VBAC after a C-section 

© Dr. Michael D. Jacobson, D.O. Do not reproduce this article without permission.

A CHM member recently wrote,

My husband and I are considering adding to our family of five. Our oldest children (twins) were delivered in 2012 via c-section because Baby A was breach. Our third was a VBAC delivered in 2017. At that time, my doctor insisted on continuous monitoring and other precautions. The baby was delivered safely with no sign of issues. I want to know if my successful VBAC means I have a lower risk this time around. Do you have suggestions of where to find information that isn’t flooded with bias?

Dr. Jacobson’s response: The simple, quick answer to your question is, “yes.” A successful vaginal birth after cesarean (VBAC) means that you have proven you can tolerate a trial of labor after cesarean (TOLAC) without uterine rupture.

TOLAC is not only my personal preference, it’s what our family chose many years ago. Our oldest child was born by cesarean section. Six years later, my wife opted for a TOLAC. From an obstetrical perspective, her labor and delivery went smoothly, and by using a birthing stool with the assistance of a very experienced midwife, our second child (who was born two weeks later and over a pound heavier than our first) was delivered in only four pushes. The only complication was significant post-partum bleeding, successfully managed with uterine massage and medication.

Our experience is from 26 years ago, so I went to get an updated and informed answer to your question. After using the National Library of Medicine (NLM) website and searched for review articles on VBAC, what I found was quite disappointing.

First of all, it doesn’t seem like the field of obstetrics has learned significantly more since 1993 about VBAC’s risks and benefits. There have been few randomized clinical trials comparing outcomes between those who opt for elective repeat C-section, and those who determine a TOLAC. This makes it difficult, if not impossible, to give a solid, credible answer to the question.

Secondly, it means that there is no clear mandate within the obstetric and midwifery communities of the best course of action following initial cesarean. Since the most important factor determining whether a woman will choose a TOLAC is if their doctor advises them to do so, it’s no surprise that TOLAC rates are actually declining in most developed countries. Currently, less than 25 percent of women attempt TOLAC.

With that in mind, here are the facts as we know them:
  1. If someone elects to have a repeat C-section, it more than likely means that all future pregnancies will be by cesarean.
  2. Factors that contribute to unsuccessful VBAC:
    • maternal age
    • pregnancies that go beyond 40 weeks
    • severe maternal obesity
    • preeclampsia
    • a need for induction of labor
    • a history of prior C-sections with no vaginal deliveries
    • a delivery within the past 18 months
  3. Factors that contribute to successful VBAC:
    • the above criteria do not apply
    • no history of uterine rupture or uterine surgery other than their prior C-section
    • prior C-section involved only a low transverse incision into the uterus (the incision is underneath the skin and out of sight). In other words, candidates for VBAC have never had a high vertical (classical) uterine incision.
  4. For those who attempt a TOLAC, the likelihood of a successful VBAC is 65 to 80 percent. Said another way, at least 2 of 3 women who attempt VBAC will succeed.

So, what are the benefits of VBAC over elective repeat C-Section?

  1. The risks of complications for women eligible for VBAC are actually lower if they attempt a TOLAC over those who opt for elective repeat C-section. Essentially, VBAC is safer.
  2. Recovery time after delivery is shorter.
  3. The risk of surgical complications, including bleeding, infections, injury to abdominal organs, and future scarring and adhesions, are lower with VBAC.

As stated before, my personal preference is to attempt TOLAC in hopes of a successful VBAC. However, each woman and her husband should consult her doctor when considering delivery options after having a C-section. With the help of her healthcare provider, a woman can determine whether she is an eligible candidate to attempt TOLAC based on her health history and previous deliveries.

References:

  1. mayoclinic.org/tests-procedures/vbac/about/pac-20395249
  2. Ryan, G. A., S. M. Nicholson, and J. J. Morrison. 2018. “Vaginal birth after caesarean section: Current status and where to from here?” Eur J Obstet Gynecol Reprod Biol 224:52-57. doi: 10.1016/j.ejogrb.2018.02.011.
  3. Gardner, K., A. Henry, S. Thou, G. Davis, and T. Miller. 2014. “Improving VBAC rates: the combined impact of two management strategies.” Aust N Z J Obstet Gynaecol 54 (4):327-32. doi: 10.1111/ajo.12229.
  4. Dodd, J. M., C. A. Crowther, R. M. Grivell, and A. R. Deussen. 2017. “Elective repeat caesarean section versus induction of labour for women with a previous caesarean birth.” Cochrane Database Syst Rev 7:CD004906. doi: 10.1002/14651858.CD004906.pub5.
  5. Sargent, J., and A. B. Caughey. 2017. “Vaginal Birth After Cesarean Trends: Which Way Is the Pendulum Swinging?” Obstet Gynecol Clin North Am 44 (4):655-666. doi: 10.1016/j.ogc.2017.08.006.
  6. Bonzon, M., M. M. Gross, A. Karch, and S. Grylka-Baeschlin. 2017. “Deciding on the mode of birth after a previous caesarean section - An online survey investigating women’s preferences in Western Switzerland.” Midwifery 50:219-227. doi: 10.1016/j.midw.2017.04.005.
©2019 Christian Healthcare Ministries. All rights reserved.