Since I started this work in 2007, I have encountered a lot of misinformation about VBAC from parents and professionals alike. Conventional wisdom (often incorrect), the misinterpretation of current guidelines, and the lingering specter of obsolete recommendations are just a few factors that continue to negatively influence how medical care is dispensed after a cesarean as well as the process of informed decision making.
All of the myths below have come straight from readers who have asked me, “Is this true?” And every single time, the answer has been, “No.”
I thought it was time to collect the most pervasive VBAC myths in one article. These myths cover the basics like uterine rupture rates to difficult topics like death and logistics like hospital policy.
In the end, all of these myths confuse women and birthing people about their options making it impossible for them to make a truly informed decision between VBAC and elective repeat cesarean section.
What myths have you heard about VBAC? Let me know in the comments below.
Many people still believe, “once a cesarean, always a cesarean.” This prevailing conventional wisdom is greatly influenced by persistent and pervasive myths about VBAC. It’s time for some clarity.
Myth: Once a cesarean, always a cesarean.
All too often, people believe that national recommendations discourage VBAC or that VBAC is an "alternative" choice. Nothing can be further from the truth.
National Institutes of Health (NIH) said back in 2010, “VBAC is a reasonable and safe choice for the majority of people with a prior cesarean.” [1]
The American College of Obstetricians (ACOG) concurred when they said: “The preponderance of evidence suggests that most women with one previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about and offered TOLAC [trial of labor after cesarean].” [2]
These words affirm that VBAC is a mainstream, evidence based option to which national organizations encourage access because the medical evidence supports it.
This is the case outside of the US as well. I have read the VBAC guidelines from several countries and while aspects of their recommendations vary, the overall message that VBAC is a reasonable, evidence based option that should be available is consistent.
Myth: Planned labor after one cesarean has a 60% uterine rupture risk.
There is simply no excuse for clinicians who cite statistics like this. They are untrue and thus inhibit informed decision making. They often result in people "consenting" to a cesarean and exposing them to the risks of cesarean surgery.
Additionally, when parents learn the truth, it can dramatically decrease the trust they have for the medical system as a whole. Unfortunately, this medical mistrust can impact if, when, and how people engage with the medical system for the rest of their lives. Especially for partnered mothers, this can impact the healthcare that their partners and children receive. The consequences of medical mistrust reach far beyond the postpartum period.
The bottom line is: People are entitled to factual information when making medical decisions.
The risk of uterine rupture during a labor after one low transverse (bikini) cut cesarean is about 0.5%–1% depending on factors. [1] First time parents are also at risk for timely complications that can require delivery via emergency cesarean. [3,4,5] Parents often don't think about this during their first pregnancy because of how information to conveyed to first time parents versus those who have had a prior cesarean.
Myth: Hospitals ban VBAC because uterine rupture is a serious and unusual complication which they cannot manage.
Hospitals with labor and delivery units have protocols in place to respond to obstetrical emergencies. The guidelines used to manage emergencies among first time labors and repeat cesareans are also used to address uterine rupture in those planning VBACs.
Additionally, ACOG has clearly stated since 2017 that Level 1 hospitals, as defined as those who provide basic care, can offer VBAC. As of this writing, it has been eight years since this statement and yet I frequently encounter people, including physicians and nurses, who claim that their local hospital "cannot" offer VBAC because they don't have the "required" 24/7 anesthesia or physician presence. This is not a requirement.
It is a vestige of an outdated recommendation from ACOG's 1999 VBAC guidelines: "a physician immediately available throughout active labor who is capable of monitoring labor and performing an emergency cesarean delivery.” [6]
But ACOG has been clear since 2010, 15 years as of this writing, that even if a hospital cannot meet this recommendation, of which they provided no clear definition, hospitals, and individual providers, still should not tell people that they must have a cesarean. Women and pregnant people always have the right to decline a cesarean surgery even if the existence of a hospital VBAC ban implies the opposite.
Myth: To expedite an emergency cesarean, epidurals are required in planned VBAC. [OR] Those planning VBACs can’t have epidurals because they obscure the pain of uterine rupture.
Per ACOG's latest VBAC guidelines, epidurals may be used during a planned VBAC [2] and evidence suggests that epidurals do not mask uterine rupture-related pain. [7] Additionally, only 26% of women who experience a uterine rupture report abdominal pain, so it is an inconsistent and unreliable symptom. [8]
When you combine the fact that people can still feel uterine rupture-related pain through an epidural and only one-fourth of uterine ruptures are associated with abdominal pain, you can see why a policy to withhold epidurals for the sake of "safety" falls flat.
If a laboring person wants an epidural for pain relief, they should have one. If they don't want an epidural, they shouldn't be mandated to have one.
While planned VBAC is often surrounded with this cloud of fear, we have to remember: Any labor could require a cesarean, emergency or otherwise. Cesareans themselves, including elective repeat cesareans, can have emergency complications including hemorrhage and emergency hysterectomy.
There is no evidence based reason to have different labor protocols for planned VBACs and this is true regarding epidurals. To have one, or not have one, is a choice for the laboring person. It is not a place for hospital policy.
Myth: There is a 25% chance that someone will die during a VBAC.
The risk of maternal death is very low whether a birthing person plans a VBAC (0.0038%) or an elective repeat cesarean (0.0134%). [1] It is critical to note that term "planned VBAC" refers to everyone who labors after a cesarean, regardless of how their baby is born. As a result, within the category of "planned VBAC" are those who labored and had a VBAC as well as those who labored and had a cesarean, including emergency cesareans.
Now look at those numbers again. The risk of maternal death in both scenarios is quite low, but it's five times higher with an elective repeat cesarean. That is because, inherently, cesareans carry higher rates of maternal morbidity (complications) and mortality (death) than vaginal birth and that includes elective repeat cesareans that occur before labor and in the absence of a medical reason.
How do we know this? Because the studies that generated these statistics were intentional with how they collected and reported cesarean maternal death data. They deliberately measured the risk of maternal death among elective repeat cesareans in healthy pregnancies so they could isolate the risk associated with surgical birth without having that data be muddied by complications like pre-eclampsia.
Here's an example of what that looked like. This maternal mortality statistic is from the 2010 NIH VBAC Evidence Report [1] and is cited as recently as ACOG's 2019 VBAC guidelines. [2] Wen 2004 was the largest study the NIH included in their review featuring the outcomes of over 300,000 people. [9]
Wen states, "Underlying diseases requiring cesarean delivery do not explain all of the increased risk of maternal mortality related to cesarean section, because the cesarean section related risk appears to remain after various exclusions/adjustments." In other words: even when we remove all the reasons someone could have a bad outcome with a cesarean, the risk is still higher than vaginal birth.
They came to this conclusion because they excluded the outcomes of labors that had sixteen different criteria: "multifetal pregnancy, pre-e/eclampsia, non-vertex presentation, preterm labor, placenta previa, placental abruption, herpes and those under 14 years old."
As they state, "These conditions are likely to effect the woman's chance to undergo a trial of labor, and at the same time may be associated with the study outcomes [including maternal death] and therefore may confound the associations under study."
Confound is the scientific word for "mix up our data." In other words, they want to isolate the risk maternal death purely associated with cesarean section as much as possible. Not have that data combined with, or influenced by, the higher rates of complications associated with the conditions they excluded.
This is what good, strong studies examining maternal death after a cesarean do. There are a whole host of conditions and complications that increase the risk of mortality and morbidity. Strong studies control for those variables so we can get as close as possible to the risk of death associated with mode of delivery without having those numbers influenced by other factors.
Wen ultimately compared two groups: those who did, and did not, labor after a cesarean. They found a 10 per 100,000 maternal death rate among those who planned elective repeat cesarean sections and 2 per 100,000 for those who labored after a cesarean when excluding the 16 criteria.
So if you hear someone say, "The only reason why the risk of maternal death and complications are higher among cesareans is that those surgeries take place in unhealthy pregnancies," know that is incorrect.
We can clearly see here: Elective cesarean sections carry a five times higher rate of maternal death than planned VBAC. Thankfully, in both scenarios, the risk of maternal death is very, very low.
While the risk of an infant death during labor or within 28 days of being born (perinatal mortality) is higher with a planned VBAC (0.13%) than a repeat cesarean (0.05%), the risk is still low. [2]
What about the risk of infant death and uterine rupture? Limited research suggests that 2.8 – 6.2% of uterine ruptures during planned VBACs result in perinatal mortality. [1] This translates into an overall risk of 0.0196% - 0.04340%. This risk is even lower when labors begin and progress naturally because the risk of uterine rupture is lower.
Myth: There are no risks associated with cesareans other than surgery.
There are numerous real complications associated with cesarean section including placenta accreta spectrum, hysterectomy, hemorrhage (excessive bleeding), blood transfusion, placenta previa, ICU admission, and surgical injuries to the bladder, bowel, and ureters. [10] The likelihood of all of these complications increase as the number of prior cesareans rise. [10]
This is why we cannot behave as if only planned VBACs carry risks and cesareans have none. Both options have risks and benefits and every pregnant person should be provided with the opportunity to decide which set of risks and benefits are most tolerable to them.
While parents evaluating the risks and benefits of VBAC and elective repeat cesarean should be made aware of these complications, there are two that give me the greatest pause. First, placenta accreta spectrum, when the placenta embeds too deep within the uterus and does not detach normally after the baby is born.
Every prior cesarean increases the likelihood of placenta accreta spectrum developing in a future pregnancy. Placenta accreta spectrum carries its own risks including very high rates of excessive bleeding, blood transfusion, hysterectomy, surgical injury, and ICU admission as well as a higher rate of maternal death. [10, 11]
Many people with placenta accreta, increta, or percreta (the three degrees of placenta accreta spectrum) have a cesarean-hysterectomy in response to uncontrollable bleeding after the baby is born. Cesarean-hysterectomies are associated with their own set of significant complications and outcomes including premature menopause. (See our interview with Dr. Stroud for more on cesarean hysterectomy and our interview with Dawn Baranski on her experience surviving placenta percreta after three cesareans.)
We are not just talking about the loss of fertility here. We are talking about early onset menopause, even with ovarian preservation, which, in the absence of hormone replacement therapy (HRT), harms the brain, bones, cardiovascular system, and urinary track.
This is why all who receive a cesarean-hysterectomy should be counseled about the symptoms of perimenopause (so they know what to look for) as well as hormone replacement therapy to protect these four vital systems in their bodies for the remainder of their life (because so many clinicians are undereducated on the topic.)
The book "Estrogen Matters" and Dr. Mary Claire Haver, especially her Instagram page, are excellent resources on this topic. (Purchasing a book through that link supports a Black owned bookstore, Uncle Bobbie's, in Philadelphia.)
Further, many parents find that their local hospital is unable to provide the complex response that placenta accreta spectrum requires in order to generate a good outcome. As a result, they find themselves traveling great distances so they can birth at well resourced and staffed facilities who not only offer a variety of surgical subspecialities but also adequate blood banks.
After two cesareans, the risk of placenta accreta spectrum is 0.57%, [10] slightly higher than the risk of uterine rupture during a non-induced or augmented labor after one low-transverse cesarean (0.4%). [12]
It is so important for parents, and clinicians, to understand that while elective repeat cesarean section almost always circumvents the risk of uterine rupture (look at ACOG's VBAC guidelines, the risk is not zero), that cesarean also increases the risk of an even more complex and grave complication in future pregnancies: placenta accreta spectrum.
This is literally trading one serious complication now for a even more serious complication in the future. Parents need to understand this.
This has substantial implications for those who want more children. This is why every person who is pregnant after a cesarean should be asked: Do you want more children? And they should be informed about the risk of placenta accreta spectrum as that is part of the informed decision making conversation regarding VBAC.
This is also why every person with one prior cesarean should have the opportunity to VBAC, when the risk is low. As people have more cesareans, the risks increase no matter how they intend to birth those future pregnancies.
Additionally, we know from research that those with a history of abdominal surgery - including cesarean section and hysterectomy - are more likely to experience life threatening bowel obstructions, even multiple decades later. [13]
Bowel obstructions are associated with high rates of mortality. When surgery takes place within 36 hours of onset, the mortality rate is 8% and increases to 25% if surgery takes place after 36 hours. [14] If surgery does not take place, the mortality rate is 100%.
This is why I advocate for the inclusion of bowel obstruction symptoms in discharge papers so people know what to look for (such as nausea, vomiting, constipation, and abdominal distension.)
Further, ER physicians should routinely ask those presenting with signs and symptoms consistent with bowel obstructions if they had a prior abdominal surgery and specifically mention cesarean section and hysterectomy. This is one of the numerous reasons why access to VBAC is a public health issue.
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Myth: I can’t have a VBAC in my state because it’s illegal.
VBAC is legal throughout the United States and in some states, it’s legal for a midwife to attend a community VBAC where birth occurs at home or at a birth center.
In other words, while there may be legal repercussions for midwives who attend community VBAC in states where VBAC is "outside the scope" of midwives, it is not illegal for a baby to emerge from a vagina after a cesarean.
Parents should not fear that they will be arrested just because they had a fast labor and delivered in the car or on the side of the road.
Myth: My doctor will lose their medical license if I have a uterine rupture.
I am sure that some physicians carry this fear. Fortunately, there is no evidence to suggest that a physician has lost their license for attending a planned VBAC in the absence of medical negligence.
Farah Diaz-Tello, Senior Counsel & Legal Director at If/When/How: Lawyering for Reproductive Justice clarifies, “I have never heard of a situation in which a physician has lost their license for adhering to a woman’s wishes after providing them with full informed consent, and attending them in a manner that is consistent with the standard of care. Even physicians who have been found liable for medical malpractice do not automatically lose their license.”
Additionally Hermine Hayes-Klein, an informed consent expert and international human rights lawyer, affirms, “The law of informed consent should mean that providers are never held liable for their clients' choices. The provider's responsibility ends where the patient's rights begin, and with the right to make the choice comes responsibility for the choice.”
Myth: Planned VBACs shouldn’t be induced.
Induction can play an important role in many pregnancies which is why it should always be on the table as an option. When a complication requires the baby to be born sooner rather than later, but not necessarily in the next ten minutes, which is when an emergency cesarean would occur, induction can make the difference between a VBAC and a repeat cesarean. This is why ACOG maintains that medically indicated induction “remains an option” during a planned VBAC. [2]
This myth might originate from the data which indicates the risk of uterine rupture can increase with induction. Nevertheless, there are things we can do to lower that risk. (See our training on induction after a cesarean available within professional membership to learn more.)
Additionally, when induction is removed as an option, the only remaining choices are to remain pregnant with the complication or have a repeat cesarean. Neither of these options are risk free. People are entitled the understand the risks and benefits of all of their options so they can make an informed decision that honors the current pregnancy as well as future pregnancies and their long term health.
Myth: Hospitals ban VBAC because they can’t meet ACOG’s “immediately available” requirement.
As we touched on above, some hospitals interpret ACOG’s “immediately available” recommendation to be a mandate that an anesthesiologist or physician must be in the hospital 24/7. Some hospitals that cannot provide that level of coverage have "banned" VBAC. However, closer examination of hospital VBAC policy in the state of California found that fully one-third of hospitals with VBAC bans had 24/7 anesthesia. [14]
This illustrates how VBAC bans are not about safety. They are about hospitals who opt out of providing this important service under the assumption that some other hospital in the community will do so. However, due to insurance constraints, even if other hospitals offer VBAC, sometimes those facilities are not an option for families. This is another reason why every Level 1 hospital should offer VBAC.
Myth: Hospitals that do not have 24/7 anesthesia coverage ban VBAC.
There are rural, low resource, and community hospitals that offer VBAC without 24/7 anesthesia. For example the rural hospitals that serve the Navajo Nation in New Mexico are an example with a 38% VBAC rate. [16] Contrast that to the VBAC rate in the US: 14%. [17]
One thing I have noticed during almost 20 years in this work: The single common factor among hospitals that offer VBAC is the motivation to do so. If they want to offer VBAC, nothing stands in their way because they recognize - in the face of complications like placenta accreta spectrum, cesarean hysterectomy, hemorrhage, and bowel obstruction - it supports public health to ensure that people have access to vaginal birth after cesarean.
Myth: The evidence shows that 24/7 anesthesia coverage creates a safer environment for VBAC.
While this makes logical sense, ACOG confirms that the data illustrating this decreased risk is not available: “Although there is reason to think that more rapid availability of cesarean delivery may provide a small incremental benefit in safety, comparative data examining in detail the effect of alternate systems and response times are not available.” [2]
In the absence of empirical evidence, the “immediately available” recommendation has historically been based on the lowest level of evidence: “consensus opinion.” [2] This simply means that the experts involved with the writing of ACOG's VBAC guidelines think that there could be an increased risk.
But here's the challenge: We don't have the evidence to support that. The truth is, rural hospitals can, and do, offer VBAC safely. (I have a 45-minute segment on this topic examining the evidence in "The Truth About VBAC™ for Professionals," one of the many trainings available within VBAC Facts® professional membership.)
Hospitals without 24/7 anesthesia who want to ensure the best outcomes for all births, including planned VBACs, incorporate a variety of policies to make birth as safe as possible including implementing standard protocols (you can download some here), performing regular fire drills, ensuring that anesthesia is present during active labor (6 centimeters), and, when needed, emergency cesarean under local anesthesia. [16]
Facilities with limited resources should be honest with patients about staffing and resources and give them the option: labor at our facility knowing that the risk of a bad outcome may be higher or travel to a larger facility to birth. Also talk about how the facility responds to emergencies in first time labors.
(If the idea of this conversation makes you apprehensive, I invite you to learn more about VBAC evidence, policies, and public health with me. We can work through that fear so you can make informed decisions or so you can provide the very best VBAC education and support to cesarean families.)
Having that frank and honest conversation is what informed decision making looks like and it's very different than blanket hospital policies that "ban" VBAC and mandate repeat cesareans for everyone. VBAC bans deny people the opportunity to make their own health care decisions while imposing cesarean risks upon them with lifelong consequences. That does not serve a community.
Myth: If a hospital bans VBAC, people with a prior cesarean have to have a repeat cesarean.
As Howard Minkoff MD said at the 2010 NIH VBAC Conference, “Autonomy is an unrestricted negative right which means a woman, a person, anybody, has a right to refuse any surgery at any time.”[18]
ACOG affirms that, “Respect for patient autonomy also dictates that even if a center does not offer TOLAC [trial of labor after cesarean], such a policy cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery.” [2]
While people can always technically decline a cesarean, depending on the climate of a facility, the pressure applied by an individual provider, and the kind of information the provider supplies during informed consent, women may not be aware that they have that right or they may not feel like they can exercise that right.
This is why, no matter what a hospital's policy is regarding VBAC, clinicians should assure patients that they always have the right to decline a cesarean. There may be times when the risk/benefit conversation around VBAC and repeat cesarean changes throughout their pregnancy and labor. But the presence of a hospital VBAC ban should not be the sole reason why someone schedules a cesarean.
There are real risks and benefits to planned VBAC and elective repeat cesarean section. In order to make an informed decision, parents need to understand their options, discern truth from fiction, know their legal rights, and learn the facts. This is where “The Truth About VBAC™ for Families” comes into play. It’s the most comprehensive course available to parents on VBAC.
If you are a birth professional who wants to provide cesarean families with the very best VBAC information and support, then join VBAC Facts® professional membership. It is the most trusted and extensive VBAC curriculum available and our trainings have been approved for over 20 nursing contact hours (and growing!)
It is our ethical obligation to ensure that everyone - including those pregnant after a cesarean - has access to respectful, evidence based health care.
It is within our power to provide this level of care.
Together, we can make this a reality.
I'm standing with you!
Jen
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About Jen Kamel
founder of VBAC Facts®️
Jen Kamel is the CEO and Founder of VBAC Facts® Since 2007, her focus has been to provide objective, accurate information about the data available on VBAC and repeat cesarean to parents, professionals, policymakers, and the court so all decisions can be informed, ethical, and just. VBAC Facts® works to achieve this mission through their educational courses for parents, online membership for professionals, continuing education trainings, and consulting services.
As an internationally recognized consumer advocate, Jen speaks at conferences across the world, presents Grand Rounds at hospitals, advises on midwifery laws and rules that limit VBAC access, educates legislators and policy makers, and serves as an expert witness and consultant in legal proceedings.
VBAC Facts® envisions a time when every pregnant person seeking VBAC has access to unbiased information, respectful providers, and community support so they can plan the birth of their choosing in the setting they desire.
What do you think?
Leave a comment.
I’ve heard a lot about how you can’t have a VBAC if it is less than 18 months between pregnancies. My pregnancies were 9 months apart. Would a VBAC be an option?
Hi Kyleigh, I write about birth intervals and VBAC here. The short answer is, yes, VBAC is an option with short birth intervals.
Imagine if the consumers started questioning them on this fact.
FACILITY “oh, we can’t offer you a TOLAC/VBAC because of resources, staffing, insurance…..”
CONSUMER “I’m so sorry! I didn’t realize that surgery was so risky at your facility. Sounds like I should have my baby someplace where the staffing and resources are adequate to take care of both of us”
If the facility does not have enough staff or resources to offer care during a TOLAC /VBAC then how on Earth do they have enough staff to offer the higher acuity of care needed during and after major surgery.
In every instance where I worked at a facility that did not offer the VBAC care, the reasoning was stated as insurance, resources, etc. The ACTUAL reason was because the provider either did not want to, or did not like to offering that service. 🫤
Exactly! People need to know that all of these “reasons” sound “reasonable-ish,” but they conceal the truth: a powerful someone(s) doesn’t want to attend VBAC. Period.
I’ve had a b-lynch suture during my first c section – and have been advised against a VBAC. I can’t find anything to support this online and my hospital won’t provide me with an answer. Is this something that’s possible? Are there previous VBACS with women who have had the same suture?
I don’t know the answer to this question and I suspect that this is an area of unknown risk. So the first step is consider how you feel about that. Weigh the risks, benefits, and unknown risk of labor after a cesarean against the risks and benefits of a repeat cesarean. Consider if you want more children and how does you birth now impact those future pregnancies.
Dr. Chris Stroud is a MD in Indiana who provides VBAC consults. I would schedule a consult with him and talk through your options.