There are a host of cultural and social misconceptions about VBAC, including that it is unsafe, irresponsible, or just not even an option at all. You may have heard the saying “Once a cesarean, always a cesarean.” Turns out that’s not really a thing—but sayings like that do actually affect people’s care and experiences.
Jen Kamel, the founder of VBAC Facts (an evidence-based resource about VBAC for families and medical professionals), explains: “The misinformation is one of the major reasons why almost 90 percent of those with a prior cesarean in the United States have a repeat cesarean. Most of those people are good candidates for VBAC, but they never had a real option.”
The lack of options and information about VBAC has a host of complicated causes, including outdated practice guidelines, a changing obstetric culture, and more. According to the CDC, 87.2 percent of women with a previous cesarean birth have a repeat C-section.
Yet the American College of Obstetricians and Gynecologists’ official position on VBAC is that the majority of people with a previous cesarean (and sometimes two previous ones) are good candidates for the option. Making the choice to either try VBAC (vaginal birth after cesarean) (VBAC) or schedule a repeat cesarean birth can be intense, confusing, and difficult—but many women with prior C-sections are good candidates, and of those good candidates, a majority will be successful.
Rebecca Wayman, MD, FACOG, an obstetrician in Kansas City, Missouri, explains, “If a woman has had a low-transverse cesarean (which most women have, as other incisions are only used in rare situations) and doesn’t have a contraindication to a vaginal delivery (i.e., a reason they should not have a baby come out vaginally, such as active herpes), they are cleared for vaginal birth.” Research indicates that about 75 percent of people who attempt a VBAC will be successful.
The main risk of VBAC is uterine rupture, which is when the uterus breaks open, usually along the previous cesarean scar. Studies show that the risk of uterine rupture is low—about 5 out of 1,000 women (0.5 percent). The risk of uterine rupture goes up with each cesarean. Uterine rupture is an obstetric emergency that requires an immediate cesarean birth and has risks for both mother and baby.
A repeat cesarean, too, comes with risks for the person giving birth, including a higher chance of hemorrhage and of placenta accreta (a dangerous condition with the placenta grows into the uterus and surrounding organs) for future pregnancies. For babies, those born via a repeat cesarean have higher chances of needing oxygen and/or an NICU stay.
In terms of what actually happens during labor and birth, there actually isn’t much difference between a VBAC and any other vaginal birth (although if you give birth in a hospital, you will be required to have continuous monitoring of the fetal heartbeat). Some providers may also be hesitant to induce someone who has had a previous cesarean birth. The labor process for someone who wants a VBAC is called a trial of labor after cesarean (TOLAC).
Birthing people have varied reasons for planning a VBAC, including wanting a faster and easier recovery time after birth, the experience of labor, and more. Repeat cesareans, too, are attractive to some families—you can plan and predict your birth and do not have to experience the unknown aspect of what a vaginal birth might be like. (An approach called the gentle Cesarean is newly taking root in the United States.)
Planning a VBAC often takes more energy (in terms of emotional processing, medical advocacy, and more) than planning a repeat cesarean—for some people it’s more like preparation for your first baby but more complicated. VBAC-hopeful families may spend considerable time in research and education as they ready themselves for a vaginal birth.
If VBAC is your ultimate goal, it’s key to choose a provider and place of birth carefully. Dr. Wayman suggests asking around in your community to see what providers and hospitals are supportive: “I think that word of mouth/reputation is probably the best way to choose a hospital and doctor/midwife. I would recommend discussing with their doctor/midwife and asking what their parameters for VBAC are, and if they seem extensive this can be an indication of someone who isn’t very comfortable with VBAC.” Kamel’s website has an extensive list of questions to ask potential providers.
Both Kamel and Wayman suggest having a contingency plan for a cesarean. “I think it’s important to think through what you want so if a vaginal birth is no longer an option, you know what your options are and what you want,” says Kamel.
Dr. Wayman advises that the aforementioned gentle, or family-centered, cesarean can be a wonderful experience for families, regardless of whether or not they attempted a VBAC: “I am known for saying, ‘We all have our own journey.’ For some women, that journey is a surgical birth, which doesn’t have to be horrible. If a cesarean becomes the best option for a patient, I encourage her to ask about a family-centered cesarean.”
This type of cesarean can include having immediate skin-to-skin with your baby in the OR, watching the birth through a clear drape, delayed cord-clamping, and other ways of planning and executing the surgical birth so that it’s more emotionally resonant and optimized for mother-baby bonding.
Whether or not you’d like to try VBAC or go for a surgical birth, consider hiring a doula (who can provide important physical and emotional support for you throughout pregnancy, birth, and the postpartum period).
No matter what you decide, be sure that the decision is yours and yours alone. Kamel says, “When you become a parent, it’s time to find your voice. You now have little people who are depending upon you to love and protect them. So it’s time to stop worrying about what other people think and do what is right for you.”
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