Vaginal Birth After Cesarean (VBAC)
What Is VBAC?
The dictum “once a cesarean always a cesarean” dominated obstetric practice until 30 years ago. Since then, large studies have documented the relative safety of a trial of labor after a previous cesarean. The American College of Obstetrics and Gynecology now recognizes VBAC as a reasonable alternative for appropriately selected candidates.
Am I a Good VBAC Candidate?
Candidates for VBAC should have had only one previous cesarean delivery with a low transverse (horizontal) uterine incision. An exception exists for patients with two prior cesareans and one previous successful vaginal delivery. Patients who had a cesarean for a non-recurring reason — such as fetal distress or breech presentation — are generally better candidates than those whose cesarean was due to dystocia (failed labor due to baby size or pelvis size). Early in pregnancy your doctor can assess your pelvis; later in pregnancy, fetal weight estimates may also affect recommendations.
Note: The scar on your abdomen does not necessarily match the scar on your uterus. If you do not know the type of uterine incision from your previous cesarean, your doctor may need to review a copy of your previous operative report.
Patients who should NOT attempt VBAC generally include those with:
- Two previous cesareans and no prior successful vaginal deliveries.
- A vertical (classical) uterine incision — associated with high risk of uterine rupture.
Risks and Benefits of VBAC
VBACs should only be attempted in a hospital setting where emergency delivery can be performed. There is a 0.5–1% risk of uterine rupture with VBAC, which carries an increased risk of excessive blood loss, hysterectomy, fetal injury, and death.
Benefits of a successful VBAC include:
- Shorter hospital stay
- Quicker recovery
- Lower risk of excessive blood loss and infection
It is also important to note that the more cesareans a patient has, the greater the risk in future pregnancies for placenta previa or placenta accreta — conditions in which the placenta implants improperly and can be associated with heavy bleeding, transfusion, and possibly hysterectomy.
Patients who attempt VBAC but ultimately require an emergency cesarean face slightly greater risks than those who opt for a planned repeat cesarean in a controlled setting. In summary: a successful VBAC is less risky than an elective repeat cesarean, but a failed VBAC resulting in a cesarean can carry more complications than a planned repeat cesarean.
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