Vaginal Birth After Cesarean (VBAC)
VBAC is the term for “vaginal birth after cesarean.” A woman who has had a previous cesarean and would like to try to have a vaginal birth has a “trial of labor after a cesarean” and is sometimes referred to as a TOLAC. This is a controversial topic within the medical model of care because of the risk of uterine rupture, postpartum hemorrhage due to placenta accreta and even maternal death. You may have been told that it was too risky to attempt or maybe didn’t even know that this was an option before now, because no one had ever told you about the possibility. However, the risk of uterine rupture, hemorrhage due to placenta accreta and maternal death are very low and not much more than the risk of the same during a repeat cesarean. We will start with uterine rupture because it’s the one most talked about.
- 0.87% is the risk of uterine rupture when trying for a VBAC with no prior birth
- 0.45% risk of uterine rupture when trying for a VBAC with 1 prior vaginal birth
- 0.026% risk of uterine rupture in a repeat cesarean
Want a lower risk? Here’s some ways that you can decrease your risk even more!
- If you have had a prior VBAC (vaginal birth after cesarean)
- Having 18-24 months between your children’s birthday
- Waiting for labor to spontaneously begin without medications that induce or augment
- Being healthy. That includes exercise, food choices, and avoiding teratogens such as cigarettes
- Taking educating yourself seriously; Childbirth education is a must!
….but, you can increase the risk of rupture when you allow medicine to be used during your TOLAC. Here are the percentages for those increased risks based on each pharmaceutical.
- 1% risk of uterine rupture with the use of Pitocin
- 2% risk of uterine rupture with the use of prostaglandins such as Cervadil
- 6% risk of rupture with the use of misoprostol, also known as Cytotec
There are signs and symptoms that a possible rupture will soon occur that give us some clues to transfer care as soon as possible, so we aren’t totally oblivious to what may be happening. Uterine rupture does mean there is a need for emergency intervention. The majority of babies will survive. The risk of fetal death in a pre-term baby is 6%, but depending on which study you read, that number can range from 1.3-3% in full-term babies. With a Texas midwife, babies must be delivered between 37-42 weeks, so all of ours are term which changes those numbers significantly.
What about the other risks?
Well, placenta accreta is a condition in which the placenta attaches itself to the uterus, but implants further into the uterine wall, along the scar tissue left behind from your last cesarean making it inseparable. This is a risk that you take with each pregnancy, no matter whether you choose a TOLAC or repeat cesarean, but of course if you are already under anesthesia and having a cesarean, then your OB can quickly turn to a hysterectomy should the need arise. Again though, look at the numbers. The likelihood that a woman will have placenta accreta increases with each additional cesarean. Here’s your likelihood based on the number of cesareans you have had:
- 0.31% after 2 cesareans
- 0.57% after 3 cesareans
- 2.13% after 4 cesareans
There is more.
Blood transfusions, hysterectomy, infections, length of hospital stay and maternal death are all topic that have been studied over and over. (I’ll include all the links I used below.) Those who had a repeat cesarean had higher incidences of these. NICU admission and APGAR scores were very much the same whether undergoing a trial of labor or repeat cesarean. Stillbirth and perinatal death numbers were higher in TOLACs than cesarean births. That number is 1.4 babies in 10,000 with a repeat cesarean compared to 4 in 10,000 with a trial of labor after a cesarean. The difference here being that those that undergo a repeat cesarean usually do so by 39 weeks and those that choose to try for a VBAC are typically waiting for labor to begin, giving them more time for an issue to arise. There is also much evidence that shows a reduction in gut bacteria as the microbiome is affected during cesarean birth. This can affect immune development, increase the incidence of allergies and asthma. Just as important is the effect that cesarean birth has on breastfeeding based on the interrupted skin-to-skin contact and delay in initiation of breastfeeding.
So, what are the contraindications for a trial of labor after cesarean?
- Classical or inverted-T uterine scar
- A prior uterine rupture
- Placenta previa during this current previous
- Your fetus is in a transverse lie
- Fibroids or cysts that lie on the cervix or lower uterine segment
Do you have more questions about vaginal birth after cesarean? Call me today to learn more about your specific situation.
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