Preparing for a Successful VBAC: Know Your Risks and Make a Plan

It's difficult to decide what course to take after having a c-section with your first baby - take the time to discuss it with as many people as possible who you think will help you make an informed decision.
It's difficult to decide what course to take after having a c-section with your first baby - take the time to discuss it with as many people as possible who you think will help you make an informed decision. | Source

The Basics

A VBAC, which stands for vaginal birth after cesarean, is something that more and more women are considering, as the c-section rate in the United States stays very high. In 2010, the rate was over 32% (link to lots of research and good information about c-section rates). The term TOLAC is also used to refer to the trial of labor after cesarean, which I suppose is a more accurate term, because when you are planning, all you are able to choose is that you will go into labor. The rest will not be entirely under your control.

According to the American Pregnancy Association:

  • 90% of women who have had a previous c-section are candidates for VBAC
  • In most published studies, 60-80% of women who have previously had a c-section can deliver a subsequent baby vaginally
  • The American College of Obstetrics and Gynecology (ACOG) has stated that VBAC is safer than a repeat cesarean, and VBAC with more than one previous cesarean does not pose any increased risk

With these types of articles, I also think it's helpful to provide my own personal background and biases so the reader can know where I'm coming from. I had a c-section (non-emergency, but non-scheduled) with my first born, almost three years ago. I was in labor for a very long time and then basically ended up with a c-section because of failure to progress. I am now considering what to do for the birth of my second son. I am fortunate to be assigned to a hospital that supports VBACs, so I have a choice, and my doctor is not pushing me in any direction.

Understanding Risks

Risk is such an amorphous and scary word, that I think it's really important to break down what type of risk we are talking about when we talk about VBACs. It's also tricky because you are comparing risks of various paths, and you don't know which path you are going to go down. For example, here are various paths you could end up on if you try for a VBAC:

  • Try for a VBAC --> end up with a natural delivery
  • Try for a VBAC --> end up with a non-emergency c-section
  • Try for a VBAC --> end up with an emergency c-section
  • Try for a VBAC --> end up with uterine rupture

Each of these paths then has its own attendant risks.

1) Vaginal delivery:

  • There are various risks involved with having a vaginal delivery, including placental abruption, cord prolapse, shoulder dystocia. These are all more likely than uterine rupture. (Midwife Thinking article). I had a hard time categorizing these as risks to mother or baby, because these generally involve some risk to both. As far as mortality, the risk to the mother is lower than with a c-section (see below), and the risk to the baby seems difficult to calculate, but seems lower.

2) C-section:

  • There are the general risks to the mother of any abdominal surgery, including infection as well as maternal mortality (higher risk than vaginal delivery) (see more here).
  • There are also some risks to the baby, including premature birth (if c-section is scheduled and due date is calculated wrong), breathing problems, lower APGAR scores, and very small chance of being nicked or cut during the surgery (more here). It seems to me that some of these risks are reduced or not present if a woman attempts a VBAC but ends up with a c-section (for example, premature birth).

3) Uterine Rupture:

The general risk of uterine rupture is reported to be less than 1%. (Link to source).

There are two types of uterine rupture, one much more serious than the other:

  1. Catastrophic (symptomatic) – the old scar separates long its length, the amniotic sac ruptures and the baby is pushed into the abdominal cavity. This results in significant bleeding, shock and the baby is in grave danger.
  2. Asymptomatic – the scar separates partway along its length, the amniotic sac stays intact and the baby remains in the uterus. Bleeding and shock is minimal and the baby usually survives. This is the most common type. (these explanations are taken from this article).
  • The risk to the baby of the more serious (and rare) rupture is very dangerous. It looks like in these scenarios they have about 16-17 minutes to get the baby out via c-section or the blood flow will be cut off.
  • The risks to the mother of uterine rupture are generally blood loss, hysterectomy, damage to bladder, infection, & blood clots (see more here).

I've included a chart below because uterine rupture is really the major risk of a VBAC, and I thought it was helpful to lay out the various factors that increase risk of uterine rupture. This can help with making an informed birth plan (more below).

Understanding Various Risk Factors of Uterine Rupture

Event (column below)/Risk Increase (row to right)
Increases Risk of Uterine Rupture
Going past your due date
No
Being induced
Yes
Labor augmented
Yes
VBAC after multiple c-sections
Slight
This information is taken from the following article: http://midwifethinking.com/2011/02/23/vbac-making-a-mountain-out-of-a-molehill/

Comparing Risks and Making a Decision

This is obviously where the proverbial rubber hits the road. I think the most important thing to keep in mind is that no one can know another person's comfort level with different types of risk. A 1% risk is a 100% risk if you are the one that it happens to. For some people, that is enough. On the other hand, a 1% risk is a very low risk and we make decisions every day (like getting in a car, or ignoring the global warming project - oops, sorry for slipping that in!) that subject us to significant risk. I do think it's important for our decisions to not be fear based, but also to be realistic and honest with ourselves about our comfort level, and to own our own personal comfort level.

The American Pregnancy Association has an incredibly helpful table comparing a repeat c-section with a VBAC. I won't duplicate it here, but go check it out (it's down towards the bottom)! The one that stood out to me is that the risk of infection doubles if you attempt a VBAC but end up with a c-section. Those risks are most interesting to me, because it's such a difficult risk to factor in - bottom line, when you decide to attempt a VBAC, you don't know if you are going to end up with a vaginal delivery or another c-section.

Making a Birth Plan for a VBAC

For women who decide to have a VBAC, there are a lot of helpful resources about how to develop a birth plan for this particular scenario. I found this article most helpful because it talks for a while about the various things to consider putting in, and then provides two samples. I liked the overall tone of the article and it really doesn't push you in any direction, just gives you a lot to think about. For example, I hadn't considered that it would be a good idea to put in a plan for an emergency c-section if that ends up happening during the attempted VBAC.

Other resources (articles and sample birth plans):

  • Sample VBAC Birth Plan from ICAN of New Jersey. (Link). This one is very hypno-birthing oriented. It has a longer version of the birth plan as well as a shortened version.
  • Sample VBAC Birth Plan from Birthrites.org (Link). Includes plan for in case of cesarean.

If others have suggestions for how to prepare and plan for a successful VBAC, please leave them in the comments below!

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