“Once a cesarean, always a cesarean” is what was once told to women who have had cesarean births. Depending on who you talk with these days, we’ve noticed old protocols and practices die hard. Evidence and the American College of Obstetrics and Gynecologists (ACOG) support a vaginal birth after cesarean (VBAC), for women that have had one or two prior cesareans. There have been dozens of amazing birth stories from women that have had a vaginal birth after multiple cesareans (VBAMC) as well as women that have had a vaginal birth after a special scar (VBASS) though these circumstances are not usually addressed in the literature. We won’t go into the Myths behind VBAC, as Jen Kamel of VBAC Facts does an amazing job of tackling those on her site. Instead here are some of the risks and benefits of VBAC along with our local community resources to help to support and guide you on your VBAC journey.
There are risks associated with having a VBAC, but they do not necessarily outweigh the risk of a repeat cesarean section (RCS). The VBAC maternal mortality rate is .0038% and perinatal mortality is .013%. In an elective repeat cesarean birth, the maternal mortality rate is .0134% and perinatal mortality is .005%. We fear the term “Uterine Rupture”, but do we truly understand it? Statistics and evidence has shown this risk to be 0.5% chance, instead of the once stated 1-2% risk. There are also different types of uterine rupture ranging from a small "window" rupture of the uterus or at the site of a previous cesarean scar, all the way to what is most often cited- a "catastrophic" uterine rupture in which the uterus fully ruptures, expelling the baby into the pelvic cavity. Obviously, one type of rupture may not cause that much of an issue, where another can be life threatening for both baby and mother. That 39% chance of uterine rupture your friend, mother-in-law or even doctor told you about… was based on fear and a lack of education regarding the real risks based on scientific data and of course, we tend to fear what we don’t know. According to one study, 45% of women are interested in a VBAC, though 57% cannot find a supportive provider. Overall, 92% of women are opting for a RCS.
Complete or catastrophic uterine rupture has an associated risk of .5% to 1%. This form of rupture can lead to severe internal hemorrhage of the mother, possible hysterectomy, and death or serious injury to the baby. Warning signs of a complete uterine rupture include decreasing fetal heart tones that do not improve with maternal position change, maternal vitals become unstable, the mother may report extreme pain along the incision line or vaginal bleeding, palpating baby outside of the womb, softening of the uterus, baby’s head moving back up the birth canal, and interruption of contractions. Having a skilled provider that not only knows the warning signs, but listens to a mother’s intuition can aid in the diagnosis and immediate transport, if at home to the hospital, or in the hospital to the OR, in a timely manner.
Uterine dehiscence, or “incomplete uterine rupture”, “uterine window” also carries the same risk percentage as a complete uterine rupture, but may not carry any signs or symptoms or require any additional care as it’s not a full separation of the uterine muscle. There is also the possibility that a placenta may be retained, or a mother develops increta, percreta, or acreta, where the placenta grows over or in the scar tissue and uterine wall. In ANY given birth, there is a 3% chance of placental abruption, but some believe this only happens to women that have had cesareans even though that is not what is supported by research. The risk of uterine rupture is not significantly increased beyond the estimated due date but does increase with an augmentation of labor. So that “supportive” provider that won’t “let” you go past 41 weeks is not practicing evidence based care.
Then there is the current debate on single vs double layer suture. There have not been enough studies done on this topic to say whether one is more successful in a VBAC or if one leads to a higher risk of uterine rupture. While a double layer seems to be the favorable stitching measure, I would prefer the attending surgeon to do the suture they have always done, instead of trying a method they have very little (to no) experience with.
Having a VBAC not only reduces these risks with each subsequent birth, but you’ve avoided major abdominal surgery and lowered your chance of maternal morbidity or mortality. Many women also report they have a faster and easier recovery, increased bonding with baby, and often experience an emotional healing from previous birth-related trauma. For baby, they not only get to choose their own birthday, but they receive gut flora colonization, stronger immunity, and the benefits of a normal, biological birth that can increase bonding and breastfeeding success.
Women that choose a RCS, whether it be for personal fear, a misunderstanding of the true risks, lack of a supportive provider or family, or other influences are exposing themselves and their babies to more, often unnecessary risk. Many RCS are scheduled at 39 weeks, some OB’s may agree to a later date, but in our area at least, it’s not typical. They want to get you in before possible labor starts and be home for dinner (ok, maybe some of them want to get to golf or other engagements- then again some genuinely think they are just doing you a favor!) How can this affect baby? Women have a 5 week window of "term" gestation. This means "due dates" are not an exact science- dating can be off and yes, so could those ultrasounds. Not to mention, eve if you know when you ovulated, implantation can occur a week or more after conception. So that 39 week planned cesarean in a low risk woman could actually be only 35-37 week gestational age for baby and could cause what we in the healthcare field call iatrogenic (aka "doctor caused") prematurity. This means possible health issues or a NICU stay for a battery of issues- mostly under developed lungs. If a cesarean birth is a necessary option, which in some cases it absolutely is, it’s best to try to wait until labor starts spontaneously. If you walk into a hospital needing a cesarean for issues like placenta previa, they aren’t going to turn you away because you didn’t schedule your cesarean ahead of time like a “good patient”. But you do give your baby the option of choosing their own birthday- a sign that they are ready to be on the outside. Ready to use their own lungs, regulate their own temperature and heart rate, and breastfeed well.
Other risks associated with a RCS, or even a cesarean birth after cesarean (CBAC), termed this way after a trial of labor after cesarean (TOLAC), include an increased maternal mortality rate, hysterectomy, hemorrhage, & transfusions and increase with each additional cesarean. For subsequent pregnancies’ after one prior cesarean, your risk for placenta accreta is.31%, or 1 in 323 or after two prior cesareans it increases to .57%, or 1 in 175. Placenta previa increases to 1.3% in a primary cesarean, or 1/14% in an additional cesarean. If previa is present, the risk of accreta jumps to 11% with a primary cesarean or 40% after two or more cesareans.
The benefits of a RCS include a lower risk of perinatal death, lower risk of uterine rupture, ease of planning, option of delivery at any hospital, possible less retraumatization for survivors of sexual/emotional abuse, no battle with finding a provider if there is not one local or you are not comfortable with a homebirth midwife.
Finding support can sometimes be the biggest challenge in your VBAC journey. In our community we are lucky to have a few providers that are VBAC friendly and supportive. It’s important to know that you have rights and no one can force a cesarean on you. If you notice that your provider is baiting and switching you, there are still options to switch care providers! We joke that it is never too late unless you're pushing! A supportive provider is someone that truly believes in VBAC, not with time limits or scheduling cesareans at your 38 week appointment. Hiring a doula that is experienced with VBAC is important, this will be your person that you can confide in and discuss fears and hopes for your upcoming birth as well as count on to be your best-birthy-friend throughout your pregnancy, birth and postpartum period. It’s important to have someone, if not your entire team, that understands what it means to have had a cesarean and the feelings that are associated it with.
An amazing resource that can help locally is the International Cesarean Awareness Network (ICAN) chapter where you can get involved online and in the community with support meetings. Having a community of women and families that have been in similar situations, having had a VBAC, planning a VBAC, or RCS are right alongside you in their journey and can give you more confidence in down your own path! Knowing you are not alone, hearing others experiences, and knowing your options can be extremely empowering.
The Tampa Bay Birth Network hosts childbirth options seminars as well as many other events throughout the year to bring community awareness to issues surrounding childbearing families and has an entire directory for local birth professionals. Meeting birth professionals at these events can help to get a feel for who is out there in the community, but do not use it as a substitute to having multiple interviews with providers and doulas.
If you have had a special scar, which is any scar aside from the low transverse, your options may be slightly more limited but not impossible. ICAN’s list of VBAC friendly providers includes Special Scar Friendly providers, consider also getting involved with Special Scars – Special Women which is a great way to meet a very unique community and receive support.
We have a few providers who truly support VBAC mamas here in the Tampa Bay area. Of course, we offer home birth services to women who are good candidates for out of hospital births, as well as comprehensive prenatal care for women who would prefer to deliver in the hospital with an experienced doula. There are also other home birth midwives with varying levels of comfort with VBAC. Unfortunately, it is currently illegal for women to receive any prenatal care or birth in any of our local birth centers according to Florida Law. There are a few obstetric practices that provide women with a possible trial of labor locally, most notably The USF Group at Tampa General Hospital. There are other providers you can check out here- but be sure to do some digging before you make your final decision!
It’s your body ladies! Birth your babies! Use your vagina- it is yours after all!
Melissa Goodnow is a mother, doula, co-leader for the International Cesarean Awareness Network (ICAN) of Tampa, and birth advocate. Her passion for natural birth, woman empowerment and belief in a woman’s ability to give birth while understanding that birth is unpredictable was ignited after her planned birth center water birth became a transfer cesarean birth. Through her healing journey, she has found that helping other moms-to-be receive the resources and support to make their own informed choices has been beyond rewarding. Melissa is honored and excited to join the journeys of women and their families as they embark on their paths into parenthood.