a  VBAC post 40 weeks gestation.

                If you’ve experienced a cesarean for your first birth, and are weighing the pros and cons of a VBAC versus repeat cesarean, here are a few bits of information worth considering:

1.       Sixty-to-eight percent of healthy moms who underwent an uncomplicated cesarean with a low transverse incision (the most popular kind of cesarean) are good candidates to attempt a VBAC.[iv] 

2.       Though one cesarean does not predict what type of birth moms can attempt the next time around, the risk of future cesareans goes up with each cesarean. Multiple scars on the uterus increase the risk of[v]:

  • Scar rupture
  • Ectopic pregnancy (fetus developing outside the uterus)
  • Placenta previa (placenta grows over the cervix, blocking the opening of the uterus)
  • Placenta accrete (placenta grows into/through the uterus)


3.       Three out of four women who attempt a VBAC are successful.[vi]

4.       The risks of a vaginal birth (VBAC or otherwise) are significantly lower than those of a cesarean (i.e. major surgery).[vii]

5.       Risk for uterine rupture decreases with each additional planned VBAC.[viii]

6.       The recovery time is longer with a cesarean than with a vaginal birth. 

7.       Mothers who experience cesareans often have less skin-to-skin time with babies in the first moments of life, important for both bonding and developing a prolific breastfeeding relationship (though, due to moms educating themselves and including it in their birth plans, skin-to-skin post cesarean is becoming more popular).

8.       Babies born via cesarean are more likely to experience breathing problems, including asthma.[ix]

9.       Labor benefits baby in a handful of very unique ways. A VBAC[x]:
 

  • Helps release surfactant in baby’s lungs, subsequently helping him breathe.[xi]
  • Increases blood flow to baby.
  • Increases energy supply release to baby – this helps sustain baby (+ colostrum) while waiting for mom’s milk to come in.
  • Stimulates alertness in baby, subsequently increasing bonding between baby and mom. 
  • Increases immunity in baby – extra white blood cells are released as the adrenal hormones are secreted.


If electing to attempt a VBAC, it is important that you do so in (or very near) a facility that is equipped to handle an emergency cesarean, and with a team of people readily able to identify the symptoms of a possible uterine rupture. Though previous guidelines suggested moms needed “thirty minutes from decision to incision,” current VBAC guidelines issued by the ACOG (American Congress of Obstetrics and Gynecology) encourage moms to give birth in a facility immediately equipped to handle an emergency cesarean.[xii] This updated recommendation led to many medical facilities ceasing to offer VBAC as an option as their standard processes and procedures “could not” meet this standard of immediacy in care.[xiii]

                So, who are these women who are good candidates for an attempted VBAC? I’m so glad you asked:

  • Previous vaginal deliveries (either before or after a cesarean) increase the likelihood of a successful VBAC.
  • The fewer previous cesareans mom has had, the higher the likelihood of a successful VBAC.
  • If the previous cesarean was for a reason not present in your current pregnancy (e.g. breech baby, etc.), there is high probability for a successful VBAC.
  • Risk of uterine rupture is diminished if it has been longer than 18-24 since previous cesarean. 


As with every decision around childbirth, one of the best gifts you give yourself, your birth team and your child is to engage in the birthing process through education and information exploration. 

Attempted a VBAC? How did it go? Any thoughts you want to share, we’d love to hear! Send me an email atKelsey@cordmama.com. Looking forward to hearing from you!

Sources:
[i] http://americanpregnancy.org/labornbirth/vbac.html 
[ii] http://www.nsc.org/news_resources/injury_and_death_statistics/Documents/2014-Injury-Facts-43.pdf 
[iii] http://www.vbac.com/what-is-a-uterine-rupture-and-how-often-does-it-occur/ 
[iv] http://americanpregnancy.org/labornbirth/vbac.html 
[v] http://www.childbirthconnection.org/article.asp?ck=10210
[vi] http://www.childbirthconnection.org/article.asp?ck=10210 
[vii] http://www.childbirthconnection.org/article.asp?ck=10210 
[viii] http://www.vbac.com/what-is-a-uterine-rupture-and-how-often-does-it-occur/ 
[ix] http://www.childbirthconnection.org/article.asp?ck=10210 
[x] http://pregnancy.about.com/cs/laborbirth/a/aa042300a.htm 
[xi] http://pregnancy.about.com/cs/laborbirth/a/aa042300a.htm 
[xii] http://www.vbac.com/what-is-a-uterine-rupture-and-how-often-does-it-occur/ 
[xiii] http://www.vbac.com/what-is-a-uterine-rupture-and-how-often-does-it-occur/