Thoughts on VBA3+C (VBAC after three or more prior cesareans)

Note regarding “TOLAC.”  When reading from medical texts, remember that you are no longer in the land of emotion and warm fuzzies.  Rather, envision that you have been transported to another world, a clinical world, where terms like TOLAC/TOLAMC, or trial of labor after (multiple) cesareans, are used.  I don’t think that most care providers understand the emotional sting that many women seeking VBAC associate with the term TOLAC.  It’s important for women to understand the language care providers use so that they can translate TOLAC into “planning a VBAC” and not feel slighted.  You might want to read this article which describes what the term TOLAC means, how it’s used in medical research, and why it’s not synonymous with VBAC.

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A mom recently asked, “Does anyone have some facts on VBA3C?”

I provided this collection of info…

Who makes a good VBAC/VBAMC candidate?

ACOG’s 2010 VBAC recommendations affirm that VBA2C (vaginal birth after two cesareans) is reasonable in “some” women.  But they remain silent on VBAMC (VBAC after multiple cesareans.)

Some have interpreted that silence to mean that ACOG does not recommend VBAMC, yet ACOG is clear that women shouldn’t be forced to have cesareans.

Between what they say about VBA2C and who is a good VBAC candidate, we might be able to discern who might be a good VBAMC candidate.

A couple things to keep in mind while reading…

Reason for prior cesarean/history of vaginal birth.  Research has shown that women who have had cesareans for malpresentation (breech, transverse lie, etc) and/or a history of a prior vaginal delivery would have the highest VBAMC success rates.

Scar type.  Low transverse incisions (also called bikini cuts) carry the lowest risk of rupture in comparison to classical, high vertical and T/J incisions.  With the likely increased risk of uterine rupture in a VBAMC, having low transverse scars is a way to minimize that risk as much as possible.

What does ACOG say about VBAC?

In ACOG’s 2010 VBAC guidelines, it describes the qualities of a good VBAC candidate:

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 VBAC and offered TOLAC.  Conversely, those at high risk for complications (eg, those with previous classical or T-incision, prior uterine rupture, or extensive transfundal uterine surgery) and those in whom vaginal delivery is otherwise contraindicated are not generally candidates for planned TOLAC.  Individual circumstances must be considered in all cases, and if, for example, a patient who may not otherwise be a candidate for TOLAC presents in advanced labor, the patient and her health care providers may judge it best to proceed with TOLAC.

What does ACOG say about VBA2C?

In those same guidelines, ACOG specifically addresses VBA2C:

Given the overall data, it is reasonable to consider women with two previous low transverse cesarean deliveries to be candidates for TOLAC, and to counsel them based on the combination of other factors that affect their probability of achieving a successful VBAC.  Data regarding the risk for women undergoing TOLAC with more than two previous cesarean deliveries are limited (69).

The power of context and training

How a provider approaches VBAMC depends a lot on their training as well as the support of their hospital administration. In the video below, Dr. Craig Klose discusses the merits of vaginal birth after cesarean and the various factors that may impede women obtaining VBAC.

One thing that stood out to me was Dr. Klose’s comments on VBAC after multiple prior low transverse cesareans (TLC). To sum, he says that he was taught that multiple LTCs were “no biggie” and he has attended up to VBA5C. This is the power of training and context!

ACOG guidelines, your legal rights, and “forced” cesareans

As attorney Lisa Pratt asserts, “ACOG guidelines are just that, guidelines, they are not law; while it is nice when they put out a guideline that supports your factual situation, falling outside of their recommendation does not mean you must consent to something you do not want.”  You can read in the article, “VBAC bans, exercising your rights, and when to contact an attorney.”

Further, ACOG’s 2010 VBAC guidelines also says that women cannot be forced to have cesareans even if there is a VBAC ban in place:

Respect for patient autonomy also argues that even if a center does not offer TOLAC, 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.

You may also wish to review your options when encountering a VBAC ban and the story of a mom seeking VBA2C who was threatened with a “forced” cesarean when her OB group withdrew support at 38 weeks.

Making a plan and moving forward

Your best bet is to review your medical records with several VBAC supportive care providers and get their opinion.  Obtain a copy of your medical records and operative reports from each prior cesarean, get the names of VBAC supportive providers, and ask the right questions.

If you want to get up to speed quick on VBAC, repeat cesarean, hospital birth, home birth, and VBAC bans, the best way is via my online program, “The Truth About VBAC.”

27 thoughts on “Thoughts on VBA3+C (VBAC after three or more prior cesareans)

  1. Allison leadbetter

    I am curious about doing a vba3c i had a emergency cesarean with my first because of his cord being wrapped around his neck. My second i just had a scheduled one. By third i scheduled it after the doc told me i couldn’t do vbac. I had the same doctor for all three of them and he has always told me I’m an amazing healer so want sure why he would tell me i couldn’t. Me and my husband want to have 2 more children but it scares me to keep having surgery and risk possibly not even being able to have the second additional child. I live near st. Louis missouri ( Jefferson county really) and was winding if there are any doctors that would be willing to let me try to do a vaginal birth. We are going to start trying little after our son turns 1 year ( getting older so want to have them at a reasonable age to keep up). Any doctors names i can call and discuss it with would be fantastic.

    Reply
  2. Lindsay

    My name is Lindsay Landsteiner, I’m 26 years old. I’ve been married for almost 10 years. I have 5 beautiful children.
    Now here comes the part that doctors/midwifes don’t like to hear, all of my children were born by C Section. Not something I wanted, ever. My first daughter was a induction, done before term. I was 18 and was having a hard time emotionally, so my doctor decided to induce. Being so young i just went along with what he said. 12 hours later, an epidural and 2½ hours of pushing, forceps, and the vacuum I was taken into OR, with pelvic displacement. Come to find out later that when I was told to start pushing I was not fully effaced or fully dilated. I was never given a fair chance.
    All of the rest of my C Sections were done because of the rule “once a c section, always a c section”. I have never had any health issues, pregnant or not. I have had all healthy babies. My C Section cut has been done the same every time, bikini cut. I don’t understand why I can’t be given a chance to give birth to my children. I don’t know what to do. I need information and support.

    Reply
  3. Kiki M.

    Hi, My name is Kiki and I had 3 C-section but I want to try for a VBA3C sometime next year. I wanted to know is there any doctors in the Savannah,GA area that I can talk to about my decision to try a VBA3C. Its been my desire to give birth naturally and to experience the chance to give birth they way I want. just wanted to know is there a doctor I can visit and speak with about my decision.

    Reply
    1. Jen Kamel Post author

      Hi Kiki!

      I just posted your question on my Facebook page which you can view here. Hopefully we will get some replies!!

      Best,

      Jen

      Reply
  4. Natara

    I have dilated completely with all 3of my kids and still ended up with csections for my babies head not coming down idk I jus don’t get it
    I have 17,10,and 2yearold going for my fourth n I do not want a c section electively I want a trial of labor again. How do I go about this will the drs group discharge me for not wanting a scheduled csection
    I don’t plan on having any more after this but I feel that I can get this baby out no problem dilating that went great why won’t baby come out

    Reply
  5. Kristen

    I have had 4 c-sections. All scheduled, no complications. My first was breech. My doctor has said I was stitched up in two layers, and a nurse who assisted in the last surgery went out of her way to come into my room and tell me she couldn’t believe I’d had four sections. All of that said, I was always disappointed that I hadn’t had the opportunity to TOLAC. Would exploring the possibility after 4 sections be unthinkable? One other point to note, I never dilated a single cm or effaced a single %. Even after delivery, I was only a “fingertip.” I’ve never gone through one contraction in my life.

    Reply
    1. Jen Kamel Post author

      Kristen,

      It all depends on what you want. There are certainly women who plan VBA4C though it is rare. The hardest part will be finding a provider. As I wrote above, there is an unknown level of risk with that decision. Some women are ok with that, others aren’t.

      When you say that you never dilated or had one contraction… how many weeks were you when you had your cesareans? In the past, repeat cesareans were sometimes scheduled at 38 weeks. The current recommendations state that no elective inductions or cesareans should occur before 39 weeks.

      Even looking at 39 weeks, only about one-third of women go into spontaneous labor before 39 weeks. (Check out the chart here.)

      Even if you had your cesarean at 40 weeks, about a third of women go into labor after 40 weeks gestation.

      My point is, the fact that you never dilated or had a cesarean points to the fact that your cesareans occurred before you went into labor, not that your body is somehow broken or doesn’t work.

      Best wishes on your journey,

      Jen

      Reply
    2. liz

      I had a successful vba3c in 2014 and will soon be having a repeat tolac for baby #6. I never dilated with any of my others but what worked with the last was a gentle induction. I went 2 weeks past my date and was only fingertip dilated, despite having repeat membrane sweeps. On the day of induction they inserted a catheter into my undiluted cervix and inflated it with water. It hurt worse than anything I’ve ever experienced (including that first time getting up after a c-section) but after 24 hours I was dilated to a 4 and it came out with a gentle tug from the doctor. My contractions were helped along with a very low pit drip and my water was manually broken at 7 cm. The doctor told me I had until 7pm that day to get the baby out or I would be sent for a repeat section. I started pushing at 6:50 and had my baby in my arms by 7:05. Don’t let a lack of dilation hold you back from trying a tolac. There are several ways that they can help you dilate, including the catheter or sweep, which are low risk and gentle on an untested cervix and a scarred uterus.

      Reply

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