Vaginal Birth After Cesarean (VBAC)

From an age where having a cesarean once meant that you were forever destined to future cesareans, to this age where we are now blessed to have more information and evidence on this topic, we can be confident in knowing that choosing to have a vaginal birth after a cesarean is (thankfully) a viable option.

But just because we know that having a vaginal birth after a cesarean is possible, doesn’t exactly make it easy to achieve; with hospital policies, continuous fetal monitoring, being classed as a ‘high risk’ case, being misinformed, given cut-off times and dates, and care provider preferences, achieving your vaginal birth after a cesarean may prove to be quite challenging. This is why is it important to educate yourself.

Why do women choose to have VBACs?

Well, some women feel that their cesarean was either forced, unnecessary, or traumatic in some cases and some women just want to experience a natural birth and reap its benefits. Some women hope to achieve a faster recovery with a natural birth while some seek to avoid the short and long term risks associated with a repeat cesarean.

Each woman has her own reason for choosing a VBAC and although there is so much research and evidence on the topic, there is also still so much misinformation going around, making the decision to have a VBAC confusing and stressful. In fact, research shows that there is a 60% – 80% success rate for VBACs and women should be given this as a primary birth option.

Evidence On VBACs

Let’s have a look at the concern around uterine rupture as this is one of the biggest worries around VBACs:
Although uterine rupture is a valid concern and it does happen in some cases, statistics show that uterine rupture is actually very rare and occurs in less than 1% of VBAC births. A UK study in 2012 concluded that the rates of uterine rupture were as low as 0.2% and that the need for a repeat cesarean was more likely due to medical complications such hemorrhage or prolapse.
It also showed that the rates and risk of uterine rupture are lower for women who have a low, transverse, uterine incision scar (the classic cesarean scar) as opposed to a vertical incision scar. So always double check what incision scar you have to understand your risk.

What about having a VBAC after 2 or more cesareans? Does that increase your risk?
Well, according to a US study done in 2006, the conclusion was that having had more than one cesarean did not greatly increase the risk of uterine rupture; the results of risk were very similar (0.7% vs 0.9%); and that a trial of labour and vaginal birth should be an option for women with repeat cesareans, given that they are a low risk pregnancy with no medical complications.

Then there’s also the concern with twin and breech births. Are VBACs an option for these types of births?
Regarding twin births, US studies concluded that twin births posed no greater risk than singleton births for VBACs and the ACOG (American College of Obstetricians and Gynaecologists) issued new guidelines for VBACs stating that women should be offered the option of a VBAC, given that their incision scar is low transverse and there were no medical risks to their pregnancy.
However, in terms of a breach VBAC, there is not sufficient evidence on this due to breach births often being classed as high risk, as well as VBACs, so allowing a women to combine these two is not even a topic of consideration for care providers at all.

Home births for VBACs are often highly discouraged by care providers and with good reason; the outcome of a VBAC birth is unpredictable, especially if it is your first VBAC birth. Most care providers (especially midwives) will feel comfortable allowing a woman to attempt a “home” birth at a private home birthing centre if it is a woman’s first VBAC attempt and she is hoping to avoid a hospital birth. Often, most midwives feel a lot more comfortable allowing a home birth for a VBAC if the woman has already achieved at least one successful VBAC birth before.

The last concern around VBACs is care providers not allowing women to attempt a VBAC at all, and this often strips them of their own right of choice and proper evidence based information from their own care providers. Most women feel dis-empowered due to the assumption that just because their care provider won’t allow them to attempt a VBAC; they think they can’t have one. And this is simply not true. Each care provider has different experience and attitudes towards VBACs and finding a care provider that will honestly support you with integrity and a high standard of care can be very difficult. The best thing you can do is educate yourself on VBACs and ask your care provider for their reasons of refusal in writing and to provide you with evidence based information that supports their refusal… the next step would be to find a second (or even third) opinion, repeating the same process with the first (reasons of refusal in writing with evidence to back them).
Keep in mind though, as I stated above, that VBACs have a 60-80% success rate. That means that they also have a 20-40% failure rate which could be caused from a number of factors such as foetal distress, uterine rupture, etc. That is 1-2 failed VBACs in every 5 births. It’s no wonder that doctors are hesitant to support it.

If you are choosing a VBAC, which you do have a right to, you also have the prime responsibility to research the topic and fully educate yourself on it as well.

I have provided some links below for further reading but I also highly encourage you to seek even further resources to grow your knowledge on this topic. And while speaking to women who have had successful VBACs is great, it would also be wise to listen to those with failed VBACs too.

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