Markers for VBAC Requirements After 1st and 2nd C-section

When it comes to deciding where and how someone welcomes their baby into the world, there are many factors to consider. Birthing parents deserve to know their options and what the risks and benefits of each option are, but it can be hard to figure out where to start when researching providers and asking questions. 

When it comes to discussing a VBAC there are a lot of questions someone may be thinking about. Here are our top 8 questions to ask your provider, and why you should ask them. 

1. Is your provider VBAC supportive? 

Your provider may not feel comfortable supporting a VBAC, but that does not mean it is not an option for you. You may want to consult with multiple providers. We also recommend making sure other providers in the practice are supportive because the provider attending your birth might be whoever is on call. 

2. Is your provider VBAC supportive after more than one c-section?

Some providers may feel comfortable attending a VBAC after one cesarean, but that support can change after two cesareans. 

3. Have they attended a VBAC before? How many were successful? How many were successful in the past year?

It is important to make sure you are confident in your provider's skill set and that they have a proven track record that would allow you to have your desired outcome for your birth. Always remember, you have options when it comes to birth and who attends your birth. If your current provider's views do not align with your own, but you meet the qualifications for a cesarean set by the American College of Obstetricians and Gynecologists, you may want to look into other providers in your area. 

You can also reach out to ICAN, the International Cesarean Awareness Network. They have local chapters and they may provide you with a list of local VBAC supportive providers. You can also join their Facebook group to receive support from other VBAC families. 

4. What are the risks? What are the benefits?

Research is constantly being released. Make sure that you are up to date on what the benefits and risks for a VBAC are, and what risks are specific to you. A provider who knows your history is the best person to answer this question. 

Gentle Cesareans involve skin to skin in the OR, a clear curtain, and sometimes delayed cord clamping. This may be worth asking about beforehand to prepare in the event that a repeat cesarean does occur. 

5. How far past your due date will they recommend you go before a repeat cesarean is recommended? If you go past your due date would they recommend trying an induction first?

This question allows you to better know what to expect and ask questions accordingly. If you have the option to be induced you may wish to request that before you reach your due date or you may have questions about what to expect if induction does occur (if you have not had one before). If being induced is an option there are different routes, one may be an option for you while others may not be. It is important to know what those are. If induction is a no altogether, you may want to know that sooner rather than later. 

6. What type of monitoring do you recommend for VBAC patients?

Knowing what monitoring is recommended, and will most likely be used, allows you to plan accordingly for different labor positions. If you are going to be restricted to a bed it may be important to you to research bed labor positions, peanut balls, etc. 

7. How long are they comfortable letting patients labor for, after their water breaks?

This is another question you may want to ask to prepare yourself for what to expect. This may also determine your decision to use Pitocin or request an epidural. Pitocin is typically used to “speed up” labor. An epidural is used for pain management but can slow down contractions. Someone might not want an epidural if they have a small-time limit after their water breaks. 

8. What policies should you be aware of that may make a VBAC harder to achieve?  Or what policies should you be aware of?

The hospital or birthing center you are delivering at may have policies that make a VBAC harder to achieve. There may be policies preventing movement or hydrotherapy. The policies may make you more likely to request an epidural. This may impact someone's decision to give birth there or impact the preparation they do to plan pain management techniques. 

For any birthing parent, it is important to know when providers recommend you arrive, based on your medical history. You may also want to know about policies around eating in labor. 

Around 70% of birthing parents who elect for a trial of labor are successful. 

Research is constantly being published showing that a VBAC is safe if the birthing person meets a set of qualifications, these qualifications may differ depending on the practice you attend and a provider's comfort level.

You may be a good candidate if:

• Pregnant with one baby, have a history of one or two prior low transverse C-sections, and have no problems that would prevent VBAC.
• Pregnant with one baby, have a history of one prior C-section with an unknown type of uterine incision and have no problems that would prevent VBAC — unless it's suspected that you had a prior high vertical uterine incision.
• Pregnant with twins, have a history of one prior low transverse C-section, and are otherwise a candidate for a twin vaginal delivery.
• No more than 2 low transverse cesarean deliveries.
• No additional uterine scars, anomalies, or previous ruptures.
• Your health care provider should be prepared to monitor labor and perform or refer for a cesarean if necessary.

You may not be a good candidate if you fall into the following categories:

• Stalled labor
• Advanced maternal age
• Pregnancy that continues past 40 weeks
• Body mass index of 40 or higher
• Excessive weight gain during pregnancy
• Preeclampsia
• Previous delivery within 18 months
• History of two or more prior C-sections and no vaginal deliveries
• A need for labor induction when starting with a closed cervix
• A prior high vertical (classical) uterine incision
• An unknown type of prior uterine incision and it's suspected that it was a high vertical (classical) incision
• A prior uterine rupture, in which the cesarean scar on the uterus breaks open
• Certain types of prior uterine surgery, such as fibroid removal

Risks may include:

• Emergency C-Section
• Hysterectomy (removal of the uterus), meaning you would not be able to carry another pregnancy
• Uterine rupture, the rate is 1 in 500 for patients with a low transverse incision.

The Mayo-Clinic has listed the following benefits:

• A faster recovery. If you deliver vaginally, you’ll spend less time in the hospital. This means fewer expenses. You can also expect to feel physically better sooner.
• A greater sense of involvement in the birth. Delivering vaginally may make you feel like a more active participant in the birth of your baby.
• Less risk in subsequent pregnancies. Risks like infection, organ injury, and blood loss can increase with repeat elective cesarean deliveries. If you’re planning a large family, a VBAC may be a good option for you.

References:

ACOG, Midwifery Today, Winter No 36, page 47.

Levine EM, Ghai V, Barton JJ, Strom CM. Mode of delivery and risk of respiratory diseases in newborns. Obstet Gynecol 2001;97(3):439-42.

Habak PJ, Kole M. Vaginal Birth After Cesarean Delivery. [Updated 2021 Aug 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507844/

International Cesarean Awareness Network , I. C. A. N. (2021, March 19). Advocacy. International Cesarean Awareness Network. Retrieved January 31, 2022, from https://www.ican-online.org/advocacy/

Mayo Clinic (2020, June 9). Vaginal birth after cesarean (VBAC). Mayo Clinic. Retrieved January 31, 2022, from https://www.mayoclinic.org/tests-procedures/vbac/about/pac-20395249 

Stamilio DM, Shanks A. Vaginal birth after cesarean (VBAC) outcomes associated with increasing number of prior VBACs. Womens Health (Lond). 2008 May;4(3):233-6. doi: 10.2217/17455057.4.3.233. PMID: 19072472.