VBAC 101: what to Know About a Vaginal Birth After Cesarean
I’m often asked by previous c-section moms my thoughts on VBACs, so let’s talk about it! First things first, VBAC is an acronym for Vaginal Birth After Cesarean. Another commonly used acronym is TOLAC, which stands for Trial of Labor After Cesarean. A little disclaimer- all of the statistics and facts about VBACs in this blog comes from research from The American College of Obstetricians and Gynecologists (ACOG). Oftentimes, it can seem like having a VBAC is the ultimate goal or what everyone should “want” and strive for. I want to say- this specific conversation is really to be had between you and your doctor. You should talk to your provider about the risks and benefits of a VBAC for you and decide if a VBAC or repeat c-section is what’s best for you. You also shouldn’t feel like you “have to”try for one if you don’t want to! The way your baby is born is a miracle either way. Bringing a human into this world is a miracle. However, if you talk to your doctor and decide a VBAC is what you’re going to try for, it’s totally okay to have goals and feel amazing accomplishing them. Fun fact- Women who are VBAC candidates have a 60-80% success rate per the ACOG. That’s pretty great!
So what makes someone a candidate for a VBAC? Again, this really needs to be discussed with your care provider since they know your medical history, they know you (including your wants, needs, and goals). However, some circumstances that shouldn’t prevent you from having a VBAC: your previous c-section was a result of baby’s heart rate dropping, or if baby was in breech presentation. Those situations are going to vary baby to baby, pregnancy to pregnancy, labor to labor. So next time things could be completely different and go swimmingly! Other situations that make you a good candidate for a VBAC would be if during your last c-section, you had a transverse incision, have only had one previous c-section, and if baby is currently healthy and head down. If your c-section was a result of your labor stalling, baby having shoulder dystocia, baby having trouble descending, or if you didn’t dilate to a full 10cm, those things don’t necessarily exclude you from being a VBAC candidate, but it is something to have an in depth conversation with your care provider about. Ideally, you would come up with a game plan for how long you would labor before turning to a repeat c-section, so that everyone is on the same page. Again, your doctor knows your history, they know you, they know with your last delivery what happened and what led to the c-section. They can talk with you about why that would or wouldn't make you a candidate for a VBAC. Prior situations that may lessen the likelihood of being a VBAC candidate: your baby is breech presentation, multiple previous c-sections (some doctors wont attempt after more than 1 c-section), previous classical (vertical) incision, prior uterine rupture, or previous transfundal uterine surgery. Again, having these conversations with your doctor is going to be your #1 priority!
BENEFITS AND RISKS
So believe it or not, VBACs actually have a pretty high success rate and they are also associated with lower adverse outcomes than a repeat cesarean. According to the ACOG the benefits of a VBAC include: no abdominal surgery, quicker recovery time, lower risk of infection, and likely less blood loss. While VBAC risks include: an increased risk for infection if the VBAC fails and uterine rupture (very rare, but biggest risk as previous uterine scar can rupture).
Another thing your care team is going to consider is the number of previous c-sections you’ve had, along with what type of incision you had with previous c-section or c-sections. The number of c-sections matters because each time you’re having a c-section, it’s a new incision on your uterus, which weakens that area and leads to scar tissue. So your risk for uterine rupture is going to slightly increase with each c-section you have. Eddemtially, if you had 2 previous c-sections, you're at a higher risk than a woman who has only had one c-section. Typically c-sections are given with a low transverse incision, which is a horizontal incision down by the pubis. A vertical incision is higher risk for rupture and typically won’t allow for VBAC attempt. The ACOG recommends not attempting a VBAC if you have had an vertical incision.
The biggest risk we hear about with VBACs is uterine rupture. The chances are very low if you’re falling on that list of being a candidate for a VBAC. However, that risk is still there and it’s a big deal. This was something I was so afraid of. I knew the risk was very small, but I actually had a coworker that happened to, so I was more terrified and confused about which route to go. My doctor talked me through that and was my biggest advocate. This helped tremendously. I felt so grateful to be in collaboration with my care team instead of just “told what to do”. If you disagree with your doctor, there’s nothing wrong with getting a second opinion. That’s a matter of gathering more information. But if you have multiple doctors telling you no for similar reasons, there's a reason for that. Be an advocate for yourself, but be safe about it!
HOW TO HAVE THE CONVERSATION
So when you’re talking about a VBAC with your care provider, the first question should be “Why?” Why am I a good candidate for a VBAC or why am I not a good candidate? Having someone who is making a collaborative decision with you and has facts, evidence based research, and experience to back it up will make you feel so much more confident about your decision. Please remember, whether or not you wish to have a VBAC- this needs to be a collaborative decision between you and your healthcare team. Whether your doctor agrees to attempt a VBAC, or disagrees, the first question we should consider asking is “Why?”
The other thing you want to look at when you're considering a vbac (after talking with your doctor) is that the hospital you’re delivering at is well equipped for a VBAC. You want to make sure that you have 24/7 anesthesia staffed, doctors, and nursing staff and that they have all the supplies and equipment necessary for emergency situations. I will tell you from personal experience, having a VBAC in a hospital, knowing that I had the support staff and emergency supplies necessary in case something happened or went wrong, knowing I was in good hands, 100% helped me feel more confident and more comfortable in attempting a VBAC. To wrap things up, making sure it’s a team effort in deciding what’s best for you is going to be the best and safest for everyone involved. Your care team should support you in helping advocate and move forward with a VBAC if that’s what you want, or be there to listen and support you if you need to grieve not being able to attempt a VBAC. Hope this was helpful!
