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. Ruth

    Please advise. I had a failed induction leading to cs in 2009, then a successful vbac in 2010. I had an intrauterine death in 2015 which led to another failed induction and emergency csection in 2015. Both csections in 2009 and 2015 were low transverse cuts with no subsequent complications. I am now (2017) 30 weeks pregnant. I badly want to have a vaginal birth but my Dr insists on a csection. He says it’s because the last csection was done at the thicker part of my uterus at 24 weeks gestation and so the uterus hadn’t had a chance to develop to the point where it would permit a vbac. Yet what I have is basically one scar right on top of the other at my bikini line. So I don’t get why Dr is so bent on a csection for me. Am I putting my life on the line by asking for a vba2c?

    Reply
    1. Jen Kamel Post author

      Hi Ruth,

      It sounds like the lower uterine segment was not developed when your 24 week cesarean was performed. What this means is, the cut on your uterus is in the upper part which is associated with higher rates of rupture. This is why your doctor is recommending another cesarean.

      Whether you want to plan a VBAC is a huge question. And you can only make this decision once you know the facts. There are many things to consider and I, unfortunately, can’t go through them all in this reply.

      Keep in mind that there are no “right” answers here. Only what is Right For You. That’s because two women can look at the exact same information and make entirely different decisions. There are many things to consider and we each process information and experiences in our own way.

      Example: 1 in 3 American women are sexual abuse survivors.

      For some of those women, the sensations of childbirth are triggering and having a repeat cesarean gives them a sense of control.

      But for other survivors, being numb and disconnected from their body is triggering and so they want an unmedicated vaginal birth because that gives them a sense of control.

      Again, there is no right or wrong here. Just every pregnant person making the choice that is Right for Them.

      And the only way you can decide what is Right for You in terms of VBAC is by knowing the facts. That is the only way to navigate the misinformation and confusion and find your path to clarity.

      This is why I created my online course, “The Truth About VBAC for Families,” because it’s all the information I wish I had when I was considering my options: the real risk of uterine rupture, all about VBAC and repeat cesareans, how to make sense of statistics, hospital birth, home birth, and my legal rights.

      After I had my cesarean, and I was trying to figure this all out, there was no resource out there that had pulled together all the things that I wanted to know… plus, and this is a big one, all the things I didn’t know I didn’t know that I needed to know.

      So I had to create it from scratch. Fortunately, you don’t have to reinvent the wheel because I’ve done all the work for you!

      And if you sign up with two or more friends, you can save 50% off of registration!

      I’m sorry I can’t answer your question in this reply because there is so much to consider. I am sure you will find the course helpful!

      Best of luck regardless of what you decide!

      Jen

      Reply

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