This is a guest post from natural mama Abby Deliz. Abby is a mother of three children (Luke, 8; Hannah, 5.5; and Landon, 7 months), and she is also a Master’s student at Claremont Graduate University. Abby has also contributed articles on this site about Cesarean Recovery and Gentle Cesarean.
America’s cesarean rate includes over 1/3 of birthing women. This rate varies by state and ranges from 23% to 40%. This is nearly triple the World Health Organization’s recommendation.
Of course, there are certainly real, absolute emergencies where a c-section is necessary, and thank God we have them. But most first births are long, erratic, and don’t fit well within a Western model of medicine.
Many “primary” (or first-time) cesarean births are the result of medical interventions. And the medical interventions usually follow a sequence known as the “Cascade of Interventions.”
The Cascade of Interventions looks something like this…
- First-time mom reaches her due date
- Doctor schedules an induction (even though statistically, most first moms give birth 1 week and 1 day past her due date if left to her own devices)
- Labor isn’t progressing (probably because baby/mama wasn’t ready!)
- Pitocin is administered
- Artificial rupture of membranes (provider breaks the bag of water)
- Contractions are intense and hard, with no cushion from her bag of waters, so mom requests an epidural
- Epidural renders mama immobile, in bed, on her back
- Labor now take longer than doctor would like (studies like this one show that epidurals can prolong the 2nd stage of labor)
- Baby begins to show signs of fetal distress
- Necessitating an “emergency” C-section
Primary cesareans are statistically the number one reason why many women choose to have repeat cesareans
However, as we shall see, attempting a natural Vaginal Birth After Cesarean (VBAC) is the safest (yes!) and most beneficial option for both mother and baby, even if it results in another cesarean.
Furthermore, second, third, and subsequent cesareans pose a greater risk to both mother and baby than the risk of a VBAC. Keep reading to find out why.
The Recent History of VBACs
In its 1995 bulletin, the American Congress of Obstetricians and Gynecologists (ACOG) recommended that repeat cesareans be limited, and encouraged a trial of labor after cesarean (TOLAC) – even after two previous cesareans.
In 1999 they stated that a physician should be on call to perform an emergency cesarean “just in case.” This severely limited a woman’s right to try a VBAC birth in hospitals without 24-hour anesthesiology, forcing those women to either birth in an alternative hospital, or to schedule a repeat cesarean. This was the case, even though research did not indicate “any improvement in maternal or infant death rates related to the characteristics of hospitals or the availability of physicians.”
In their 2010 bulletin, ACOG maintained its previous recommendations, but they also declared a host of precautionary measures, many of which were founded upon inconclusive research. So what does the research indicate?
VBACs are beneficial
The hormones produced during labor have major benefits (even if a TOLAC ends in another cesarean!).
Oxytocin ripens the cervix and has a calming, analgesic effect on both mother and baby. In natural birth, oxytocin is nature’s “pain reliever” and is also known as the “love hormone” as it assists with the bonding between baby and mama. Oxytocin also helps to shrink the uterus and decrease the chances of postpartum hemorrhaging.
Rising estrogen levels prepare the uterus for labor, promote breastfeeding postpartum, and also reduce the likelihood of hemorrhaging. During labor, babies also develop catecholamines, or stress hormones, which promote breathing; send blood flow to their heart, brain, and kidneys; and boost their immunities.
Furthermore, recent research shows the more efficient elimination of fluid from the lungs during a VBAC might also prevent baby from developing allergies, asthma, and vaginal birth decreases a baby’s chance of type 1 diabetes, and obesity, while supporting a healthy microbiome.
Perhaps most importantly, VBACs provide the opportunity for a mother to heal emotionally from her previous cesarean. She may gain a sense of personal satisfaction, accomplishment, and exhilaration that she never had before.
VBACs are safe
Are you afraid of the risk of uterine rupture during a VBAC? This seems to be the biggest fear among women looking into a natural VBAC birth.
Risk of uterine rupture for VBAC mamas
Fewer than 1 in 100 women who’ve had a low transverse uterine incision experience a rupture while attempting VBAC. Importantly, the phrase “uterine rupture” encompasses a spectrum of ruptures, and only small percentage of these are true ruptures that include the entire uterine incision. This “is the same as the risk of death for any baby at the end of a first pregnancy.”
Risk of placenta accreta for repeat cesarean
Placenta accreta is a condition that involves the blood vessels of the placenta attaching too deeply to the wall of the uterus. Placenta accreta is an extremely serious – 7% of women die from placenta accreta, and it’s associated with postpartum hemorrhage, hysterectomy, preterm labor, etc.
After 2 cesareans, the risk of placenta accreta is 0.57% – similar to the risk of uterine rupture after 1 cesarean.
According to this article, “Women are literally exchanging the risk of uterine rupture in a current pregnancy for the more serious risk of accrete in future pregnancies.”
Four conditions may increase one’s risk of having a ruptured uterus:
- An incision other than a low, transverse one from a previous cesarean
- An incision that was sutured with one layer of stitches rather than two (a practice rarely done in the United States in recent years)
- A uterine wall thickness measuring less than 2.3 to 2.5 mm
- Having labor induced
Still, according to this article from Mayo Clinic, the risk of uterine rupture is less than 1% for women who have had a low transverse uterine incision (the most common type of cesarean incision).
If you are thinking, “I don’t want to take even the slightest risk with my baby,” please read on. Repeat cesareans are riskier to both mother and baby.
Repeat cesareans risks
It is interesting to note that many obstetricians will counsel a woman on the risks of a VBAC, without ever seriously counseling her on the risks of a repeat cesarean. And the risks are noteworthy.
A cesarean section is major abdominal surgery. Its maternal mortality rate is at least three times greater than during a VBAC.
A list of repeat cesarean risks is below. I marked the complications that I experienced during or after my third cesarean with an asterisk *.
- Any infection (most commonly in the uterus or vagina)*
- Cardiac arrest
- Blood clots or hematoma*
- Post-surgical hypotonic uterus*
- Complications with the use of anesthesia
- Future fertility issues
- Postpartum depression and anxiety*
- Difficulty breastfeeding*
- Injury to surrounding organs
- Scar tissue formation causing chronic pain*
- Jaundice in baby
- Four times the risk of respiratory distress in baby
- Future risk of obesity/asthma/allergies in baby
- Severe blood loss necessitating blood transfusion*
- Each surgery increases risk of placenta previa and/or placenta accreta in future pregnancies
Chart: VBAC Risks vs. Repeat Cesarean Risks
This chart is adapted from the ICAN brochure “After A Cesarean: What’s the safest path to your future births?” Savage, MN: Author; 2008.
What is the prognosis for mama & baby if a uterine rupture does occur?
The prognosis is good, provided that the facility where you are giving birth is ready to address this complication if it does occur.
This study concluded that, “In an institution that has in-house obstetric, anesthesia, and surgical staff in which close monitoring of fetal and maternal well-being is available, uterine rupture does not result in major maternal morbidity and mortality or in neonatal mortality.”
VBAC Success Rates
On average, about 60-80% of women who attempt a VBAC succeed. This number is dependent on your provider and other circumstances. Some really good providers have numbers closer to 90%.
This is fantastic news! And yet many doctors don’t recommend this as an option to second time mamas.
A successful VBAC does not depend on the following:
- Weight of the baby. Ultrasound does not accurately predict birth weight, and VBAC rates in these cases range from more than 50% to 75%.
- Previous failure to progress. VBAC rates in these cases are 2 out of 3.
- Unknown type of uterine scar. Odds are 99 to 1 the scar is transverse and this should not be an issue.
- Low vertical uterine scar. Research shows this is as strong as a transverse scar.
- More than one previous cesarean. Your odds still range from 60-79%.
- Currently pregnant with twins or a breech baby. You may still be a candidate.
Is a VBAC right for me?
Of course, this is a discussion for you to have with your healthcare practitioner. I would highly recommend seeking out a midwife with VBAC experience. Generally speaking, if you are a low-risk pregnancy, you are a great candidate for a natural VBAC birth. Moms with few complications or conditions during their pregnancy can successfully birth their babies vaginally and reap the many benefits. Some other considerations when thinking about a VBAC include the following:
- Type of surgical incision from the previous cesarean
- Reason for the past cesarean
- Whether or not a previous vaginal birth was ever achieved
- How many previous cesareans one has had
- The gestational age of the baby
- Whether or not there was ever a previous uterine rupture
- The mother’s health issues, if any
- The age of the mother
- The shape of her uterus
- The presentation of baby
Women can and do have successful VBAC births, even if some of the above conditions are less than ideal.
How do I prepare for a VBAC?
Consider practicing the following points.
Release any residual emotions from your previous c-section(s).
To move forward, this is critical! You want to let go of any trauma, sadness, disappointment and grief as this can flavor your current pregnancy and birth. Join support groups, talk to a counselor, pray to God (if that’s your thing) and make peace with yourself. This will help you look forward to your next birth with expectancy, hope and excitement.
Get mentally prepared.
Once you’ve dealt with your emotions, you need to commit to a VBAC. It might sound weird but by committing to a VBAC, you will set yourself up for success. Don’t let doubt, fear or peer pressure sway you. You need to keep your mind focused and positive. As part of this, you want to steer clear any negativity around birth. If your parents, siblings, and friends try to discourage you from a VBAC, do not discuss with them.n the end, this is your body, and your decision. It certainly helps to have their support, but you are the one who needs to believe that you can do this.
It’s important to have your spouse or partner onboard, since they can play a critical role in your emotional, physical, and spiritual support. If they are resistant to the idea, present them with the facts. Speak about the safety of VBACs, as this is usually their chief concern. If necessary, make an appointment with a knowledgable midwife you can talk with your partner about your concerns.
You also want to read birth stories of moms who’ve had a successful VBAC daily. Join a support group. Listen to birth affirmations. Visualize having a successful VBAC. (See resources below.) All of this will serve you well for your VBAC.
Get your medical records from your previous cesarean.
You can then be certain why the cesarean occurred, what type of scar you have, and any other pertinent information. This will empower your decision for a VBAC and arm you will all the information you need to know if you run into any resistance.
Work with a VBAC-friendly practitioner and place.
If you still want to go the doctor route, ask him or her about their VBAC rates. It is important to remember that hospital policy does not always align with your doctor’s philosophy! Find out beforehand if your local hospital supports VBAC.
As mentioned earlier, partnering with a midwife may improve your odds for a successful VBAC. Giving birth in a birthing center is an excellent and safe option. If you give birth at home, be sure you live within a 10-15 minute drive to a hospital in case a transfer is necessary. (As an FYI, it takes 16-17 minutes to deliver a baby by cesarean following a uterine rupture, in the rare event that one might occur.)
If you don’t have access to midwifery, and you arrive in labor at a hospital that doesn’t support VBACs, know that you can refuse to consent to a surgical birth. It might sound extreme, but remember – they are not the ones recovering from this, you are. Come armed with research and prepare to stand firm. You may have to sign a consent form to VBAC, but no one can force you to have surgery against your will. That would be a lawsuit waiting to happen (and, unfortunately, it has come to that in some situations).
Get a doula.
Hire an experienced doula for labor support! Be sure she’s attended several successful VBACs (the more, the better). Her encouragement, steadfastness and experience will be invaluable during your birth. Doulas also tend to help calm and empower partners to be active participants in labor. Even though I ended up having a third cesarean after planning for a VBAC, I will never forget the love and endless support from my doula.
Write a birth plan.
There’s something about putting your birth preferences down in black and white that’s very powerful. Create a plan with as many contingencies as you need, even preparing for a repeat, gentle cesarean.
Eat healthy and exercise regularly.
This is going to reduce your odds for high blood pressure, gestational diabetes, edema, toxemia or preeclampsia. Any of these complications, particularly preeclampsia, can increase your risks for interventions and ultimately c-sections.
Do exercises to help baby get into optimal birthing position.
Here’s a video that demonstrates 7 easy exercises to get your baby in great position for a vaginal birth. If you don’t know your baby’s current position, talk to your midwife or try belly mapping.
See a chiropractor.
Find a Webster chiropractor who specializes in the treatment of pregnant women. He/she can help balance your pelvis and get your body ready for a vaginal birth. Some mamas find acupuncture, myofascial release and massage therapy can also help get their bodies balanced, relaxed and ready for a natural birth.
Join ICAN (International Cesarean Awareness Network).
The International Cesarean Awareness Network is a phenomenal resource for c-section mamas who need support, whether that’s grieving from their cesarean or encouraging them for a VBAC. No one can help a mama who wants a VBAC more than a woman who has had a successful VBAC! You can find local chapters with weekly or monthly meetings. Or, get support from their Facebook group and/or their website is loaded with valuable information.
If you don’t feel comfortable with your provider, switch!
Even if it’s late in your pregnancy. I switched from a doctor to a midwife at 30 weeks pregnant, and I know some who have done it in their final few weeks. It is never too late to change your mind.
What’s the best way to labor during a VBAC?
Ideally, you would let your body let you know its best way to labor. Your baby and body would initiate labor. You would be allowed to labor as long as needed in a safe and peaceful environment. Your midwife wouldn’t rush to suggest interventions if your labor stalls or plateaus (something that’s very common in natural childbirth). You’d be able to move freely… walk, squat, shower, eat and drink while going through the phases of labor. And, you’d be able to push and deliver baby vaginally with no complications. This is the goal and most midwives would support this natural process of labor as long as baby and mama are showing no serious signs of distress or danger.
As much as you can, you want to avoid induction. These drugs have been known to slightly increase your risk for complications, including uterine rupture.
If the only two options are induction or a repeat cesarean, an induction is safer – especially if Pitocin is only used once you are in active labor. Most midwives suggest natural ways to induce labor before they start using more formal interventions.
While it’s best to not have an epidural, as this can lead to other interventions, recent research has indicated that they can be used safely, and they do not mask the pain of uterine rupture. Do your best to keep moving, eating, drinking, and resting when you can.
YOU CAN DO THIS!!!
Remember, VBACS have a high success rate. The odds are with you!
Trust your body; trust your baby; and trust the process. As much as you can, stay relaxed, calm, and fearless. Stress, fear, and anxiety increase hormones that will counteract your desire for natural, vaginal childbirth. Get the support you need and fill your mind with positive thoughts and visions of your successful VBAC.
If you wholeheartedly attempt a VBAC and it wasn’t successful, remember that you are not simply your ability to birth your child! It’s easy to compare yourself with friends who rushed to the hospital with barely enough time to change into a gown before they gave birth.
Whether or not you are able to achieve a VBAC birth, you are still an amazing mother. You are still a powerful woman. You are still enough, just as you are. Very few people understand just how much strength it takes for a woman to go through a VBAC or a cesarean. Embrace your experience. Grow from it. Heal any wounds. And move on to the act of mothering your precious newborn.
I wish you the best in your birth experiences.
Resources for VBAC mamas:
Here’s what other natural mamas had to say about their VBAC births
I asked the moms on my Facebook page what helped them achieve a VBAC birth. Here are some of their responses.
- I had my VBAC 8 weeks ago! Wow, what an experience. I had a little over a week of prodromal labor, and 32 hours of actual labor. What I believed helped me to achieve my VBAC was: 1. Supportive husband who was with me for every second 2. A great doula 3. Birthing in a birth center with a supportive midwife 4. No drugs or medication 5. Letting labor begin on its own 6. Family to take care of my toddler so I did not feel rushed or worried during labor. – Amanda C.
- Acupuncture, chiropractor and having a MIDWIFE!!! My VBAC baby was almost 10 pounds too. I was told by my OB, during my first birth, that my pelvis was inadequate too. Imagine that! – Angela E.
- I had a wonderful VBAC 14 months ago. My first birth ended with an injured son in the NICU, so I worked REALLY hard to get through the trauma and emotions surrounded his birth. I went to counseling, found an amazing supportive team of midwives and a wonderful OB, hired a fantastic doula who has tons of VBAC experience, and did the Hypnobabies home study course. I really felt like at the end of my pregnancy I was at peace and could give up control to let her be born how she needed to be born. I had done everything I could to tip the scales in the favor of a VBAC but I also knew that however she was born I would be surrounded by love and be empowered. My daughter was born in the triage room at the hospital – I showed up (not on purpose) ready to push and pushed for 2 hours in many different positions. It was so peaceful and I felt so safe and completely in control. She was handed directly to me and no one removed her from me or my husbands arms for 5 hours until we wanted to know how much she weighed. Getting that time with her immediately after she was born was PRICELESS to me because my son’s first hours were the worst of my life. Looking back I LOVE that my body gave birth to her completely natural. Not because I am opposed to medical intervention when needed – but my son’s injuries were caused by Pitocin and vacuum (he was in a contraindicated position for those interventions) and giving birth to my daughter without those really helped me learn to love and trust my body again. I am just glad for my mental stability that their births were polar opposites! I am now a co-leader of ICAN of Knoxville and love supporting and encouraging other women on empowered birth – whatever that is for them. – Erin M.P.
- Things that helped: choosing a midwife in a birth center, being educated about evidence based practice, attending Ican meetings, prayer, staying positive and light hearted during labor. I’m so glad I made the choices I did this time around. – Anna R.
- I had a vbac just about 3 months ago with my son. It was a completely different experience than my first. My first birth was a planned csection because I didn’t know any better and this time I went to a group of midwives and they helped me a ton to achieve my goal of having a vbac. There are a lot of things people don’t understand about having a c-section first. The thing I heard from quite a few people was that I was “taking the easy way out,” which really hurt. Trust me, no you don’t have to push a baby out, but they are still surgically removing that baby which causes tons of issues that don’t heal as quickly. I had an extremely hard time getting back into my workout routine after my csection. After natural birth, it only took 5 weeks to start back up and I felt normal again. I am losing weight 100x faster this time because my body wasn’t trying to recover from surgery. I’m not saying having a vbac was easy, but it was also much more rewarding. I actually got to soak up having a baby instead of being hooked up to all these wires and drugged up. If I had another, I would totally go natural again! – Manda M.
- I have had 4 VBACs. My emergency Csection (due to Eclampsia) 7.11.09. My first VBAC 1.2.11 2nd- 3.7.13 3rd-3.3.14 & 4th-2.14.15. I would do vaginal 100x over vs. A c section. The recovery, for me, was SO much easier! – Brooklyn W.
- Had an hbac 7 months ago. I think what helped me is having the most supportive midwife and team surrounding me. What I wanted and desired were never questioned. After my hospital experience with my first son I just couldn’t see myself in that environment again. I didn’t feel I should have to fight or be scared. Being at home was the best for my needs. I spent my time watching home birth videos and reading vbac birth stories. And I read Ina Mays Guide to Childbirth. – Dynesha L.B.
- I just had a vbac a couple weeks ago. It would not have been possible with any other care provider than the midwife I carefully chose. I switched providers at 27 weeks because the doctor I was with was being vbac tolerant and willing to “let me try” but more and more I got the impression he wasn’t truly supportive. I wanted to make sure I had someone who would fight for my VBAC as hard as I was prepared to do. I had to drive an hour for each appointment but it was worth it. As with most births, things didn’t go perfectly as planned but my midwife stuck with me and kept me and baby safe while still providing evidence based care and we made it together! – Laura G.
- I had a successful VBAC in October of 2013. My son was born at 40 weeks and a day in less than 3 hours start to finish, without pain meds. My first son was an emergency c-section after 21 hours of labor and lots of interventions, including pit, epidural, vacuum, iv, etc. What helped achieve my VBAC was going with a group of doctors and midwives who fully supported and encouraged VBAC over a repeat c-section. Our group provided statistics on VBAC and natural birth vs. a repeat c-section. I knew from day one I wanted zero interventions and to VBAC. I am so grateful for knowledgeable doctors. The hospital I delivered at has one of the lower rates of c-section in my state, though with my first son, I ended up in the c-section category. With my first birth, I feel they were very “standard” when it came to delivering him, and I felt like I had minimal control over the situation and the interventions. It’s funny because the doctor who delivered my second was the one who induced me with my first. At no time during my pregnancy with my second did any of the doctors encourage a section, and they didn’t even go into “induction” mode when I hit 40 weeks. I think overall, it was a combo of them and I, working towards a safer path and better birth. – Megan E.M.
- I just had my 3rd natural VBAC in October 2014, my c-section was with my 2nd child and due to my little one being “sunny side up”. the hospital basically didn’t want me to labor anymore or help me turn him so they just sent me for a section against my wishes as I was still trying to push! (neither of us were distressed) .. After the trauma of the section I was determined to never go through that again. I would definitely say having a midwife & a supportive husband helped me achieve my VBAC births.. along with being in shape for delivery! I ate healthy, worked out daily and I felt ready to give birth when it was time! I also didn’t go into the hospital until my water broke & I was already 6cm the first VBAC! My 2nd VBAC I was 7cm when my midwife broke my water & our little one came into the world 2 hours later. My last VBAC was in October sounded by our family & was magical. I pulled my little girl out, delivered the placenta still attached & her big brother cut the umbilical cord after it was done pulsing of course smile emoticon Good luck to all the mammas going for a VBAC!! Listen to your guts ladies and be very picky in your choice of care provider. It truly does make all the difference in the world. – Joleen M.C.
How about YOU?
Have you had a VBAC? What helped you achieve this? Please share with us!
- Gaskin, Ina May. Ina May’s Guide to Childbirth. New York: Bantam Books, 2003.
- Goer, Henci. The Thinking Woman’s Guide to a Better Birth. New York, N.Y.: Berkley Pub. Group, 1999.
- Vadeboncoeur, Helene. Birthing Normally after a Caesarean or Two: A Guide for Pregnant Women, Exploring Reasons and Practicalities for VBAC. Chester-le-Street, Eng.: Fresh Heart Publishing, 2011.
- Wainer, Nancy, and Lois J. Estner. Silent Knife: Cesarean Prevention and Vaginal Birth after Cesarean, VBAC. S. Hadley, Mass.: Bergin & Garvey Publishers, 1983.