Wednesday, January 29, 2014

Is there birth after cesarean? VBAC Facts 101

The most recent Listening to Mothers Survey (2014) revealed that 48% of women with a previous cesarean wanted a vaginal birth (VBAC, or Vaginal Birth After Cesarean) for their subsequent birth. An unbelievable 46%, nearly half, were denied even the option. It’s possible that some of these women were denied a VBAC for a valid medical reason, but we know that at least 39% were denied the option because of the unwillingness of their care provider (24%) and their hospital (15%)to provide the service. 

Despite these grim statistics I believe it’s important for women to consider VBAC for themselves and to continue to push for it as an option at their hospital. All women should have the informed right to birth how and where they choose. 

I participated in a great workshop last month by Jennifer Kamel, author of VBACFacts. As a result I wrote an article for City Pages Kuwait and thought I’d share the same information here. If you are pregnant or considering becoming pregnant again after a cesarean, get the facts before you decide whether to have a repeat cesarean or try for a normal delivery, and make an informed decision. 

Myth: “Once a cesarean, always a cesarean.”

Fact: The National Institute of Health (NIH) stated at the NIH Consensus Development Conference on Vaginal Birth After Cesarean (VBAC) that, “VBAC is a reasonable and safe choice for the majority of women with prior cesarean.” (1) The American College of Obstetricians and Gynecologists (ACOG) concurred with these findings, and added that “most” women with one prior cesarean and “some” women with two prior cesareans are candidates for VBAC. (2) 

Myth: If I have any of the following, I am not a candidate for a VBAC: Twins, vertical incision, a large baby, 40+ weeks pregnant.

Fact: ACOG states that the above conditions are NOT contraindications for a VBAC. (2) The following conditions are contraindications for a VBAC: a “T” or “J” incision, a prior uterine rupture, or a previous surgery on the upper uterus. (2)

Myth: VBAC after one cesarean has a high risk of uterine rupture.

Fact: The risk of uterine rupture after one cesarean is about 0.5%-1%, depending on factors. (1) Keep in mind that first time moms are at risk for complications that are equally serious to uterine rupture and occur at a similar rate such as placental abruption, (3) cord prolapse, (4) and shoulder dystocia. (5)

Myth: Doctors and hospitals in [insert your hostpial] are not trained to handle the serious complications that might accompany a VBAC.

Fact: Any hospital with a labor and delivery unit has protocols in place to respond to obstetrical emergencies. The same guidelines used to manage complications arising from any vaginal birth (including placental abruption, cord prolapse, or shoulder dystocia) are used to address uterine rupture in VBAC moms. This is because most complications involve one or both of the same two problems: oxygen loss to the infant and/or maternal bleeding. Hospitals and obstetrical doctors are trained to handle these rare events. 

Myth: To be prepared for an emergency cesarean, epidurals are required in VBAC moms. Or, others claim that VBAC moms can’t have epidurals because it will “obscure” the pain of uterine rupture.

Fact: According to ACOG, epidurals may be used in a VBAC (2) and evidence actually suggests that epidurals do not mask uterine rupture-related pain, (6,7) 

Myth: There is a high risk of either baby or mom dying during a VBAC.

Fact: The risk of maternal mortality is very low whether a woman plans a VBAC (0.0038%) or an elective repeat cesarean (0.0134%). (1) Limited evidence, because of the rarity of uterine rupture to begin with and the varying circumstances that surround uterine rupture, suggests that there is a 2.8-6.2% risk of infant mortality when a uterine rupture occurs (1). 

Myth: Repeat cesareans carry fewer risks than a VBAC

Fact:  The most serious cesarean-related complications become more likely after each successive cesarean (8) These complications include placental abnormalities such as placenta accrete which carries a 7% maternal mortality rate (9) and a 7% maternal mortality rate (9) and a 70% hysterectomy rate. (10) After two cesareans, the risk of accrete is .57% (8) similar to the risk of uterine rupture after one cesarean. So a woman who has opts for a second cesarean is merely trading the risk of a uterine rupture after one cesarean, for placenta accrete after two. 

Myth: If your hospital doesn’t offer VBAC, you have to have a repeat cesarean.

Fact: Howard Minkoff MD reiterated at the 2010 NIH VBAC Conference that “Autonomy is an unrestricted negative right which means a woman, a person, anybody, has a right to refuse surgery at any time.” (11) ACOG concurred that “restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will.” (2)

Myth: Most VBACs are not successful.

Fact: Women who attempt a planned VBAC have an overall success rate of 74%. (12-16)

It is important for women who are pregnant after a cesarean to accept that there is no risk free option. Each woman should consult with her husband, doctor, and childbirth educator to determine which risks she is more willing to tolerate, as she is the one who have to live with the outcomes.  If you have more questions, see VBACfacts.com, ICAN.com, or VBAC.com

If you are interested in a VBAC in Maryland, DC, or Virginia and are looking for some support, please feel free to contact me ~ together we can make your birth work for you!


  1. 1. Guise, J.-M.et al. Vaginal Birth After Cesarean: New Insights; Agency for Healthcare Research and Quality (US): Rockville (MD), 2010, http://www.ahrq.gov/clinic/tp/vbacuptp.htm
  2. 2. American College of Obstetricians and Gynecologists. Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Obstetrics and Gynecology 2010, 116(2), 450-463, http://www.acog.org/Resources_And_Publications/Practice_Bulletins/Committee_on_Practice_Bulletins_--_Obstetrics/Vaginal_Birth_After_Previous_Cesarean_Delivery
  3. 3. Deering, S. H.; Smith, C. V. Abruptio Placentae, 2013. Medscape. http://emedicine.medscape.com/article/252810-overview#a0199.
  4. 4. 5. Beall, M. H.; Chelmow, D. Umbilical Cord Complications, 2012. Medscape. http://emedicine.medscape.com/article/262470-overview#a30.
  5. 5. 6. Allen, R. H.; Chelmow, D. Shoulder Dystocia, 2011. Medscape. http://emedicine.medscape.com/article/1602970-overview#a03.
  6. 6. Johnson, C.; Oriol, N. The role of epidural anesthesia in trial of labor. Reg Anesth., Nov-Dec 1990, 304-308.
  7. 7. Kamel, J. Can you feel a uterine rupture with an epidural?, 2012. VBAC Facts. http://vbacfacts.com/2012/06/22/can-you-feel-a-uterine-rupture-with-an-epidural/.
  8. 8. Silver, R. M.; Landon, M. B.; Rouse, D. J.; Leveno, K. J. Maternal Morbidity Associated with Multiple Repeat Cesarean Deliveries. Obstetrics & Gynecology 2006, 107, 1226-1232. http://journals.lww.com/greenjournal/fulltext/2006/06000/maternal_morbidity_associated_with_multiple_repeat.4.aspx
  9. 9. American College of Obstetricians and Gynecologists. Placenta accreta. Committee Opinion No. 529. Obstet Gynecol 2012, 201-211. http://www.acog.org/~/media/Committee%20Opinions/Committee%20on%20Obstetric%20Practice/co529.pdf?dmc=1&ts=20120623T1523006523
  10. 10. Shellhaas, C. S.; Gilbert, S.; Landon, M. B.; Varner, M. W.; Leveno, K. J.; Hauth, J. C.; Spong, C. Y.; Caritis, S. N.; Wapner, R. J.; Sorokin, Y.; Miodovnik, M.; O’Sullivan, M. J.; Sibai, B. M.; Langer, O.; Gabbe, S. The frequency and complication rates of hysterectomy accompanying cesarean delivery. Obstet Gynecol 2009, 114 (2, Part 1), 224-229. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2771379/
  11. 11. National Institutes of Health. NIH VBAC Conference, Day 2, #04 – Discussion, 2010. Vimeo. http://vimeo.com/10898005.
  12. 12. 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.
  13. 13. 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.
  14. 14. 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.
  15. 15. 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.
  16. 16. 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.

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