VBAC: Vaginal Birth After Cesarean Section

What is a VBAC?

A Vaginal Birth after Cesarean is exactly what it sounds like. A birth during which a woman who has previously given birth via cesarean, delivers her baby vaginally.

Are VBACS safe?

For women who have had one or two uncomplicated cesareans, who do not present any risks, and who are otherwise experiencing a normal, healthy pregnancy, vaginal birth after cesarean is a reasonable option.

Many hospitals, home birth midwives, and birth centers offer monitored and safe VBAC options to families wishing to attempt a Trial of Labor after Cesarean. Midwives are currently the only type of providers in Redding offering VBACs to eligible patients.

Those interested in trying for a VBAC are required to meet the screening criteria, and must provide surgical reports to rule out any risk factors that may manifest.

Can I have my VBAC at home?

Yes! If you meet the criteria and are a good candidate for VBAC delivery, you can have your VBAC at home or in the birth center. We have had many successful VBACs at home. We require VBAC home births to be with 30 minutes of Mercy Medical Center, or no more than 10 minutes South of St. Elizabeth’s Hospital.

Vaginal Birth After Cesarean: The Medical Evidence

The American College of Obstetricians and Gynecologist's (ACOG) practice bulletin number 54 issued in 2004 still supports a woman's right to choose VBAC, but states that patients attempting VBAC should have "physicians immediately available to provide emergency care".

This position was first stated in a practice bulletin issued by ACOG in 1999. This has been interpreted by hospitals to mean that there must be a constant presence of a surgical team while a woman is in labor. This interpretation includes having an obstetrician and an anesthesiologist on the premises the entire time a woman is in labor. 

The American Academy of Family Physicians (AAFP) presented a review of information on VBAC in March 2005 and issued recommendations that continued to support VBAC. Their recommendation included "TOLAC (trial of labor after cesarean) should not be restricted to facilities with available surgical teams present throughout labor since there is no evidence that these additional resources result in improved outcomes."

This is NOT an endorsement of out-of-hospital VBAC! They simply found that there was no merit to the ACOG recommendation that the continuous presence of an obstetrician and anesthesiologist improved outcomes in any way.  The AAFP also stated in this paper that induction and augmentation of labor, and specifically prostaglandins, should not be used in women desiring a VBAC since these increased the likelihood of failure and uterine rupture. This is consistent with findings in other research concerning the risks of cesarean.

Further Research

To fully educate yourself you need to study the risks of cesarean and elective repeat cesarean in order to compare the benefits vs. risks compared to VBAC. You can find information on VBAC on the following pages: 

• International Cesarean Awareness Network

• The Childbirth Connection

• VBAC.com

• The Power to Push

• ACOG Guidelines on planned home birth

• 135 Planned home births with an Obstetrician

Things to consider if you are planning a VBAC:

Past obstetrical / surgical history

Women with any of the following conditions may still be candidates for in-hospital VBAC, but should be advised that they have additional risk factors that they must consider when making their decisions and will not be good candidates for VBAC out of hospital:

• History of prior C-section before 26 weeks gestation

• History of uterine infection or impaired uterine scar healing

• Current birth spaced less than 18 months from C-section delivery

• Scar thinning or separation seen on ultrasound done at term for current birth

• History of more than two previous cesarean deliveries

Current health considerations: 

Several situations may arise toward the end of pregnancy or during birth that would necessitate the transfer of your care from the midwife to the doctor at the hospital.  These may include:

• Fetal positioning at the end of pregnancy or during labor

• Long or abnormal active part of labor or pushing stage

• Abnormal detachment of the placenta and/or increased bleeding after the baby is born.

Time and distance: 

Morbidity and mortality rates increase when C-section is delayed with a true uterine rupture. Ideally the nearest hospital with emergency C-section capability should be less than 20 minutes from planned birth site.  In the unlikely event of a catastrophic uterine rupture, an emergency C-section delivery within this time frame will not guarantee a healthy outcome for mother and especially for the baby.  Traffic, road, and weather conditions (especially related to the time of year) are factors to consider when thinking about planning a VBAC in an out-of-hospital setting.  Within Redding, the local maternity hospital does have a 24/7 OB and anesthesiologist on site, but may not have an OR available soley for VBAC emergencies.  This is the reason they do not do VBAC deliveries.  If a transport was required in the case of a uterine rupture, this absence of a surgical suite upon arrival may further delay help for both mom and baby.

Legal liability issues: 

Your midwives do carry malpractice insurance, which cover only birth center VBAC deliveries. There is no coverage for home VBAC deliveries.  Your insurance company may not reimburse providers for attending your VBAC at home, although we have not traditionally seen home VBAC reimbursement be an issue. This can be determined in advance through www.birthprofessionalbilling.com.