January 3rd, 2011
09:19 AM ET

Is it OK to have a VBAC?

Every weekday, a CNNHealth expert doctor answers a viewer question. On Mondays, it's pediatrician Dr. Jennifer Shu.

Question asked by Anne of Gainesville, Florida:

I'm pregnant with my third baby and am due next month. I had C-sections with the first two babies but would like to try having the baby naturally this time. People have told me that this is not safe, but I found an obstetrician who is willing to do a VBAC. What's the latest information on having a vaginal delivery after having a C-section?

Expert answer:

Thank you for your question. Many women who have had cesarean sections inquire about the possibility of attempting a vaginal birth after C-section (VBAC), sometimes also called trial of labor after C-section (TOLAC). To better help you, I consulted Dr. Gary Glasser of Atlanta Gynecology and Obstetrics in Decatur, Georgia.

Glasser shares the following information:

This is a very timely subject, as guidelines concerning vaginal birth after cesarean (VBAC) were updated in August by the American College of Obstetrics and Gynecology. In the past, the dictum was "once a cesarean, always a cesarean," and the cesarean section rate increased for this and other reasons during the 1970s and '80s. The 1990s saw a renewed interest in attempting VBACs, and the cesarean section rate dropped. But as the rate of delivery complications from VBAC (including uterine rupture) increased, attempts at VBAC decreased, although there are some benefits to avoiding repeated cesarean sections.

The current thought in the American College of Obstetrics and Gynecology guidelines, therefore, is that a trial of labor after cesarean delivery is "a reasonable approach in selected pregnancies."

For patients with a previous cesarean, a successful VBAC has fewer complications (those associated with major surgery) than a scheduled cesarean. Multiple cesareans can increase the risk of injury to other surrounding organs, the need for a hysterectomy and the chances of requiring a blood transfusion.

However, VBAC is not risk-free. VBAC increases the risk of uterine rupture (reported to be between 1 in 100 and 1 in 200), which can be sudden and catastrophic for both mother and baby. Both a successful VBAC and a scheduled cesarean, however, have fewer complications for both the mother and the baby than a failed trial of labor after cesarean.

Mom defies docs, has baby her way

Women who are good candidates may therefore be advised to attempt a VBAC if the chance of success is high. Overall, the success rate is about 60% to 80% and depends on many factors (such as the type of uterine incision and the reason for the previous cesarean, among others). As new data have become available, more patients are eligible for the possibility of an attempted VBAC, including patients with two previous cesareans and those with a previous cesarean section who are currently pregnant with twins.

There is no formula or algorithm that fits every patient. A thorough discussion with your health-care provider is essential to get the most up-to-date and personalized information about the risks and benefits of attempting a VBAC.

soundoff (24 Responses)
  1. Bonnie

    I was surprised to see this question, since I had a VBAC 24 years ago! I assumed it was very common now. When I had my first child, she was breach, and the doctor said I would have to have a cesarean for any subsequent births. However, when I was pregnant again, about 3 years later, my ob/gyn(same doctor) encouraged me to consider the VBAC. I did and everything went very well. It was definitely an easier recovery. Obviously, each situation is different, but I am glad I did it.

    January 3, 2011 at 12:21 | Report abuse | Reply
    • Janna

      I agree. I did the same thing. My first was a boy, C-section due to his large head not fitting through my pelvic area. I think they rushed me, though. He would have eventually came out. Anyways my daughter came along over 2 and 1/2 years later. Was in labor 6 hours. Got 8 centimeters before I got my epidural. She came out pretty fast after that. Smaller over all. I am happy with my choices, even if I can not change the choices my first OB made.

      January 3, 2011 at 20:42 | Report abuse |
  2. Michelle

    Two sentences of this long response should be read together to yield the best response to the original question.
    1) "a successful VBAC has fewer complications (those associated with major surgery) than a scheduled cesarean"
    2) "Overall, the success rate is about 60% to 80% and depends on many factors (such as the type of uterine incision and the reason for the previous cesarean, among others)."
    What you have to compare is the known risks of cesarean with the risk of your VBAC failing (a failed VBAC is one ending in either an emergency cesarean or death of one or both of the mother or child). The risk of your VBAC failing is something your OBGYN can tell more precisely based on your particular uterine scarring and other factors. Compare those two numbers which are both specific to you, and pick the one with the lower risk. If you look at the whole population to get a guess as to how the numbers will shake out for you, you need to take into consideration that every C-section ups the risk of subsequent VBAC failure. The article doesn't give a rule of thumb here. According to the wisdom of the internets though, one C-section seems ok (i.e. VBAC risks are <= C=section number 2), but two seems situation dependant requiring long articles like this one in response. For three or more there's a presumption of too much scarring.

    January 3, 2011 at 17:00 | Report abuse | Reply
    • Sydney

      @Michelle: Your post is misleading in saying that a failed trial of labor (tol) results in either a repeat cesarean or the death of the mother or baby. There are no statistics for mothers dying in a failed tol. Babies can sometimes die in the case of catastrophic uterine rupture, and the mother may suffer a hysterectomy, but as far as mortality, there are just no statistics on it. There are statistics, however, for mothers dying on the operating table during routine repeat c-sections. Mothers should know these risks before deciding which option is best for them and their family.

      January 10, 2011 at 11:54 | Report abuse |
  3. m

    There was a whole article about this recently. One of the things mentioned in the article is that in order to attempt a VBAC an OR and team needs to be available and ready in the event of a rupture. If this cannot be arranged then there can be no VBAC attempt.

    So check with your Dr. that this is so at your hospital. Otherwise, you will very likely wind up with another C-section.

    January 3, 2011 at 17:32 | Report abuse | Reply
    • Justin Brown, MD

      Thanks for making this point. VBAC can be a reasonable a responsible choice in many situations. It is a dangerous choice to VBAC at home without trained medical personnel and an operating suite available.

      January 3, 2011 at 21:15 | Report abuse |
    • Marcella

      An OR should be available for all deliveries. I have been a labor and delivery nurse for 20 years and have seen more emergencies with non VBAC attempts. I have also seen uterine ruptures with non-scarred uteruses. The sad thing is that in another 10 years this forum will be talking about placenta accreta and the maternal mortality rates associated with that.

      January 12, 2011 at 12:12 | Report abuse |
  4. Paul

    My wife has had two, and both went just fine. We are now expecting our fourth and will do another VBAC. Recovery after natural childbirth is much easier than a c-section. Due to the requirement of the 24/7 on-site anesthesiologist you have to find out which hospital near you will do them. We have to travel 40 miles to get to the nearest hospital that will do VBACs. It's a shame that more hospitals won't do them.

    January 3, 2011 at 18:46 | Report abuse | Reply
  5. Patricia

    I had 3 successful VBACS, the first one over 25 years ago. I was very surprised to learn this is not common by now. Maybe I was just lucky, but the VBACS were certainly much easier to recover from than the C-section. The C-section was due to my child having a prolapsed cord, something that was unlikely to occur again. I would encourage any woman to discuss the possibility with their doctor..

    January 3, 2011 at 19:15 | Report abuse | Reply
    • LEB

      It's not as common as back when you had kids simply because c-sections have increased astronomically. Many doctors simply won't perform a VBAC, mostly from fear of complications that will lead to patient or infant injury... and thus a big, fat lawsuit. Many doctors are more interested in protecting their own rear ends over giving patients the service that they want.

      January 5, 2011 at 01:48 | Report abuse |
  6. JZ

    Thank you for this important discussion. It's very important for women to have a true sense of options before making a decison. I HAD A UTERINE RUPTURE nearly a decade ago and it was so horrible I can't begin to describe it. I will spare you the medical details, but we are fortunate that the baby and I both survived. When they tell the odds are 1:100-200 (I was told 1:1000 back then) then I interpreted that to mean "not going to happen to me." I know know those statistics mean "it COULD happen to me..." so I should consider that when making an informed choice. I was told it was "rare" but didnt' quite 'get" that "rare" would mean what I went through. I ended up hospitalized 3 times for medical reasons after, was apart from my baby, had to hire a nanny because I couldn't care for the child because of the medical sequelae...and ended up also with PTSD. This is RARE but it can happen so it is important that you consider your options carefully and as Michelle wrote to think about your PERSONAL medical situation very carefully to make the best informed decision for yourself.

    January 3, 2011 at 19:24 | Report abuse | Reply
  7. jlb

    I had a VBAC after an emergency c-section due to a surprise breech. I am so glad I live somewhere VBACs are encouraged. Much easier recovery.

    January 3, 2011 at 19:42 | Report abuse | Reply
  8. jlls

    I had a successful VBAC 20 years ago after two prior c-sections. The first was due to fetal distress (cord wrapped around his neck) and the second was primarily to clean up a messy scar left from complications of the first. After experiencing both methods of birth, I will definitely say that the recovery of the VBAC was much easier. However, my uterus was irritable and I had contractions 4 minutes apart for the last 8 weeks of my pregnancy, and they had to stop premature labor several times. Its definitely not a decision to be made lightly and should be discussed thoroughly with your doctor.

    January 3, 2011 at 20:08 | Report abuse | Reply
  9. robbie

    I had a vbac with my 2nd child and it didn't go well.I ended up with [what they called at the time]a fourth degree tear and I couldn't urinate correctly for about a month.Wish I would have had the c-section.

    January 3, 2011 at 20:08 | Report abuse | Reply
  10. Meg

    I had 2 successful VBAC's after 1 c-section....... the first VBAC 20 years ago and the second 15 years ago. My first VBAC did have complications – I did not have a uterine rupture but did hemorrhage for an unknown reason, and when it could not be stopped, I ended up having an emergency DandC to hopefully stimulate my uterus to stop bleeding and take the proper course. It was successful in doing that, and though I lost a large amount of blood, and it was traumatic at the time, the actual birth and the aftercare was still a very happy occasion and I was grateful to have done it. My opinion is that the placenta was "urged" out a bit too fast and that's what caused the hemorrhage – a rip in the uterine wall – but we will never know for sure. My 2ond VBAC had no such complications and was a happy occasion all around. I have nothing against a necessary c-section – my first labor did not progress after being induced, and my baby was showing signs of stress – but all in all, having the 2 VBAC births, for me, was a really wonderful opportunity and I'm so thankful I was able to do it.

    January 3, 2011 at 20:59 | Report abuse | Reply
  11. Eugenia

    I had a C-Section with my first son and my next two deliveries were VBAC. When my firstborn was just four months old, I became pregnant and once again two years after that. I had concerns about the C-Section incision rupturing during my pregnancies and deliveries, but neither became an issue. In fact, I'm happy to state my incision has never bothered me. It is critical to find an OB that values and validates the patient's input and concerns about labor and delivery. In fact, my OB agreed with me laboring long enough to dialate past 10cm so my body would do more of the "work" and I wouldn't have to push so long. My doctor stated that as long as my instructions for labor and delivery were in writing, signed by me, and a copy was given to the Labor and Delivery nurse, the doctor, and my husband; my wishes would be respected. Best wishes!

    January 3, 2011 at 21:00 | Report abuse | Reply
  12. tams

    Being a labor and delivery nurse this is very near and dear to my heart. Certainly people can try a trial of labor, however please discuss with your dr. What worries me about this woman is she has had 2 c/sections so now not one but 2 scars on her uterus. while VBACs are certainly possible I would take in account why you had other c/section if it was breech, or fetal distress, chances would probably be good, but failure to progress and failure to dialate are all signs that baby might just not fit.

    January 3, 2011 at 21:18 | Report abuse | Reply
  13. J

    My wife and I had our first two children via c-section. We were young and learned much since. Following that we had 4 vbacs. Those four were completely natural, no medication, and with lots of preparation. As we look back on it now, the epidural and IVs, being stuck in that hospital bed on her back, and all the interventions actually caused the "failure to progress" the first two times. Natural childbirth worked for us beautifully.

    January 3, 2011 at 23:01 | Report abuse | Reply
  14. CeeCee

    After a c-section for breech 23 years ago I had 3 successful VBAC's without problems. But I had a friend who experienced a uterine rupture with her first pregnancy! NOT during a VBAC, just happened spontaneously. Emergencies can pop up at any time for many reasons. This question can only be answered on a case by case basis.

    January 3, 2011 at 23:02 | Report abuse | Reply
  15. Barbara

    Worked for me... a painful but drug-free three-hour labor/delivery for #2 Son.

    January 3, 2011 at 23:10 | Report abuse | Reply
  16. Cass

    I just had a VBA2C two weeks ago today. Best decision I ever made!

    January 3, 2011 at 23:29 | Report abuse | Reply
  17. tu71586

    There's no question that VBAC offers less blood loss and easier recovery. For patients who have a successful VBAC, it's great. And, most people (60-80% as per the article) will have a successful VBAC. But, what about the 1% of patients who have a uterine rupture? What about those patients who have a uterine rupture and their baby dies? What about the 1% of patients who has a uterine rupture, their baby dies, and they sue their obstetrician? The stakes are high. Nobody wants a dead baby, and nobody wants to be sued. That's why even though numbers-wise, it makes total sense to VBAC, you don't see it as often.

    January 4, 2011 at 08:15 | Report abuse | Reply
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