Vaginal Birth After C-Section (VBAC)

The term VBAC is an acronym for Vaginal Birth After C-Section. If you have had a C-section with a previous birth, you may want to consider having a VBAC instead of a repeat C-section. With the advent of the successful uterine suturing, the arrival of the antibiotics to treat infections, and the better availability of blood transfusions, the safety of C-sections increased. However, women who had had one C-section were told “Once a C-section always a C-section.”

I encourage patients to ask their doctors how many C-sections they have done. If you want a C-section, you want a surgeon who has done at least a hundred or so. You also want to know how many of their C-section patients had hemorrhaging during or after their surgery. If you prefer a natural birth, you want to know what percentage of your doctor’s deliveries are C-sections. If it’s more than 15 percent, you may want to look for a doctor with a lower C-section rate.

The U.S. C-section rate is now approximately 33 percent. This rate is a result of several different factors. Certainly, the safety of a C-section has improved over the last 100 years. Increasingly, doctors are not trained to do vaginal breeches, and in some places, doctors, medical malpractice insurance carriers, health insurance companies and the American College of Obstetricians and Gynecologists (ACOG) don’t want to do a vaginal birth after C-section (VBAC). Some of those reasons include the resistance of insurances in covering VBACs and ACOG’s various opinions on VBACs over the years. As the safety of C-sections increased, the issue of risk became a smaller factor in a decision to have a C-section and convenience became a larger factor. Let’s face it. In spite of the fact that your vaginal birth is cheaper and safer than a C-section, the C-section is much more convenient. A natural, unobstructed labor and vaginal birth are time consuming and can provoke anxiety in the hospital caregivers. The time spent on working with women to enable natural deliveries may interfere with a doctor’s surgery schedule since gynecologists do surgeries as well as deliver babies. And, of course, we can’t forget the fact that a C-section is reimbursed at approximately twice the level of a vaginal birth.

Then there’s the problem with breeches. I was trained at a time when we still did vaginal breech births and I learned how to do them. Today, we have fewer medical staff members proficient in vaginal breech births. Proficiency in a procedure is generally directly related to how many have been performed. Practically speaking, there is a minimum number of times a procedure is performed in order to gain some kind of proficiency.

According to the National Institutes of Health (NIH), the risk of dying from a VBAC is .0038 percent, while the risk of dying from a repeat C-section is 0.0134 percent. Even though these numbers are both very small, the risk of dying from repeat C-section is 10 times greater than the risk of dying from a VBAC. Some people say that a VBAC is riskier than a repeat C-section because the uterus is contracting. In my 45 years of delivering babies and approximately 1000 C-sections, I have never observed this to be true. The most likely risk for a VBAC is infection because there’s a lot more manipulation of the patient’s cervix, uterus, and baby. I have personally never encountered an infection, a uterine rupture, fetal distress, or even a blood transfusion with a VBAC.

Most studies have shown that 60 to 80 percent of women undergoing a VBAC are successful. However, in my experience, the success rate has been around 90 percent. Women under the age of 35 are more likely to have a successful VBAC. To undergo a VBAC, the original C-section incision had to be vertical rather than horizontal. The reason for the first C-section also needs to be considered. If your pelvis is very small or you have had a fractured pelvis, you probably will have some difficulty with a VBAC. If a VBAC fails to work, your baby will be delivered by C-section.

The average risk of uterine rupture is 0.7 percent. Without induction, the uterine rupture rate is .5 percent or a 1 in 200 chance. However, the risk of uterine rupture increases to .9 or 1 percent if you are induced with Pitocin and 1.4 to 1.8 percent if you are induced with prostaglandin.

It is never a good idea to try to persuade your doctor to do something that he or she doesn’t want to do. In the first place, you are very unlikely to succeed and you may generate some hard feelings. If you want to have a VBAC and your doctor says you can’t have one, your best bet is to try to find another doctor with whom you might agree. That is, of course, if your insurance will let you.

Although a C-section or repeat C-section might be considered convenient for the doctor, or the patient, or both, a vaginal birth or VBAC is safer and less expensive for most women and their babies. The risks to the mother and baby with a C-section are notably higher than the risks for a VBAC.