Does VBAC after more than one prior cesarean pose an increased risk? YES.
An advocate claims that the American College of Obstetricians & Gynecologists (ACOG) said VBAC after more than one prior cesarean (VBAMC) doesn’t pose an increased risk. A reader contacted me asking if this was correct.
It is not.
ACOG does not say that because it’s not true.
What ACOG Says About VBAMC
As ACOG says in their 2019 VBAC guidelines,
“Both [VBAMC] studies reported some increased risk in morbidity among women with more than one prior cesarean delivery, although the absolute magnitude of the difference in these risks was small.”
What this means is, of the two studies ACOG cites on VBAMC, both reported higher rates of maternal complications among those planning a VBAMC compared to those who planned a VBAC after one cesarean.
This is what we call the “relative risk.” It’s how the risk of two events compare. So the relative risk among VBAMC is higher.
But then ACOG says that the “absolute magnitude of the difference in these risks was small.” In other words, the increase of this risk was still small.
So while the risks do increase (relative risk), the likelihood of those events occurring is still low (absolute risk).
But it’s disingenuous, and even misleading and dangerous, to state that the risk doesn’t change. It does.
In terms of uterine rupture, those same advocates claim that “ACOG says” there is no increased risk of uterine rupture after two or more cesareans.
Here’s what ACOG said: Of the two studies they cited in their VBAC guidelines, one found no increased risk of uterine rupture and the other did:
“One study found no increased risk of uterine rupture (0.9% versus 0.7%) in women with one versus multiple prior cesarean deliveries, whereas the other noted a risk of uterine rupture that increased from 0.9% to 1.8% in women with one versus two prior cesarean deliveries.”
So it’s also inaccurate to say that the risk of uterine rupture stays the same after more than one prior cesarean.
In terms of the uterine rupture risk after three or more cesareans? ACOG says nothing because so few studies have been conducted, with so few people, that we can’t honestly say what the uterine rupture risk is among that population.
So if anyone said, “The risk of uterine rupture doesn’t increase after more than one cesarean,” they are revealing how little they actually know about the quality of the existing research. But many parents also don’t know research quality or researcher’s conclusions, so when ill-informed advocates make statements like this, many parents believe them.
And that is the problem.
I think the most honest thing we can say is:
“The risk of uterine rupture likely increases with each subsequent cesarean, but we don’t have solid evidence measuring exactly how much it increases.”
If you want to dive deeper, you can talk about the two studies with their two findings. You can talk about how those studies were conducted… like, how many of the participants were induced?
In other words, you put that research into understandable language while accurately conveying what we do, and don’t, know and what we can, and cannot, honestly say about uterine rupture after multiple cesareans.
Beyond what ACOG says in their VBAC guidelines, anyone familiar with the VBAC evidence knows that the risk of the most serious cesarean complication, placenta accreta, as well as other placental abnormalities like placenta previa, increase with each prior cesarean.
So, no matter how you slice it, the risks increase. To say otherwise simply does not align with the medical evidence.
Navigating fear-mongering providers and ill-informed advocates
This brings up a bigger issue. On one end, we have providers who exaggerate the risks associated with VBAC. They say things like, “The risk of uterine rupture after three cesareans is 75%.” And that’s just false.
On the other end, we have advocates who underestimate the risk. Often times this happens because they honestly don’t know better. They are trying to help, they are trying to provide people with factual information, but they don’t understand the evidence or statistics enough in communicate the facts accurately.
Given that birthing people cannot make informed decisions if the risks are exaggerated or minimized, it puts them in a tough spot. Between fear-mongering providers and ill-informed advocates saying what they want to hear, who can they believe?
And what happens when a provider is telling the truth, but the pregnant person doesn’t know that because they believe misinformed, but well intended, advocates?
Like someone whose provider tells her that the risk of uterine rupture increases slightly after two cesareans? And that person believes their provider is lying to them because of what an advocate online says?
That is trust eroded which is so unfortunate given how few providers attend VBAC after two cesareans!
That is the real loss here. Not only eliminating the opportunity for people to make informed decisions, but causing birthing people to lose trust in their providers who are supportive of VBAC after two cesareans and giving them accurate information.
How to deal with inaccurate VBAC information
That’s why it’s so essential to verify statements, and it’s easy to do. If someone gives you a statistic that sounds absolutely frightening, or too good to be true, go to the source and read more.
While I knew the original statement was false off the bat, it didn’t take me long to go to ACOG’s guidelines and pull a specific quote disproving it. You, too, can do this and together we can elevate the conversation about VBAC by identifying the myths and getting to the facts so people can make truly informed decisions.
And if you can’t find the facts, send me an email and maybe I’ll feature your question in a future post.
Until next time, check out other myth busting articles in our catalog on unscarred vs scarred uterine rupture, uterine rupture before labor, uterine rupture during VBAC induction, and comparing uterine rupture risk to lightning strikes or fatal car accidents.
Did I say I like debunking myths? Yes. I. Do.
PS: If you are a parent who is done dealing with ill-informed advocates and fear-mongering providers and wants someone to be straight with them, check out my online training for parents: “The Truth About VBAC for Families.”
If you are a professional who wants to learn the facts so you can honestly communicate what the evidence says to your clients (while increasing VBAC access in the process), consider joining VBAC Facts Professional Membership.
American College of Obstetricians and Gynecologists. (2019). ACOG Practice Bulletin No. 205. Vaginal birth after cesarean delivery. Obstetrics & Gynecology, 133(2), e110-e127. https://doi.org/10.1097/AOG.0000000000003078
What do you think?
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As an internationally recognized consumer advocate and Founder of VBAC Facts®, Jen helps perinatal professionals, and cesarean parents, achieve clarity on vaginal birth after cesarean (VBAC) through her educational courses for parents, online membership for professionals, continuing education trainings, and consulting services. She speaks at conferences across the US, 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. She 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.