Quick Facts
After a cesarean, most women have two choices for future births: a vaginal birth after cesarean (VBAC) or a repeat cesarean section (RCS). There is a lot of misinformation about these two options. Let’s review some quick facts.
Per the American College of Obstetricians and Gynecologists (ACOG, 2010), VBAC is a “safe and appropriate choice for most women” with one prior cesarean and for “some women” with two prior cesareans. Being pregnant with twins, going over 40 weeks, having an unknown or low vertical scar, or suspecting a “big baby” should not prevent a woman from planning a VBAC (ACOG, 2010).
Research on uterine scar thickness (Kamel, 2009) and single vs. dual layer suturing (Humphries, 2004) are on-going as the studies completed thus far are not strong enough to provide conclusive support for specific actions.
VBAC is successful 75% of the time (Coassolo, 2005; Huang, 2002; Landon, 2004; Landon, 2006; Macones, 2005). Successful VBACs have lower complication rates than planned repeat cesareans which have lower complication rates than “failed” VBACs (Landon, 2004), otherwise known as cesarean birth after cesarean or CBAC.
Uterine rupture is the major concern in terms of VBAC and while it can be catastrophic, it is rare (National Institutes of Health, 2010).
Permitting labor to begin naturally after one prior low transverse (“bikini cut”) cesarean carries a 0.4% risk of rupture which can increase upon labor augmentation or induction (Landon, 2004). These rates are similar to other serious obstetrical emergencies such as placental abruption, cord prolapse, and post partum hemorrhage.
Cesarean risks, including placenta accreta, hysterectomy, blood transfusion, and ICU admission, increase with each surgery (Silver, 2006); whereas after a successful VBAC, the future risk of uterine rupture, uterine dehiscence, and other labor related complications significantly decrease (Mercer, 2008).
With each option, the risk of maternal death is very low: 0.02% VBAC vs. 0.04% RCS (Landon, 2004). Additionally, the risk of infant death or hypoxic ischemic encephalopathy (oxygen deprivation) during a VBAC is 0.05% which is “quantitatively small but greater than that associated with elective repeat cesarean delivery” (Landon, 2004).
45% of American women are interested in the option of VBAC (Declercq, 2006), yet 92% have a RCS (Martin, 2009). Some women chose their RCS or it was medically necessary. Others felt like they didn’t have much of a choice for numerous reasons including hospital VBAC bans (Kamel, 2010); unsupportive health care providers, friends, and family (Kamel, 2009b & 2010b); or the misrepresentation of VBAC risks (Kamel, 2009b & 2010b).
Our repeat cesarean rate feeds America’s rising total cesarean rate, currently at 32% (Menacker, 2010). The World Health Organization (WHO, 2009) warns against total cesarean rates higher than 15% and indicates that at least half of American cesareans could be unnecessary. Declercq (2009) links our high cesarean rate with our high maternal mortality rate relative to other developed countries.
In all 50 states, hospital and doctor attended VBACs are legal and in some states it is legal for a midwife to attend an OOH (out-of-hospital) VBAC (Kamel, 2009c). However, of the women interested in VBAC, 57% are unable to find a supportive care provider or hospital (Declercq, 2006). This is due primarily to the 1999 ACOG recommendation that a doctor be “immediately available” to perform a cesarean, yet they provided no clear definition or standard for where the obstetrician and/or anesthesiologist should be or what they could be doing.
As a result, hospitals developed their own definitions producing differing VBAC protocols and requirements. The most severe variety was the institution of VBAC bans in one-third of all American hospitals (ICAN, 2009), disproportionally affecting women living in rural areas. As the new ACOG (2010) guidelines retracted this problematic proposal, hopefully VBAC will become a viable option to the many women who desire it (Kamel, 2010c).
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American College of Obstetricians and Gynecologists. (1999). ACOG Practice Bulletin No. 5: Vaginal birth after previous cesarean delivery. Washington DC.
American College of Obstetricians and Gynecologists. (2010, July 21). Ob-Gyns Issue Less Restrictive VBAC Guidelines. Retrieved July 21, 2010, from ACOG: http://www.acog.org/from_home/publications/press_releases/nr07-21-10-1.cfm
American College of Obstetricians and Gynecologists. (2010). ACOG Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Washington DC.
Coassolo, K. M., Stamilio, D. M., Pare, E., Peipert, J. F., Stevens, E., Nelson, D., et al. (2005). Safety and Efficacy of Vaginal Birth After Cesarean Attempts at or Beyond 40 Weeks Gestation. Obstetrics & Gynecology, 106, 700-6.
Declercq, E. R., & Sakala, C. (2006). Listening to Mothers II: Reports of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection. Retrieved from Childbirth Connection: http://www.childbirthconnection.org/article.asp?ck=10068
Declercq, E. R. (September, 2009). Birth by the numbers [video]. Retrieved from Orgasmic Birth: http://www.orgasmicbirth.com/birth-by-the-numbers
Huang, W. H., Nakashima, D. K., Rumney, P. J., Keegan, K. A., & Chan, K. (2002). Interdelivery Interval and the Success of Vaginal Birth After Cesarean Delivery. Obstetrics & Gynecology, 99, 41-44.
Humphries, G. (2004, June 14). The Suture Debate. Retrieved October 1, 2009, from International Cesarean Awareness Network: http://www.ican-online.org/vbac/the-suture-debate
International Cesarean Awareness Network. (2009, February 20). New Survey Shows Shrinking Options for Women with Prior Cesarean. Retrieved from ICAN: http://www.ican-online.org/ican-in-the-news/trouble-repeat-cesareans
Kamel, J. (2009, January 17). Predicting uterine rupture by uterine thickness via sonogram. Retrieved from VBAC Facts: http://vbacfacts.com/2009/01/17/predicting-uterine-rupture-via-sonogram-to-measure-uterine-thickness/
Kamel, J. (2009b, October 19). Response to OB: Scare tactics vs. informed consent aka why I started this website. Retrieved from VBAC Facts: http://vbacfacts.com/2009/10/19/response-to-ob-scare-tactics-vs-informed-consent-aka-why-i-started-this-website/
Kamel, J. (2009c, February 28). Is VBAC illegal? Is homebirth illegal? Retrieved from VBAC Facts: http://vbacfacts.com/2009/02/28/is-vbac-illegal/
Kamel, J. (2010, July 22). VBAC in rural hospitals. Retrieved from VBAC Facts: http://vbacfacts.com/2010/07/22/vbac-in-rural-hospitals/
Kamel, J. (2010b, March 16). Another VBAC consult misinforms. Retrieved from VBAC Facts: http://vbacfacts.com/2010/03/16/another-vbac-consult-misinforms/
Kamel, J. (2010c, March 9). American women speak about VBAC. Retrieved from VBAC Facts: http://vbacfacts.com/2010/03/09/american-women-speak-about-vbac/
Landon, M. B., Hauth, J. C., & Leveno, K. J. (2004). Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery. The New England Journal of Medicine, 351, 2581-2589.
Landon, M. B., Leindecker, S., Spong, C., Hauth, J., Bloom, S., Varner, M., et al. (2005). The MFMU Cesarean Registry: Factors affecting the success of trial of labor after previous cesarean delivery. American Journal of Obstetrics and Gynecology, 193, 1016-1023.
Landon, M. B., Spong, C. Y., & Tom, E. (2006). Risk of Uterine Rupture With a Trial of Labor in Women with Multiple and Single Prior Cesarean Delivery. Obstetrics & Gynecology, 108, 12-20.
Macones, G. A., Cahill, A., Pare, E., Stamilio, D. M., Ratcliffe, S., Stevens, E., et al. (2005). Obstetric outcomes in women with two prior cesarean deliveries: Is vaginal birth after cesarean delivery a viable option? American Journal of Obstetrics and Gynecology, 192, 1223-9.
Martin, J. A., Hamilton, B. E., Sutton, P. D., Ventura, S. J., Menacker, F., & Kirmeyer, S. (2009, January 7). Births: Final Data for 2006. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_07.pdf
Menacker, F., & Hamilton, B. E. (2010, March). Recent Trends in Cesarean Delivery in the United States. Retrieved from Center for Disease Control and Prevention: http://www.cdc.gov/nchs/data/databriefs/db35.htm
Mercer, B. M., Gilbert, S., Landon, M. B., & Spong, C. Y. (2008). Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Obstetrics & Gynecology, 11, 285-91.
National Institutes of Health. (2010, June). Final Statement. Retrieved from NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights: http://consensus.nih.gov/2010/vbacstatement.htm
Silver, R. M., Landon, M. B., Rouse, D. J., & Leveno, K. J. (2006). Maternal Morbidity Associated with Multiple Repeat Cesarean Deliveries. Obstetrics & Gynecology, 107, 1226-32.
World Health Organization, UNFPA, UNICEF and AMDD. (2009). Monitoring emergency obstetric care: A handbook. Retrieved from World Health Organization: http://www.who.int/reproductivehealth/publications/monitoring/9789241547734/en/
Last revised: 7/25/2010
I have had 3 prior c-sections:
#1:9/5/00=induction at 41 weeks. Fully dialated & pushed for 2 hours. Dr opted for c-section. Daughter born at 9lbs9oz.
#2:6/21/04=induction at 39 weeks. Dialated to 7cm. Dr noted compound presentation. Opted for c-section. Daughter born at 7lbs9oz.
#3:8/2/08=repeat c-section at 38 weeks. (water broke) Was told no other option but repeat c/s. Daughter born at 7lb4oz.
We are about to start trying for our 4th baby and I REALLY want a vaginal birth. I was SO close each time! I know that I can dialate. HELP!
[...] of the best references for VBAC information that I have found has been this site. Jennifer is AMAZING, a wealth of information, an advocate for all birthing women, a force in [...]
Christina, DO NOT consent to an induction. Your chances of UR increase with induction. Without knowing everything about you case I can say that your inductions most probably failed because your body was not ready to give birth yet.
Find a Midwife who can support you and give you more info.
[...] Quick Facts [...]
My first was a section and then I had 3 VBACs. Fantastic and no stress!
Dear Jen – Thank you for all the information on VBAC’s on your website.. It has been very enlightening for me. I was induced the first time at 41 weeks, was told my baby was large and was not advisable to wait any longer. Anyway after 24 hours, I ended up being a C-section. Me & my body did not do anything..everything was done by them….I was given cervix ripening agent..pitocin…epidural (I asked for it…twas very painful..I wish I had pain management techniques and someone to guide me thru those…I learned childbirth class is not enuff..maybe a doula would’ve helped in me having a vaginal birth)…they also broke my water..and finally I was told it would risk baby if we did not do C-section. This was 3 years ago, and I am pregnant again, and would hate to relive that experience. While reading about VBACs, I found I could have avoided my last C-section/induction, and I feel really sad and angry with myself for not keeping myself well-informed. I was in my own rosy world that it’ll be a natural birth and C-section is only the very last option. Me and hubby just went with what the nurses and doc told us at that time.
Anyway, this time I am determined for VBAC. I am 25 weeks pregnant, and my OB says she will give me a date by which if I do not labor on my own, she will do a C-section. But she cannot give me the date now, only later in last week of December (I’ll be 31 weeks then). I don’t know why we have to wait that long..maybe to find out if I have gestational diabetes or not, but again I am not sure. She is a very sweet & nice doctor..in fact both her kids were C-sections (I don’t think any woman would opt for C-section by choice). So, how can I tell if she is supportive of my VBAC or not? I go to her for 6 years now, and changing docs mid-pregnancy is an uncomfortable thought.
And on a more general note, since my first was induced which ended in C-section, what are my chances of going into labor on my own without induction. And is it possible to generally predict if will it be beyond 40 weeks or earlier or later ?
Please help…
Thanks,
Esha.
Esha,
I’m so sorry it took me so long to reply to your comment. Since it’s the last week in December now, I’m wondering what date your OB gave you. 40 weeks? 41 weeks? I suspect your OB wanted to wait until 31 weeks to give you the “labor or c-section” deadline because the later she waits in your pregnancy, the more likely it is you will stay with her, do what she says, and not switch care providers.
Here is what I would do: I would switch OBs. My personal opinion is a doctor who puts you on a timeline of give birth by X date or you are having a cesarean is not a VBAC supportive provider.
You might be surprised to know that many women opt for elective repeat cesareans because they are subtly, or not so subtly, encouraged to do so by their OBs. I would be interested in knowing if your OB scheduled her repeat cesarean without medical indication (suspecting a baby weighting less than 11 lbs or being overdue are not valid medical reasons) or if she truly wanted a VBAC and ended up with a cesarean after labor began.
Do you think that a woman who schedules an elective repeat cesarean for herself is a supporter of VBACs? Do you think she will truly support your desire to have a VBAC?
To answer your question, “since my first was induced which ended in C-section, what are my chances of going into labor on my own without induction?” With this provider, I would say your chances are slim to none. With another provider, who is supportive of VBAC and willing to wait for labor as long as you and baby are fine, your chances are much greater. Due dates vary greatly. Some women have longer menstrual cycles, some women just have longer pregnancies. You can learn more here: Figuring your due date.
You also asked, “And is it possible to generally predict if will it be beyond 40 weeks or earlier or later.” The fact that you were 41 weeks when she induced you means that it’s likely you will go to at least 41 weeks this pregnancy. The difference between your last pregnancy and this one is that you know this time around that she doesn’t support pregnancies going beyond 41 weeks. What do you think in your heart will happen if you stay with this OB?
I understand that you like your doctor and that she is sweet to you. But please know that liking your OB isn’t enough. You two should be on the same page in terms of your birthing philosophies.
You said, “I feel really sad and angry with myself for not keeping myself well-informed. I was in my own rosy world that it’ll be a natural birth and C-section is only the very last option. Me and hubby just went with what the nurses and doc told us at that time.” The question is, will you allow that to happen again?
If you want to look into finding a new provider, please read: Finding a VBAC supportive OB or midwife.
Please keep me posted!
Warmly,
Jen
Hello, I hope I am asking this in the right section
I had a c-section on Nov 7, 2008. A little background: I was in labour for 35 hours before getting stuck at 6cm at which point due to my contractions being very irregular my midwife consulted with the Dr on call and opted for oxytocin and an epidural to get me going, from my stand point everything went downhill from here! When it was finally time to push 6 hours after the oxytocin I pushed for 2 hours and my son didnt budge and was seemingly stuck. At this point I was physically and emotionally done and despite wanting a natural birth with no drugs (I counted a total of 11 different drugs by the time everything was said and done) ended up with a very complicated c-section. After the uterus had been closed, they noticed significant bleeding and upon further investigation…
My operative report says: “…the posterior lower segment of the uterus had buckled forward, giving the appearance of being the anterior portion of the cervix and so the lower anterior portion of the uterus had not been properly sutured to the upper anterior edge of the uterine incision. This was corrected. There were bilateral extensions of the uterine incision. (…) Given the extent of the extension of the uterine incision at surgery, it is recommended that this patient deliver by elective repeat cesarean next time and that she is not a good candidate for VBAC.”
Basically I am asking if anyone knows anything about this and if I do have a chance at VBAC in the future or not. I haven’t had any luck finding information on this. I am not pregnant now and don’t plan on it for another year.
Thanks in advance for any information possible
Rowen,
I’m not a surgeon or a medical professional, so here is my advice. Get the name of three VBAC supportive practitioners, set up interviews with them, and review your medical records with them. You will then get 3 opinions and will be able to move forward from there.
I wish you the best!
Warmly,
Jen
[...] quickies specifically for the numbers listed above: Baby death rate C-sec Mother dreath rate C-sec Uterine rupture risk baby death Downs Syndrome risk by age Amnio miscarriage risk Uterine rupture [...]
Jen – I was hoping you could help. I just want to say first that I’ve been searching the internet endlessly for VBAC information and finally came to your website. You have all the information I have been searching for in one place and with research to back it up. So thanks!!
But there was one thing I couldn’t find. I have been trying to find out how long you should wait after having a C-section to attempt a VBAC? Does it make a difference from 1 month, 6 months, 1 year, 2 years, etc.? Is there a certain amount of time it takes for your scar to heal?
Thanks!! -Amy
Hi Amy!
While I cover interbirth intervals in the class, I haven’t had a chance to type it all up in an article. The short answer is: evidence suggests that it’s best to have a 18-24 month interval between your cesarean birth and subsequent births. In other words, wait 9 to 15 months after your cesarean to get pregnant. That said, the studies that have been conducted are rather small, and it will be nice if/when larger studies are conducted so we have a better idea of the risk differential, if any, between births occurring less than 18 months post cesarean versus more than 18 months. I personally think it’s always a good idea to give your body plenty of time to heal and wait at least 9 months to get pregnant. You can read some of the studies available by looking for the terms ‘interbirth’ (time between cesarean birth and subsequent birth) and ‘interpregnacy’ (time between beginning of cesarean pregnancy and the beginning of subsequent pregnancies) by looking through my bibliography.
Warmly,
Jen
Ok, I’m doing a college paper on home births, prosecutions of mid wives and other related topics, and came across your website. Lots of good info on here. However, I have to comment that it might be good, right at the top of the home page, in big letters, to put what VBAC stands for, since I had no idea what the heck it was when I first was looking on here! I finally figured it out, but I just thought it might be a good idea for you to do that. There are likely other people as clueless as I am.
Thanks,
Elizabeth
Elizabeth,
Thank you so much for this comment. I’ve updated the logo at the top to include the definition of VBAC. I’d love to read your paper when it’s complete!
Warmly,
Jen
Thanks for linking this up over at The Finer Things in Life. I think this is a wonderful, concise summary of VBAC facts. The only thing that I really wish I would have seen mentioned are the cases where VBAC is not an option. My second child was born at 24 wks via a very fast, very critical classical c-section- a vaginal birth would have been traumatic for a 1 lb 5 oz baby and it was her best chance for survival. (And, happily, she did!) I gave birth to my third baby last year and, trust me, I would have LOVED to have a VBAC rather than a repeat c-section. But the risk is simply TOO HIGH. No doctor worth his salt would attempt it. I got over the disappointment and had the second c-section. What has been the hardest for me? Many women with a very flip attitude that I “could have, should have” attempted the VBAC. While I am thrilled to see more honest, clear information being published to encourage women to consider VBAC, it saddens me that so many of these articles do not really address the small population of women for whom this is not a viable option. As a result, many people assume that we just choose surgery again as an easy way out.. The very first sentence- “If you have had a cesarean, your next baby can be born vaginally safely.”? I’m sorry, but it just isn’t entirely true. Perhaps “If you have had a cesarean, you next baby can probably be born vaginally safely” would work better. I hope this doesn’t come across as argumentative… I am truly happy to see these facts outlined. It is important information! I just know only too well how the generalization that VBAC is an option for everyone can sting.
Hi Jessie Leigh!
Thank you so much for your comment. It’s a little ironic that you made this comment at 4am this morning as I was up till midnight last night rewriting this piece! I just didn’t have it in me to stay up later to finish it, so I put it aside for the night expecting to continue working on it tonight after my kids were asleep!
So I was saddened to see your comment! I think you will find the new article more fair as I agree, there are women who either desire a vaginal birth, but can’t find a care provider to attend them or, like you, have a medical reason for a repeat cesarean.
In terms of the comments you have received from others, classical incisions do have higher rates of rupture. Some people aren’t aware of that and others who know of the higher risk, still want a VBAC. But in the end, it is your body, your birth, and your decision and you don’t have to explain yourself to anyone. People can be rude and I’m sorry.
I have friends who were candidates for VBAC and opted for elective scheduled cesareans. When they asked for information, I gave it to them, and when they scheduled their surgery, I brought them a meal after their baby was born. It’s not my birth.
I would really love to know what you think of the new article, would you comment again once you read it?
Warmly,
Jen