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Vaginal Birth After Cesarean FAQ


Vaginal Birth After Cesarean (VBAC) is becoming more and more common. The once true adage of "Once a cesarean, always a cesarean" has been discarded. In this FAQ, I hope to dispel some of the myths surrounding VBAC and to give you some information to begin your search. If you have information, stories, or resources to add to this FAQ, please send me e-mail.


Topics included in this FAQ:


What is a VBAC?

Vaginal Birth After Cesarean is what VBAC stands for. It is a vaginal birth after one or more cesareans. More than 80% of women will be able to have a VBAC.

According to Midwifery Today (most recent issue, Winter No 36 page 47) ACOG recently updated their opinion on VBAC and stated "VBAC is safer than repeat cesarean and VBAC with more than one previous cesarean does not pose any increased risk". The Guidelines can be obtained from: ACOG, 409 12th St SW, Washington DC 20024.

Why would I want a vaginal birth?

There are many reasons that you may want a vaginal birth after a cesarean. Some may be medical and some may be emotional. Others may be financial or in terms of recovery. Here are some brief lists of the benefits to the mother and baby of a vaginal birth.

Mother:

  • Prevention of Death from surgery
  • Prevention of lesser complications from surgery
  • Prevention of blood loss
  • Prevention of infection
  • Prevention of injury (bowel, urinary tract, etc.)
  • Prevention of blood clots in the legs
  • Prevention of feelings of guilt or inadequacy that surgery sometimes causes
  • Breastfeeding is generally easier after a vaginal birth
  • The cost of a vaginal birth is about $3,000 less

Baby:

  • Prevention of Iatrogenic Prematurity (meaning surgery was done, because of an error in guessing a due date)
  • Reduction in the cases of Persistent Pulmonary Hypertension
  • Labor prepares the baby for extrauterine life
  • Prevention of surgery related fetal injuries (lacerations, broken bones)
  • VBAC results in fewer fetal deaths than elective repeat cesareans

What about rupture of the uterus?

This is a common fear among women who have had a previous cesarean. Most of this fear dates back to when the incisions of the original cesarean were of the classical variety (vertical incisions), nowadays most incisions are the low transverse type. There are two types of uterine rupture: complete and incomplete.

Complete uterine rupture is very unlikely today, for a variety of reasons. One is that when we use Pitocin, if needed, during a labor, we regulate the amount that goes in. In other times it was given IV to a woman and allowed to flow freely. These have also decreased due to some obstetrical practices being abandoned, like high forceps, internal version, etc. And the final reason is because of the rarity of the classical incision. A complete rupture occurs in much less than 1% of women attempting VBAC.

Incomplete rupture occurs about 1-2% of the time. However, usually these women are asymptomatic, and neither mother or infant require any assistance.

Golan published a study in 1980, where there were 93 ruptures of the uterus. 61 of those ruptures occurred in a normal uterus (never had an incision), and 32 of them had had previous incisions. There were 9 maternal deaths from the ruptures, but they were all from the group that had not had previous cesareans. For more information, see Studies on VBAC.

Pregnancy After Cesarean Section

You may be worried to be pregnant again, and really don't know where to turn for information or support. You may wonder what you can do to increase your chances of a successful VBAC. There are several things you can do, they are listed below in Preparing for your VBAC. Basically, the same rules of pregnancy apply, eat well, exercise, educate yourself, and develop a good birth team. Take responsibility for your care.

Labor After a Cesarean

The time has come. Labor has arrived! What will it hold for you? Many women are very emotional about the labor, and rightly so. Critical times may be the place where you got "stuck" at the last birth, when your water breaks, getting to the hospital, or any other time. Support is critical, turn to those around you. Here are some questions that many women have about laboring with a VBAC.

What if I had a cesarean because my pelvic bones were too small?

Most women do not truly have pelvic bones that are too small, unless you have suffered a pelvic fracture or had polio. Women with a pelvis to small to give birth vaginally are truly few and far between. Many women go ahead to deliver vaginally the next time, and have a bigger baby than the first!

What if the baby is large?

The pelvis and the baby's head are not rigid structures. Both mold and change shape to allow the birth to occur. There are certain postures that you can assume to help your pelvis expand (For example: Squatting opens the outlet of the pelvis by 10%.) The American College of OB/GYNs (ACOG) has stated that the effects of labor with a baby of more than 4,000 grams (8 3/4 lbs) has not been substantiated. However, in one study, 67% of babies weighing more than 4,000 grams were born vaginally, even when over 50% of these mothers had had previous cesareans for failure to progress.

What if I have had Herpes?

In years past, many women were delivered by cesarean for a history of genital herpes. Doctors did cultures in the last weeks of pregnancy to determine if the infection was active. ACOG has determined and recommended that unless there is a visible lesion at the time of birth, a vaginal birth is acceptable.

What if I have had more than one cesarean?

From the Guide to Effective Care in Pregnancy and Childbirth:"The available data on outcomes after a trial of labour in women who have had more than one previous caesarean section show that the overall vaginal delivery rate is little different from that seen in women who have had only one previous caesarean section."... and also ... "the available evidence does not suggest that a woman who has had more than one previous ceasarean section should be treated any differently for the woman who has had only one caesarean section".

What if the other cesarean was for fetal distress?

True fetal distress is rare, and only a handful of cesareans are done for fetal distress. One study indicates that fetal distress only occurs in 1.5% of all VBAC attempts (Finley, Gibbs), while another showed that of mothers who had a primary cesarean for fetal distress, the second labor had 3% of those mothers with fetal distress (Paul, Phelan, Yeh).

This brings us to fetal monitoring. In a normal, low risk pregnancy, fetal monitoring has not been shown to improve maternal or fetal outcomes, rather it only serves to increase the cesarean rates. Some care providers insist on continuous electronic fetal monitoring for VBAC clients. This is something that you need to research beforehand, and decide if it is something you want and can live with.

Specifications for VBAC

Who is a candidate for VBAC?

The general guidelines for VBAC are:

  • Low transverse incisions on both the abdomen and uterus
  • Adequate pelvis (See Above)
  • Willingness to prepare for VBAC

Preparing for your VBAC

There are many things that you should do to prepare yourself for a VBAC. Some are mental, emotional, physical and general preparations for your VBAC.

Information. Get as much of it as you can. Obtain a copy of your medical records from the previous birth(s) for yourself. Ask your current careprovider to explain anything that you don't understand. Talk to your careprovider, make plans with them (See Birth Plan FAQ). Talk to other people who have been there. Read a lot of books and journals.

Physically you need to prepare your body. Being in good physical condition can help your labor move more quickly as well as speed healing. Regular exercise and special birth exercises are good ways of doing this.

For more information on how to prepare yourself, check out the VBAC Checklist

Birth Alternatives with VBAC

Can I use a midwife?

You certainly can. As we have discussed before, with a few exceptions, VBAC is actually safer than an elective repeat cesarean. Midwives are trained to detect problems and can refer you to their back-up physician, should you need that type of care.

Can I give birth at a birth center?

Once again, this goes back to you and your careprovider.

Can I still have a homebirth?

This is up to you and your careprovider. Most practitioners of homebirth do not see any reason why you cannot have a homebirth VBAC.

What about medications?

Medication is labor and birth is fairly controversial, even without VBAC. When you are talking pain relief medications, you need to think some things through. Unless you do not want them or have a medical reason for not having them, pain relief medications can be used with a VBAC. However, it is important to use them wisely. We know that epidurals can increase the cesarean rate. You may want to consider delaying medications and using non-pharmacological methods of pain relief as long as you possibly can. Some studies indicate that if you delay an epidural past 5 cms then you lose the risk of increased cesarean.

Narcotics are also sometimes used in labor. While these do not have a direct effect on your chances of cesarean, they do have an effect on your mobility and your mind. Some women feel that their minds were clouded when they used narcotics. Often, once you receive a narcotic you are confined to bed, limiting your mobility, which can hinder labor. There are also effects of these drugs on babies that are much more apparent.

Pitocin, used to induce or speed labor, was once controversial in VBAC births. However, in the American College of OB/GYNs VBAC Guidelines it states that pitocin is safe for use with VBAC births, because the risks of uterine rupture is so small.

Resources for VBAC

Research and Books:

Some of these are books, others are journal articles. You can buy most of the books at your local bookstore, or order them online from Childbirth.org. Journal articles can be reviewed at your local library or medical school.

By Nancy Wainer Cohen and Lois J. Estner:
Silent Knife; Open Season; Birth Quake (Coming soon!)

By Bruce Flamm:
Birth After Cesarean

By Johanne C. Walters , Karis Crawford:
Natural Birth After Cesarean: A Practical Guide

By William and Martha Sears:
The Birth Book

By Penny Simkin:
The Birth Partner; Pregnancy, Childbirth and the Newborn (Simkin, Whalley and Keppler)

By Diana Korte and Roberta Scaer:
Good Birth, Safe Birth

By Sheila Kitzinger:
Your Baby, Your Way; Homebirth; Birth Over 35; Complete Book of Pregnancy

By Lynn Madsen:

  • Rebounding From Childbirth: Towards Emotional Recovery

    More books for VBAC

    Journal Articles:

    Flamm, BL, JR Goings, NJ Fuelberth, E Fischermann, C Jones, E Hersch. 1987. "Oxytocin During Labor after Previous Cesarean Section:Results of a Multicenter Study." Obstet. Gynecol. 70:709-712.

    Public Citizen Health Research Group. 1989. "Unnecessary Cesarean Sections: How to Cure a National Epidemic." Washington, DC

    Asakura H & Myers SA. More than one previous cesarean delivery: a 5-year experience with 435 patients. Obstet Gynecol 1995;85:924-9.
    Flamm, BL, OW Lim, C. Jones, D. Fallon, LA Newman, and JK Mantis. 1988. "Vaginal Birth After Cesarean Section: Results of a Multicenter Study." Am. J. Obstet. Gynecol. 158:1079-1084.

    Finley, BE, and CE Gibbs. 1986. "Emergent Cesarean Delivery in Patients Undergoing a Trial of Labor with a Transverse Lower-segment Scar." Am. J. Obstet. Gynecol. 155;936-939.

    Hertitage, CK, MD Cunningham. 1985. "Association of Elective Repeat Cesarean Delivery and Persistent Pulmonary Hypertension of the Newborn." Am. J. Obstet. Gynecol. 152:627-639.

    Schreiner, RL, et al. 1982. "Respiratory Distress Following Elective Repeat Cesarean Section." Am. J. Obstet. Gynecol. 143:689-692.

    Bowers, SK, et al. 1982. Prevention of Iatrogenic Neonatal Respiratory Distress Syndrome: Elective Repeat Cesarean Section and Spontaneous Labor." Am. J. Obstet. Gynecol. 143:186-189.

    Paul, RH, JP Phelan, S Yeh. 1985. Trial os Labor in the Patient with a Prior Cesarean Birth. Am. J. Obstet. Gynecol. 151:297-303.

    Support and Counseling:

    International Cesarean Awareness Network: provides information, educational opportunities, and support
    International Childbirth Education Association: provides education, support, and well documented papers
    Bradley Method®: provides support and educational opportunities
    Doulas of North America: Doulas help lower the cesarean rates as well as other interventions at birth, provide support and counseling

    Emotions of VBAC

    Emotions run high during pregnancy in general. Preparing for a VBAC can bring up plenty of extra emotions. Almost anything you feel is within the realm of normal.

    Some women are very excited about the thought of a VBAC, while others are forced into having a VBAC by insurance or their care provider. You may be afraid of labor, especially if you had a long or frightening experience the first time, you fear that it will repeat. You have familiarity of the cesarean, and you don't really know a lot about birth or labor.

    You may encounter some resistance from people, either pro VBAC or con VBAC. Be prepared to stand your ground, and remember who makes the decisions and lives with the experiences.

    Talk to people. Talk to ones who have experienced VBAC, talk to those who have never had a cesarean, talk to the professionals on your birth team. Deal with your emotions, do not sweep them under the rug and feel guilty for them.

    Some women feel very upset over their first cesarean, although this is not true for everyone. They feel cheated, robbed, defective, or many other emotions. These are very real emotions, and you have every right to feel that way. However, you must deal with it, not dwell on it.

    Personal Experiences with VBAC

    "I don't know what I could add except that I had a VBAC and felt the experience very empowering...it changed my feelings about myself from one who was likened to "a defective typewriter" to a powerful, strong and capable woman who can give birth to a baby the way GOD intended us all to do." -Renee

    "My daughter was born by Cesarean in '84 after a 36-hr labor (24 hrs induced); reason given was 'transverse arrest' (head trying to come down the birth canal sideways). My OB felt only lukewarm about my chances for a VBAC, so I sought out midwife care for my 2nd...my thinking was 1) if I didn't at least try, I'd never know what might have happened, and 2) I didn't want to have a medical caregiver who was only lukewarm about my chances. The midwives were great; they seemed to just assume that it all was going to work out fine. My 2nd & 3rd deliveries were successful VBAC's, both midwife attended (both in hospitals)...the babies were 9lb, 3oz and 9lb, 14 oz (my daughter had been 8-6!) and the deliveries were 12 & 3 hrs, respectively. I do remember a point in my 2nd labor when I might have only been half-joking when I thought, why in the world did this sound like a good idea? But I don't think I ever had any serious reservations." -Sue

    VBAC and Other Birth Stories



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