What are my options for birth after having a c-section?

Women who have given birth via cesarean section often ask, "Can I have a vaginal birth after my cesarean or should I have another c-section?"

Introduction to Birth Options after Cesarean

Elective Repeat Cesarean

Benefits of Elective Repeat Cesarean/Schedule Repeat C-section

Risks of Scheduled Repeat C-section

Vaginal birth After Cesarean (VBAC)

Benefits of TOLAC / VBAC

Risks of TOLAC / VBAC

CBAC: Cesarean Birth After Cesarean / Emergency Repeat C-section

Deciding between Scheduled Repeat Cesarean and Trial Of Labor After Cesarean/TOLAC/VBAC

Introduction to Birth Options After Cesarean

Birth after cesarean section has been controversial over the last few decades. Traditionally it was believed that if you gave birth via c-section you would always have to give birth via c-section. Eventually, doctors learned that vaginal birth after cesarean is a reasonable option, in fact, it might even be the preferred option.

In the 90s, VBAC rates began to rise but then as we started navigating the mid to late 2000s VBAC rates have been on the downturn. Many women are told that they cannot or should not attempt a VBAC birth by one doctor, and then told the opposite by another. It is crucial for women to be informed about their options so they can make the best decisions.

Today, I’m here to talk about your options regarding birth after cesarean. Before we dive into the options, I want you to know some important information. The World Health Organization estimates that only 10-15% of births worldwide should require a cesarean section. The organizations states that on a population level, cesarean rates higher than 15% are not associated with overall better birth outcomes. That means that in a country with high cesarean rates, we are not seeing more lives saved on an overall basis (this is not to say cesareans don’t save lives in some individual cases). So in a country like the United States, our 25% primary cesarean rate and 30% overall cesarean rate is evidence that many surgical births are done without medical necessity, or as a result of mismanaging birth.

More interestingly, the World Health Organization has a goal of 18% VBAC rates, and right now we’re hovering around 13%. In the United States, some regions are even lower than that. When I gave birth in South Carolina in 2017, I was informed their VBAC rate was only 8%. This was largely because many providers would not even entertain VBAC as an option.

Now that you understand this bit of background information, lets talk more about the decision you have to make: Whether or not you should have an elective repeat cesarean or vaginal birth after cesarean.

Elective Repeat Cesarean

Elective Repeat Cesarean is the decision to schedule a repeat cesarean after a previous cesarean birth. While there are many reasons why women choose this, based off the women I’ve met, I’d say the top two reasons women have a Repeat Cesarean instead of VBAC are:

1. They prefer the convenience of a planned birth and are afraid of the drama/trauma of another emergency cesarean. A repeat cesarean gives them more of a sense of control.

2. Their doctor does not give them another option, or scares them about the risks of a VBAC.

Benefits of Repeat Cesarean / Scheduled Repeat C-section

Beyond a perceived sense of control, are there any benefits to a repeat cesarean? Truth be told, this is the main benefit of ERCS. There is some evidence that suggests women who have ERCS have a lower risk of pelvic organ prolapse on the short term, and there may be a slightly lower risk of neonatal mortality rates. However it is very prudent to compare these benefits with risks of repeat cesarean.

Risks of Repeat Cesarean / C-section

• ERCS is associated with longer recovery

• Higher risk of infection

• Incereased risk of needing future cesarean

• Higher risk of maternal death when compared with successful VBAC

• Increased risk of pelvic adhesions

• Increased chance of respiratory complications in newborn

• Increased risk of hemmorhage

• Increased risk of placenta acretta in future pregnancies

• Increased risk of hysterectomy

Vaginal Birth After Cesarean

Generally speaking, vaginal birth has many benefits over cesarean. For instance, vaginal birth squeezes the baby which helps to expel amniotic fluid from their lungs, resulting in less likelihood of breathing issues. Another widely recognized benefit of vaginal birth is the colonization of the baby’s microbiome. Evidence is emerging quickly on how important our native bacteria is to our overall health including gut health, immune health, and even brain and mental health! This benefit can not be replaced or replicated with cesarean birth. Despite theories about “vaginal seeding”, there isn’t enough evidence to suggest it would replace the benefit of vaginal birth. Furthermore, there are benefits to the hormonal process for mom and baby that occurs when physiological birth is supported. While efforts can sometimes be made to replicate this during a cesarean section, the increased risks and circumstance surgical birth often interfere with this process. This can sometimes lead to challenges bonding and breastfeeding during postpartum.

Benefits of VBAC

Beyond the general benefits of vaginal birth, what are the benefits of VBAC compared to RCS?

• Successful VBAC is associated with lowest risk of Maternal Complications

• Lower risk of blood clots, hemmorhage, and infection

• Lower risk of sexual problems

• Lower risk of hysterectomy

Generally speaking, a successful VBAC is associated with LOWER risks when compared to planned repeat cesarean.

Risks of VBAC

Despite the benefits of VBAC, it would be irresponsible to avoid discussing the risks.

The major risk providers cite with VBAC is the increased risk of uterine rupture. Depending on the study, scientists estimate the risk of Uterine Rupture during VBAC is somewhere between 0.2% and 0.7%

Some data does suggest that VBAC when compared with RCS may be associated with a higher risk of poor neonatal outcomes, however, these rates are considered comparable with first time birth, meaning a VBAC birth is not considered more risky than any regular vaginal birth would be.

Additionally, "failed TOLAC" aka CBAC or emergency repeat cesarean, is associated with increased risks for mom and baby in comparison to scheduled repeat cesarean

What about CBAC? The risk of Emergency Repeat Cesarean / Failed TOLAC

The third alternative is referred to CBAC or Cesarean Birth After Cesarean Birth. This term is often used to refere to a TOLAC (trial of labor after cesarean) that results in a repeat cesarean instead of a vaginal birth. It is prudent to note that the risks associated with elective repeat cesarean do all slightly increase in the event of CBAC. This means that going into labor and then having a repeat cesarean could be the most risky approach to birth after cesarean, however it is important to note that there are many factors to take into consideration here such as reason for the emergency repeat cesarean. It is well documented that with a supportive and knowledgeable provider skilled in supporting Vaginal Birth After Cesarean, most TOLACs should end in a successful VBAC.

How to determine if you should plan a VBAC or ERCS

First, you need to connect with your intuition. What are your values and beliefs surrounding birth? What are your goals for this birth? Listing these out can help you determine which option you’d like to explore further.

Additionally you’ll want to consider if you’re a good candidate for VBAC. Things to consider would be the location of your previous cesarean scar, the reason for your previous cesarean, and your current overall health and pregnancy risk status. Some studies show that low risk women with a supportive provider have a 95% likelihood of achieving their VBAC.

Some doctors may refer to VBAC Calculators when determining risk level, however it should be noted that these calculators are notoriously wrong as they often take into consideration data that highlights bias over true risk.

If you have decided that VBAC is the right option for you, I am so excited to help you prepare. Check out this FREE VBAC CLASS to take the first step toward reaching your VBAC Goals!

Jaimie is a VBAC mother of four children, a Doula, and International Board Certified Lactation Consultant who teaches mothers how to approach their VBAC with a sense of unbreakable confidence by teaching them their options during VBAC and how to effectively advocate for their VBAC when their doctors are not supportive of their birth plan. Jaimie teaches online VBAC birth preparation courses and works privately with clients prenatally to strengthen their birth confidence. Jaimie also supports women through their breastfeeding journeys by teaching prenatal breastfeeding classes, offering private breastfeeding preparation, and postpartum lactation consulting both online and in person. Contact Jaimie Now for more information on how she can support you as you prepare for a VBAC birth and/or breastfeeding!