Vaginal Birth After Cesarean: the Facts


Women who choose a VBAC have special needs and concerns that are social, psychological and clinical. A skilled Certified Professional Midwife uses all her talents- intellect, interpersonal communication, intuition and judgment to inform, nurture, protect and empower the women in her care.

The Center for Disease Control and Prevention (CDC) reports that the US cesarean rate slightly declined from 32.7 to 32.2% in 2014.  Many women are now attempting vaginal birth after cesarean (VBAC) for their subsequent births.  In 2014, Cesareanrates.com reported in that Wisconsin’s VBAC rate was 26.1%.  Many Certified Professional Midwives (CPM) support VBAC’s as an option for women who have had previous cesarean deliveries.  In Wisconsin, CPM’s can attend home birth vaginal birth after cesarean (HVBAC) after consulting with a CNM or physician regarding the individual VBAC client. The American Pregnancy Association suggests 90% of women who have undergone cesarean deliveries are candidates for VBAC.  VBAC can be extremely therapeutic for women who have felt disappointed and/or angry about a prior birth experience.

First, why is the cesarean section rate so high? The most common obstetric procedure electronic fetal monitoring (EFM) has benefits and risks.  Some suggest EFM is used to monitor the baby’s heart rate during labor so interventions can occur if the baby is in distress.  EFM is also used so nurses can monitor multiple labors at the same time. Studies suggest EFM can lead to an increase in cesarean sections.  It has been shown that women with continuous EFM were 1.7 times more likely to have a cesarean and likely to require pain medication when compared to women with intermittent auscultation during labor.

Often in the hospital women are told that as VBACs they can have a trial of labor (TOL) which implies that their body is not ultimately capable of a vaginal birth.  With careful risk assessment, there is no reason to suggest that most women will not be successful.

Women who have had a low-transverse uterine incision have the highest rate of successful VBAC.  As reported in Outcomes of Care regarding 16,924 Planned Home Births in the United States:  the Midwives Alliance of North America Statistics from, 2004 to 2009, report that 1100 women attempted a VBAC with a success rate of 87%.  Why the high success rate?  It’s simple, homebirth allows women to birth without interfering with the physiological process.  The 87% success rate suggests that the idea once a c section, always a c section is not the case.  This outdated philosophy is changing around the country.

There are three main obstetrical complications that can sometimes occur with scarred uteruses. The first is placenta previa, which is when the placenta covers the opening of the cervix.  The second obstetric pathology is placenta accreta and percreta. These are abnormally implanted placentas, which invade the uterine wall. Placenta accreta and percreta is why it is important to verify the position of the placenta in second trimester with ultrasounds.  The third antepartum complication is uterine rupture which can happen during any birth, even when no scar tissue is present, and results predominantly if Pitocin is used.  Placenta previa, placenta accreta/precreta and uterine rupture require a cesarean section.

There are several contraindications to VBACs.  These circumstances include: classical (vertical) scar on the uterus, T- or J-incision on the uterus, previous surgery such as myomectomy, which remove fibroids from the uterus, a truly contracted or deformed pelvis, or obstetrical complications, such as, placenta previa that preclude vaginal delivery.

CPM’s undertaking home VBAC need to learn the physical and psychological differences of VBACs.  For instance, VBACs can have longer births.  Midwives who accept VBAC’s need to have a VBAC practice protocol, engage in informed consent, request an ultrasound in the third trimester to determine the placement ensure it is not overlapping the scar.  Lastly and as always, these CPMs need to have an emergency care plan completed in the event of transfer. VBAC protocols vary among midwives. An important factor is the reaction of the EMS, as well as the responsiveness of a back-up doctor and hospital to a midwife’s emergency call. Essentially a rural midwife working with a small hospital will have a different protocol than to urban midwife who is minutes from a trauma center.  For more information, contact Raquel at http://www.BlissfulMidwifery.com.

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