January 6, 2021

By Emeline Mugisha, M.S.N., M.P.H., R.N

If you had a cesarean delivery (or “c-section”) in the past, you might wonder if you can experience a vaginal birth in the future. In most cases, studies suggest that vaginal delivery after a c-section is safe and helps lower the risk of health problems related to multiple c-sections. However, this option isn’t healthy or available for all women. The following information is a guide to help you make an informed choice with your health care provider’s support.

What is a VBAC?

For the majority of women who become pregnant after a prior cesarean delivery, there are two choices for the next birth experience:

1. To schedule another c-section. This is called an “elective repeat cesarean delivery” (ERCD). “Elective” means that the c-section is planned before giving birth.
2. To give birth vaginally. This is called a “vaginal birth after cesarean” (VBAC).

If you choose to try a VBAC, you’ll go through a “trial of labor after cesarean” (TOLAC). This means that your birth plan is to go into labor with the goal of a vaginal delivery. While every woman’s experience is unique, you’ll follow the same overall process for any vaginal birth.

And as you would expect with any labor, a TOLAC may or may not go as planned. A successful TOLAC ends in a vaginal delivery. If it’s not successful, you’ll require a repeat c-section.

Who is eligible for a VBAC?

Your health care provider will use your birth history, medical history, and other factors to determine whether or not a VBAC is a safe option for you and your baby. Here are some criteria that your provider might consider when deciding whether you’re eligible for a VBAC:

• Type of uterine scar. After a c-section, you will have a scar on your uterus based on the type of cut used during the procedure. A “low-transverse incision,” which is made side-to-side across the lower, thinner part of the uterus, is the most common type of cut. A VBAC may be an option if you’ve had one c-section with a low-transverse scar.

• Medical history. It’s best to have no additional uterine scars or previous tearing of the uterus. So, a VBAC may not be an option if you’ve had more than one c-section.

• Type of pelvis. As with any vaginal birth, your pelvis shape and size may affect whether or not a VBAC is possible. Determining whether your pelvis is a good shape and size for childbirth can be helpful in some cases. However, it may not always accurately predict your ability to deliver vaginally. The chances of a successful delivery can change depending on your baby's size, the position of your baby, and other factors.

• Birth setting. A doctor who can monitor your labor and perform an emergency c-section must be immediately available throughout active labor. Anesthesia and health care workers who can handle an emergency c-section must also be available.

What are the benefits of a VBAC?

In general, the benefits of a VBAC include:

• Avoiding major abdominal surgery
• Shorter hospitalization
• Quicker healing time
• Lower risk of infection
• Less blood loss

What are the risks of a VBAC vs. a repeat cesarean?

Overall, studies suggest that vaginal birth after one low-transverse c-section is linked to a lower risk of maternal death as well as fewer complications for mom and baby. However, both a VBAC and ERCD may have serious health consequences in a small number of cases.

An unsuccessful TOLAC may increase the risk of:

• Uterine rupture (tearing of the uterus)
• Surgical injury
• Maternal infection
• Transfusions
• Newborn illness during the first 28 days of life

Multiple c-sections may increase the risk of:

• Bladder and bowel injury
• Placenta previa (a condition where the placenta covers all or part of the cervix)
• Placenta accreta (a condition where the placenta attaches too firmly to the uterine wall)
• Hysterectomy (surgical removal of the uterus)
• Maternal death

Additionally, repeat c-sections are linked to longer hospitalizations than VBAC.

How can I increase my chances of a successful VBAC?

Although a VBAC has risks, it’s a safe option for most women and babies. Studies suggest that 60-80% of women who attempt a VBAC are successful, and most have no complications.

If you’ve previously had a c-section and you’re considering a vaginal birth, you can begin talking about VBAC with your health care provider at your first prenatal visit. Discuss the risks and benefits of each option as well as your delivery expectations with them. Make sure that they have your complete medical record, including any previous births or uterine procedures.

If you’ve had a vaginal birth before, you’re more likely to have a successful VBAC. Also, waiting at least 24 months before giving birth again lowers the risk of VBAC complications.

Finally, if you’d like to attempt a VBAC, you and your provider must consider whether this option is available at the hospital you’ve chosen in advance. Some hospitals may not offer VBAC if they don’t have the staff and resources available to provide emergency care.

In the end, whether you have a vaginal or cesarean birth, we want it to be a safe and satisfying experience. Consulting your provider as early as possible will help you decide if a VBAC is right for you and increase the chances of a successful TOLAC.

Sources:

American College of Obstetricians and Gynecologists. (2017, December). Vaginal birth after cesarean delivery (VBAC).
https://www.acog.org/womens-health/faqs/vaginal-birth-after-cesarean-delivery

Guise, J. M., Eden, K., Emeis, C., Denman, M. A., Marshall, N., Fu, R. R., Janik, R., Nygren, P., Walker, M., & McDonagh, M. (2010). Vaginal birth after cesarean: new insights. Evidence Report/Technology Assessment, (191), 1–397. https://www.ahrq.gov/downloads/pub/evidence/pdf/vbacup/vbacup.pdf

Kurtz Landy, C., Sword, W., Kathnelson, J. C., McDonald, S., Biringer, A., Heaman, M., & Angle, P. (2020). Factors obstetricians, family physicians, and midwives consider when counselling women about a trial of labour after caesarean and planned repeat caesarean: a qualitative descriptive study. BMC Pregnancy and Childbirth, 20(1), 367. https://doi.org/10.1186/s12884-020-03052-1

Neff, M. J. (2004). ACOG releases guidelines for vaginal birth after cesarean delivery. American Family Physician, 70(7), 1397–1401.
https://www.aafp.org/afp/2004/1001/p1397.html




Emeline Mugisha, M.S.N., M.P.H., R.N. - Emeline Mugisha is an award-winning, master's-prepared nurse with over a decade of experience in community/public health and clinical health services at the field and management levels. She has co-authored two professional manuscripts in Women's Health Issues and the Journal of Midwifery and Women's Health. She has an M.S. in Public Health Nursing and an M.P.H. from Johns Hopkins University.