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If you delivered your first baby by way of a c-section, you’ve got two choices for your next go-round: Schedule another cesarean birth or shoot for a vaginal birth, which is dubbed VBAC (vaginal birth after a cesarean). While most have a repeat c-section, that doesn’t necessarily reflect desire. In fact, even though nearly half of those who delivered by c-section said they wanted a VBAC for future births, only about 12% wound up having VBAC, according to a 2019 report in the journal Birth. However, the Centers for Disease Control and Prevention (CDC) notes that VBAC numbers are on the rise, increasing from 12.4% in 2016 to 14.2% in 2021.

To find out if VBAC is the right option for you, keep reading! Here, you’ll find the pros, the cons, and the unexpected obstacles that many parents-to-be face when it comes to having a vaginal birth after a cesarean.

What is VBAC?

VBAC stands for vaginal birth after a cesarean section, which just means a vaginal delivery that happens after a previous cesarean. You should thoroughly discuss the possibility of VBAC with your healthcare provider early in your pregnancy.

VBAC vs TOLAC

TOLAC stands for trial of labor after cesarean delivery—in other words, TOLAC is the attempt to have a VBAC. If your labor is “successful,” TOLAC leads directly to a vaginal birth. If TOLAC proves “unsuccessful,” you’ll need to deliver your baby via another cesarean section. While your TOLAC will be similar to the labors of all other expectant parents, your healthcare provider will likely recommend continuous monitoring of your baby’s heart rate throughout.

Why consider a VBAC?

While plenty of parents-to-be are content to deliver baby number two (or three or four!) with a repeat cesarean section, research shows that 45% of parents who delivered by cesarean in their first birth wanted to have their next delivery vaginally. Many want a VBAC the next go-round to:

  • Avoid surgery

  • Avoid possible complications, like infection and blood loss

  • Have a shorter stay in the hospital

  • Return to normal daily activities more quickly

  • Experience vaginal childbirth

If you’re planning to have several children, VBAC can help you avoid certain health issues linked to experiencing multiple cesarean deliveries, such as a bowel or bladder injury, hysterectomy, and/or problems with the placenta in future pregnancies.

What are VBAC risks?

It’s widely believed that VBAC is a safe choice for most. But that doesn’t mean there aren’t some risks. The American College of Obstetricians and Gynecologists (ACOG) notes that infection and blood loss are both would-be complications of VBAC. And a recent study in the journal PLOS Medicine found that VBAC may increase your likelihood of pelvic floor surgery for prolapse or urinary incontinence after childbirth, though the overall risk is still small.

In addition, an Australian study found an increased risk of sustaining a third- or fourth-degree perineal tear during one’s first VBAC, when compared to first-time vaginal births. (A perineal tear impacts the perineum, the area between the vagina and anus.) Researchers speculate that this may be due to a “mismatch” between a uterus that has birthed before and a perineum that has not. So, when labor progresses quickly, it doesn’t allow enough time for the perineum to stretch naturally.

One rare but serious risk with VBAC is uterine rupture, when the cesarean scar on the uterus breaks open. Here, an emergency c-section is needed to prevent life-threatening complications. Between 0.4 and 0.7% of folks who attempt VBAC experience a uterine rupture, but the risk is higher when birth is induced and with increased maternal age and gestational age.  If your uterus ruptures, risks include:

  • Bladder damage

  • Blood clots

  • Blood loss

  • Hysterectomy

  • Infection

In the end, VBAC can be an excellent birthing option for many. To truly know if this is the right decision for you, consult your healthcare provider. And remember, labor, delivery—and parenthood for that matter—is unpredictable. That’s why it’s always important to surround yourself with a birth team you trust and to keep an open mind.

Who is a good candidate for VBAC?

VBAC is a “reasonable and safe choice” for most parents who’ve had a previous c-section, notes a 2021 report in the journal BMC Pregnancy and Childbirth. But most is not all. Here are some key factors that make pregnant people good candidates for VBAC:

  • Low c-section incision: A low transverse incision or a low vertical incision are the most common incisions used to perform a cesarean—and they are the types of cuts that make one a good VBAC contender. (PS: Looking at your c-section scar won’t tell you what kind of cut used to open your uterus. Your doc will need to review your surgical records for that info.)

  • Prior vaginal delivery: If you’ve experienced at least one vaginal delivery (including a prior VBAC) before or after your c-section, your chance of a successful VBAC goes up.

  • Age: Research shows that those under 35 have more success—and fewer complications—with VBAC.

  • Reason for first c-section: If your baby’s health (for example: breech or abnormal fetal heart rate) predicted the cesarean, not the actual labor process, you could be a good candidate for VBAC.

  • Good health: If you and your baby-to-be are in good health, you may be a good VBAC candidate.

The good news? According to the National Institute of Child Health and Human Development (NICHD), among appropriate candidates, about 75% of VBAC attempts result in a vaginal birth.

Who is not a good candidate for VBAC?

VBAC is not the right choice for everyone. Here are some potential risks that may make you a less-than-ideal candidate for a vaginal birth after c-section:

  • High vertical incision: VBAC isn’t recommended for folks who had a high vertical (classical) incision with a prior c-section because the risk of uterine rupture is higher.

  • Two-plus prior c-sections: Many healthcare providers won’t offer VBAC if you’ve had more than two prior c-sections.

  • Uterine rupture: If you’ve experienced a uterine rupture, you’re not a VBAC candidate.

  • Other uterine surgeries: VBAC isn’t recommended for those who’ve had other operations on the uterus (i.e.: fibroid removal).

  • Short span between pregnancies: Your risk of uterine rupture is higher if you attempt VBAC less than 18 months after your previous c-section delivery.

  • Placenta issues: A c-section might be the safest option if you have placental problems, such as placenta previa.

  • Breech position: If your bub-to-be is in any position but head-down, a repeat c-section is most likely in order.

  • Health issues: Research shows moms-to-be with gestational or pre-gestational diabetes, hypertensive disorders in pregnancy, and/or those who are obese are not ideal candidates for VBAC.

  • Multiples: Carrying triplets—or more? Then a VBAC is not the safest choice.

  • Large baby: If your healthcare provider suspects your baby is over 10 pounds, they may suggest rethinking VBAC.

  • Past due or induced: Your chance of induction increases after 40 weeks pregnant—and many physicians are hesitant to induce labor when you have a history of uterine surgery.

What’s the VBAC calculator?

In 2007, the Maternal-Fetal Medicine Units (MFMU) Network came up with an oft-used calculator to estimate a pregnant person’s chances of having a successful VBAC. The original version of the calculator factored race and ethnicity into your score, which meant Black and Hispanic folks were automatically assigning a lower likelihood of VBAC success than it did if the person was white. Thankfully, a new calculator was released in 2021 eliminating such factors. While the VBAC calculator can be a helpful resource, it’s just one tool that can be used in the shared decision making between you and your doctor, and ACOG cautions that your score should not be used as a barrier to TOLAC.

Do all doctors and hospitals perform VBACs?

No. While large, university-based or community hospitals with 24/7 labor and delivery and anesthesia teams often offer VBAC, not all hospitals have the staff or resources to perform VBACs. In fact, a 2021 report of over 1,700 parents found the most significant obstacle to VBAC was finding a VBAC-supportive provider. Some physicians and hospitals are hesitant to okay VBACs because of the potential for an emergency c-section and their facility’s capacity to handle such instances…and the possibility of resulting lawsuits. And for others it comes down to taking a more conservative approach to labor and delivery. This, of course, is a big reason to bring up your desire for VBAC as early in your pregnancy as possible, in case you need to make changes to your care team.

Of note, improved access to midwives is associated with higher rates of VBAC. The 2021 report above found that nearly 40% of study participants who planned a VBAC had a midwife for their second birth. For some perspective, usually only about 10% of people give birth with a midwife in the U.S.

While one might consider a home birth for their VBAC, know that ACOG recommends VBACs should take place in a hospital setting.

 

More on Pregnancy and Birth:

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REFERENCES

  • Women’s preference for vaginal birth after a first delivery by cesarean. Birth. March 2019
  • American College of Obstetricians and Gynecologists: Vaginal Birth After Cesarean Delivery (VBAC)
  • Centers for Disease Control and Prevention (CDC): Recent Trends in Vaginal Birth After Cesarean Delivery: United States, 2016–2018
  • Mayo Clinic: VBAC: Know the pros and cons
  • Evaluation of factors that predict the success rate of trial of labor after the cesarean section. BMC Pregnancy and Childbirth. July 2021
  • UCLA Health: A mom’s C-section no longer automatically rules out future vaginal births
  • Vaginal birth after caesarean delivery: does maternal age affect safety and success? Paediatric and Perinatal Epidemiology. March 2007
  • UTSouthwestern Medical Center: Who is a good candidate for VBAC?
  • National Institute of Child Health and Human Development: What is vaginal birth after cesarean (VBAC)?
  • Factors associated with successful vaginal birth after a cesarean section: a systematic review and meta-analysis. BMC Pregnancy and Childbirth. October 2019
  • ACOG: Counseling Regarding Approach to Delivery After Cesarean and the Use of a Vaginal Birth After Cesarean Calculator
  • Harvard Health Publishing, Harvard Medical School: Why try for a vaginal birth after a cesarean?
  • “I had to fight for my VBAC”: A mixed methods exploration of women's experiences of pregnancy and vaginal birth after cesarean in the United States. June 2021
  • Clinicians’ views of factors influencing decision-making for caesarean section: A systematic review and metasynthesis of qualitative, quantitative and mixed methods studies. PLOS ONE. June 2018

  • Planned mode of birth after previous cesarean section and risk of undergoing pelvic floor surgery: A Scottish population-based record linkage cohort study. PLOS Medicine. November 2022

  • Risk of obstetric anal sphincter injury among women who birth vaginally after a prior caesarean section: A state-wide cohort study. BJOG: An International Journal of Obstetrics & Gynaecology. July 2022
  • The Conversation: Vaginal birth after caesarean increases the risk of serious perineal tear by 20%, our large-scale review shows
  • Risk of Uterine Rupture with Vaginal Birth after Cesarean in Twin Gestations. Obstetrics and Gynecology International. March 2021
  • Cleveland Clinic: Vaginal Birth After Cesarean (VBAC)

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Disclaimer: The information on our site is NOT medical advice for any specific person or condition. It is only meant as general information. If you have any medical questions and concerns about your child or yourself, please contact your health provider.