Thoughts on 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.
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 (LTC). 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 more in the article, “VBAC bans, exercising your rights, and when to contact an attorney.”
Further, ACOG’s 2010 VBAC guidelines also say 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.
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.”
What do you think?
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What do you think? Leave a comment.
Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.