Contents cc Nicette Jukelevics | 2022 | Attribution-NonCommercial-NoDerivatives 4.
0 International | VBAC Education Project
MODULE 2
VBAC: The Benefits and Risks
for Mothers and Babies
Making an Informed Decision
If you have given birth by cesarean in the past and are
pregnant, or plan a pregnancy, you have important
decisions to make.
Giving birth is a highly personal, spiritual, and important
cultural event in a family’s life. Birthing families have
the right to choose how, where, and with whom they
want to give birth.
Evaluating the benefits and risks of having a
repeat cesarean or laboring for a VBAC is a
highly personal decision.
What You Should Expect from
Your Caregivers
Current ethical guidelines in maternity care recommend that your care
providers give evidence-based information about your birth options early in
your pregnancy.
Your care provider should explain the benefits and risks of VBAC compared to
a routine repeat cesarean and then respect the informed decision you
ultimately make.
What Decision
Will You Make?
What Decision Will You Make?
The decisions you make should be based not only on medical
benefits and risks but also on your past birth experience,
personal values, and what you feel is best for your family.
Ultimately, your decision will also hinge on the maternity care
available and on the amount of community support for VBAC.
Three Possible Birth Outcomes
After a Prior Cesarean
A scheduled repeat cesarean at term without going through labor.
Labor and a VBAC.
Labor that may result in another cesarean.
What is a VBAC?
VBAC is a vaginal birth after a cesarean.
VBAC2C is a pregnant person who had a VBAC after two prior cesareans.
CBAC is someone who labored for a VBAC but had a cesarean.
HBAC is a home birth after a cesarean.
What is a TOLAC?
TOLAC is a trial of labor after a cesarean.
A “candidate” for a TOLAC is a pregnant person that can “safely” labor for a
VBAC.
Many mothers find the terms “TOLAC” and “candidate for a TOLAC”
negative and restrictive and not supportive and encouraging of pregnant
people who want to labor for a VBAC.
Evidence Supports VBAC
as a Safe, Lower-Risk
Birth Option than Routine
Repeat Cesareans.
Offering a VBAC as an
Option After a Prior
Cesarean is Best Practice.
Who Supports VBAC as A Safe Option
to a Routine Repeat Cesarean?
American College of Obstetricians and Gynecologists (ACOG)
Society of Obstetricians and Gynaecologists of Canada (SOGC)
Royal College of Obstetricians and Gynaecologist (RCOG)
American College of Nurse Midwives (ACNM)
American Association of Birth Centers (AABC)
Why is VBAC an Option to Consider?
Research shows that cesareans may do more harm than good for
healthy pregnant people and babies.
Mothers and babies experience these harms both in the short-
and long-term.
ACOG & SMFM. (2014, reaffirmed, 2016). Obstetric care
consensus No. 1: Safe prevention of the primary cesarean
section. Am J Obstet Gynecol, 210(3), 179–193. https://
[Link]/-/media/project/acog/acogorg/clinical/
files/obstetric-care-consensus/articles/2014/03/safe-
[Link]
Why is VBAC an Option to Consider?
Each additional cesarean puts mothers at increased risk
for operative complications including:
Post-operative blood transfusion.
Infections necessitating antibiotics.
Readmission to the hospital.
Rottenstreich, M., et al. (2018). Prolonged operative time
of repeat cesarean is a risk marker for post-operative
maternal complications. BMC Pregnancy and Childbirth
477. https://
[Link]/articles/
10.1186/s12884-018-2111-8
Compared to vaginal
birth, mothers 35 years of
age and over who have a
cesarean without labor
experience signi cantly
higher risks of intra- or
postpartum severe
complications.
Korb, D., et al. (2019). Risk of severe maternal morbidity
associated with cesarean delivery and the role of maternal age:
A population-based propensity score analysis. CMAJ, 191, E352–
60. [Link]
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What You Should Know About VBAC:
VBAC is a safe alternative to a routine repeat cesarean.
If you have a healthy pregnancy, a low horizontal scar on the uterus, and go
into labor on your own at term (39th to 40th week gestation), you have about
a 70−75 percent chance to have a safe, normal birth.
What you should know about VBAC:
About 70 Percent of Women who Labor
70% for a VBAC Avoid the Complications of
Repeat Cesareans.
If 100 Women Labor for a VBAC:
About 70 women avoid complications of surgery.
About 70 babies avoid complications of surgery.
About 70 babies avoid breathing problems from a scheduled
cesarean.
About 70 mothers and babies go home sooner.
70%
What You Should Know About VBAC:
Women who are cared for by midwives or who labor in a
birth center have a higher chance of a VBAC.
Women who have the support of a birth doula are at lower
risk for a cesarean section.
Goer, H. & Romano, A. (2012). Optimal care in
childbirth: The case for a physiologic approach.
Seattle, WA: Classic Day.
What does the American College of Obstetricians and
Gynaecologists (ACOG) Say About the Bene ts of VBAC?
“… the likelihood of achieving VBAC appears to
be similar for women with one previous cesarean
delivery and women with more than one
previous cesarean delivery. Given the overall
data, it is reasonable to consider women with
two previous low-transverse cesarean deliveries
to be candidates for TOLAC …”
American College of Obstetricians and Gynecologists.
(2017). Practice bulletin No. 184: Vaginal birth after
cesarean delivery. Obstetrics and Gynecology, 130(5),
e217–e233. [Link]
Fulltext/2017/11000/
Practice_Bulletin_No__184__Vaginal_Birth_After.[Link]
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What does the Society of Obstetricians and Gynaecologist
of Canada Say About the Bene ts of VBAC?
“Provided there are no contraindications, a trial
of labor after Caeserean should be offered to
all women with 1 previous low-segment
transverse Caeserean section after appropriate
discussion and documentation of maternal and
perinatal risks and benefits. The discussion
should be documented.”
Dy, J., DeMeester, S., Lipworth, H., & Barrett, J. (2019).
No. 382-Trial of labour after caesarean. Journal of
Obstetrics and Gynaecology Canada, 41(7), 992–1011. doi:
10.1016/[Link].2018.11.008
fi
What does the Royal College of Obstetricians
and Gynecologists Say About VBAC?
“Women with one or more previous vaginal
births should be informed that previous vaginal
delivery, particularly previous VBAC, is the
single best predictor of successful VBAC and is
associated with a planned VBAC success rate of
85–90%. Previous vaginal delivery is also
independently associated with a reduced risk of
uterine rupture.”
Royal College of Obstetricians and Gynaecologist. (2015).
Birth after previous caesarean birth: Green-top guideline
no. 45. [Link]
documents/guidelines/gtg_45.pdf
What are the Bene ts of VBAC for Mothers?
“VBAC is associated with decreased maternal
morbidity and a decreased risk of complications
in future pregnancies as well as a decrease in
the overall cesarean delivery rate at the
population level (1–3).”
American College of Obstetricians and Gynecologists.
(2017). Practice bulletin No. 184: Vaginal
birth after cesarean delivery. Obstetrics and Gynecology,
130(5), e217–e233.
[Link]
2017/11000/
Practice_Bulletin_No__184__Vaginal_Birth_After.[Link]
fi
What Are the Bene ts of VBAC, Compared to a
Planned Repeat Cesarean, for Pregnant People?
Avoiding the complications of major abdominal surgery.
Avoiding the risk for a uterine rupture in a future pregnancy.
Lower rates of thromboembolism (blood clots) and major infections.
American College of Obstetricians and Gynecologists. (2017).
Practice bulletin No. 184: Vaginal
birth after cesarean delivery. Obstetrics and Gynecology,
130(5), e217–e233. [Link]
Fulltext/2017/11000/
Practice_Bulletin_No__184__Vaginal_Birth_After.[Link]
fi
Mothers Are Less Likely to Experience
Hemorrhage Requiring a Hysterectomy
Risk for hysterectomy:
Mothers without a prior cesarean: 1/25,000
Mothers with one previous cesarean: 1/500
Mothers with three or more previous cesareans: 1/20
Sandall, J., et al. (2018). Short-term and long-term effects of caesarean section on
the health of women and children. The Lancet, 392(10155), 1349–1357. https://
[Link]/journals/lancet/article/PIIS0140-6736(18)31930-5/fulltext
What are the Bene ts of VBAC for Mothers
Compared to an Elective Repeat Cesarean?
Avoiding a cesarean lowers the risk for:
Blood transfusion.
Operative injuries.
Admission to an ICU (intensive care unit).
Adhesions (bands of scar tissue that can cause internal organs to stick
together when they are not supposed to be).
Sandall, J., et al. (2018). Short-term and long-term
effects of caesarean section on the health of women
and children. The Lancet, 392(10155), 1349–1357.
[Link]
article/PIIS0140-6736(18)31930-5/fulltext
fi
What are Adhesions?
Adhesions form during the healing process. They consist of fibrous scar
tissue that connects abnormally between internal organs.
Complications from postoperative adhesions are common with any
abdominal surgery. Adhesions can cause chronic pelvic pain, bowel
obstruction, and secondary infertility.
Repeat cesareans are complicated by adhesions. They increase the length
of the operation to birth the baby and heighten the risk of bladder injury.
Avoiding a Cesarean Lowers the Risk for
Adhesions in Future Cesareans:
Risk for Adhesions:
After a second cesarean 12–46%
After a third cesarean 26–75%
Sandall, J., et al. (2018). Short-term and long-term effects
of caesarean section on the health of women and children.
The Lancet, 392(10155), 1349–1357.
[Link]
PIIS0140-6736(18)31930-5/fulltext
With a VBAC Mothers Are Less Likely to:
Need postoperative assistance with breathing (intubation).
Experience cardiac arrest.
Suffer acute renal failure.
Return to the hospital because of complications.
Experience chronic pain.
Sandall, J., et al. (2018). Short-term and long-term effects
of caesarean section on the health of women and children.
The Lancet, 392(10155), 1349–1357.
[Link]
PIIS0140-6736(18)31930-5/fulltext
With a VBAC, Mothers Are at Lower Risk for
Problems with the Placenta, including:
Placenta increta (when the placenta attaches more firmly to the uterus
and becomes embedded in the muscle wall).
Placenta percreta (when the placenta grows through the uterine wall and
may merge into other abdominal organs).
Placenta accreta (placenta grows into the uterine wall).
American College of Obstetricians and Gynecologists. (2017).
Practice bulletin No. 184: Vaginal
birth after cesarean delivery. Obstetrics and Gynecology, 130(5),
e217–e233.
[Link]
Practice_Bulletin_No__184__Vaginal_Birth_After.[Link]
Problems with the
Placenta Increase the
Risk for Hemorrhage
and a Hysterectomy.
Fewer Mothers Die in Childbirth
When Women Labor for a VBAC.
Maternal Mortality Rate:
Per 100,000 who labor for a VBAC 1.6–3.8
Per 100,000 who have an elective repeat cesarean 5.6–13.4
Dy, J., DeMeester, S., Lipworth, H., &
Barrett, J. (2019). No. 382-Trial of labour
after caesarean. Journal of Obstetrics and
Gynaecology Canada, 41(7), 992–1011. doi:
10.1016/[Link].2018.11.008
What Are the Bene ts of VBAC In a
Future Pregnancy?
Pregnant people are less likely to:
Have fertility problems, pre-term birth, or a stillbirth.
Have a low-birth-weight baby.
Experience bleeding during pregnancy and birth due to placenta
problems.
Experience a uterine rupture.
Have a repeat cesarean.
American College of Obstetricians and Gynecologists.
(2017). Practice bulletin No. 184: Vaginal birth after
cesarean delivery. Obstetrics and Gynecology, 130(5),
e217–e233.
[Link]
PIIS0140-6736(18)31930-5/fulltext
fi
Are There Any
Disadvantages to
Laboring for a VBAC?
Disadvantages When Laboring for a VBAC:
You may need an episiotomy (a surgical procedure in the tissues
surrounding the vagina).
You may need an assisted vaginal birth with forceps or a vacuum.
You may experience a perineal tear in the muscle that controls the anus or
rectum (third- or fourth-degree tear).
Childbirth Connection. (n.d.) VBAC basics: Planning
ahead. National Partnership for Women & Families.
Retrieved from [Link]
giving-birth/vbac/planning-ahead/
Tears are usually minor—but some can
be serious and require a longer time
to heal.
This usually weakens the pelvic
floor muscles and causes urine
or feces leakage for some time
after birth.
Childbirth Connection. (2020). VBAC
basics. National Partnership for Women
& Families. Retrieved from
[Link]
giving-birth/vbac/basics/
Labor Practices Affect the Pelvic Floor.
The risk for a vaginal tear is increased with certain birth practices, including:
An episiotomy.
An epidural (which may limit freedom of movement for birth).
Applying fundal pressure to push the baby out.
The use of vacuum extraction or forceps.
Childbirth Connection. (2020). VBAC basics. National
Partnership for Women & Families. Retrieved from
[Link]
vbac/basics/
A Routine Repeat Cesarean Is Not
Protective of the Pelvic Floor.
Evidence shows that having a routine
repeat cesarean does not protect
against severe urinary stress
incontinence, urinary urge
incontinence, or anal incontinence over
the long run.
Childbirth Connection. (2020). VBAC
basics. National Partnership for Women &
Families. Retrieved from
[Link]
giving-birth/vbac/basics/
What Are the Disadvantages When
Laboring for a VBAC?
You may need another cesarean section during labor. The odds are 25 out
of 100 when laboring for a VBAC, compared to 20 in 100 when giving birth
for the first time.
The risk for complications from a cesarean performed in labor are higher
than complications from a planned repeat cesarean.
Royal College of Obstetricians and Gynaecologists. (2016).
Information for you: Birth options
after a caesarean section. [Link]
globalassets/documents/patients/patient-information-
leaflets/pregnancy/pi-birth-options-after-previous-
[Link]
What are the Disadvantages
When Laboring for a VBAC?
Although the risk is small, the chances of a uterine scar separating
is higher during labor than with an elective repeat cesarean:
With an elective repeat cesarean 0.26 per 1,000
When laboring for a VBAC 4.7 per 1,000
Dy, J., DeMeester, S., Lipworth, H., & Barrett, J. (2019).
No. 382-Trial of labour after caesarean. Journal of
Obstetrics and Gynaecology Canada, 41(7), 992–1011.
doi: 10.1016/[Link].2018.11.008
Are There Bene ts of
VBAC for Babies?
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Bene ts of VBAC for Babies:
Baby is exposed to beneficial vaginal organisms (which initiate immunities).
Contractions stimulate and prepare the baby for breathing outside the womb.
Baby is more likely to have skin-to-skin contact with its birthing parent.
Baby is more likely to breastfeed after birth and continue to do so during infancy.
Goer, H. & Romano, A. (2012). Optimal care in childbirth: The
case for a physiologic approach. Seattle, WA: Classic Day.
fi
Bene ts of Breastfeeding for Babies
Breastfeeding helps to protect babies from:
Ear and stomach infections.
Severe respiratory infections.
Dental malocclusions (misalignment).
Sudden infant death syndrome (SIDS).
Death from necrotizing enterocolitis (a life-threatening
intestinal infection).
Childhood leukemia.
Victora, C. G., et al. (2016). Breastfeeding in the 21st century:
Epidemiology, mechanisms, and lifelong effect. The Lancet, 387(10017),
475–490. [Link]
PIIS0140-6736(15)01024-7/fulltext
fi
“… a mother’s breastmilk transmits
elements of her own microbiome and
immune responses, and also provides
specific prebiotics to support growth
of beneficial bacteria.”
Victora, C. G., et al. (2016). Breastfeeding in the 21st century:
Epidemiology, mechanisms, and lifelong effect. The Lancet, 387(10017),
475–490. [Link]
PIIS0140-6736(15)01024-7/fulltext
Bene ts of Breastfeeding for Babies
Breastfeeding is associated with higher performance on
intelligence tests.
Children and adolescents who were breastfed are less likely to
become overweight or obese and less likely to develop Type 2
diabetes later in life.
World Health Organization. (2020, August 24). Infant and young
child feeding. Retrieved from [Link] room/
fact-sheets/detail/infant-and-young-child-feeding
fi
Bene ts of Breastfeeding for Mothers:
Breastfeeding helps to protect mothers against:
Breast cancer.
Ovarian and pre-menopausal breast cancer.
Type 2 diabetes.
Heart disease.
Victora, C. G., et al. (2016). Breastfeeding in the 21st century:
Epidemiology, mechanisms, and lifelong effect. The Lancet,
387(10017), 475–490. [Link]
lancet/article/PIIS0140-6736(15)01024-7/fulltext
Peters, S. A. E., Yang, L., Chen, Y., Chen, Z., Guo, Y., Bian, Z.,
Li, L., Du, J., Yang, J., Li, S., & Woodward, M. (2017).
Breastfeeding and the risk of maternal cardiovascular disease: A
prospective study of 300,000 Chinese women. Journal of the
American Heart Association, 6(6). [Link]
doi/10.1161/JAHA.117.006081
fi
What Are the Risks of VBAC for Babies
Compared to an Elective Repeat Cesarean?
Complications for babies are higher and usually related to the occurrence of a
uterine rupture.
Complications Laboring for a VBAC vs. Elective Repeat Cesarean
Risk of neonatal death 1.1 per 1,000 vs. 0.55 per 1,000
Risk of perinatal death 1.3 per 1,000 vs. 0.5 per 1,000
Risk of perinatal neurological injury 8 per 10,000 vs. 1 per 10,000
Dy, J., DeMeester, S., Lipworth, H., & Barrett, J. (2019). No. 382-Trial
of labour after caesarean. Journal of Obstetrics and Gynaecology
Canada, 41(7), 992–1011. doi: 10.1016/[Link].2018.11.008
Who Can Labor for a VBAC?
Evidence shows that most mothers who have had one or two previous
cesareans with a low-transverse uterine incision can plan a VBAC, including:
Mothers expected to give birth to a “big” baby (macrosomia).
Mothers whose pregnancy may extend beyond 40 weeks.
Mothers with a prior low-vertical uterine incision.
Mothers with an unknown type of prior uterine incision.
Mothers expecting twins.
Mothers with a high Body Mass Index (overweight).
American College of Obstetricians and Gynecologists. (2017). Practice
bulletin No. 184: Vaginal birth after cesarean delivery. Obstetrics and
Gynecology, 130(5), e217–e233. [Link]
greenjournal/Fulltext/2017/11000/
Practice_Bulletin_No__184__Vaginal_Birth_After.[Link]
What is the Body Mass Index?
Body mass index (BMI) is a measure of body fat based on
height and weight that is applied to adult men and women.
The value obtained from the BMI calculator indicates
whether a person is underweight, normal weight,
overweight, or obese.
The BMI index ranges from 19 to 54.
Pregnant People Who Have a Body Mass
Index (BMI) of 30 or More Can Plan a VBAC:
A high BMI is not an absolute contraindication to laboring
for a VBAC.
With a BMI between 18.5 and 24.9, the odds for having a
VBAC are 85 percent.
With a BMI of 40 or more, the odds are 61 percent.
A higher BMI puts mothers at increased risk for
complications when having a repeat cesarean.
Having a VBAC can reduce the potential for
complications of cesarean surgery.
American College of Obstetricians and Gynecologists. (2017). Practice
bulletin No. 184: Vaginal
birth after cesarean delivery. Obstetrics and Gynecology, 130(5),
e217–e233. [Link]
2017/11000/Practice_Bulletin_No__184__Vaginal_Birth_After.[Link]
Some Mothers with a Breech at
Term Can Labor for a VBAC.
Dy, J., DeMeester, S., Lipworth, H., & Barrett, J. (2019). No. 382-Trial of labour
after caesarean. Journal of Obstetrics and Gynaecology Canada, 41(7), 992–
1011. doi: 10.1016/[Link].2018.11.008
Contraindications for a VBAC:
Planning a VBAC is not considered safe for a mother who has had:
A prior uterine rupture.
A prior uterine surgery (myomectomy, hysterotomy).
A classical scar (high vertical uterine incision).
An inverted T scar in the upper part of the uterus.
American College of Obstetricians and Gynecologists. (2017). Practice
bulletin No. 184: Vaginal birth after cesarean delivery. Obstetrics and
Gynecology, 130(5), e217–e233. doi: 10.1097/AOG.0000000000002398
Planning a VBAC May Be Challenging.
But many mothers:
Feel empowered by having a VBAC.
Gain self-confidence in their ability to give birth.
Often heal from the trauma of a prior cesarean.
This is How Some
Mothers Have Felt after
Laboring for a VBAC
VBAC Success Stories
“We did it! Vbac! I had to fight pretty
hard at the end for it but we went into
spontaneous labour at 41 weeks, and
my little girl arrived without “It was honestly the most beautiful and
intervention … I ended up with this empowering thing I have ever done....
amazing midwife whose timing and And to add a bonus the consultant who
experience set me up for success …” cared for me over the weekend came in
to tell me afterwards that I had really
inspired him to assist other women
proactively who were wanting vbacs.”
VBAC Success Stories (Facebook Group), July 2021.
VBAC Success Stories
“I CAN’T BELIEVE I DID IT! So many
people who assumed I was going to have
a RCS we’re so doubtful and it was hard “I had an awesome supportive practice
to stay positive and overcome, but I of midwives and OBs behind me and an
stayed vigilant throughout my pregnancy, amazing team of VBAC supportive nurses
read and listened to everything vbac I once I got to the hospital. I am still in
could get my hands on.” shock and elated to have had this healing
birth after my traumatic csection.”
The VBAC Link Community (Facebook Group) August 2021.
If You Have Never Labored Before:
Your labor pattern will be similar to someone giving birth
for the first time.
Look for comprehensive information about what to
expect from labor and birth.
Learn the labor skills that will help you feel comfortable
and safe and help your labor progress.
Look for caregivers that are confident in your ability to
give birth and give you all the support you need.
Find encouragement and support in VBAC-support
groups.
Caregivers Differ About Who Can
Labor for a VBAC:
Some, advise mothers based on their own personal experience and comfort
level with VBAC—rather than on the evidence.
If you feel strongly about planning a VBAC, don’t get discouraged by the
first caregiver that tells you it’s not possible.
In your search for a caregiver, consider obstetricians, family physicians,
midwives, and DOs (doctors of osteopathic medicine).
From an Author and a VBAC Mom:
“On many occasions over a long period I dreamed
that I would one day be able to push my own baby
out into the world. Those three years of research
left me convinced that there is not just one
obstetric reality, but several, and that these
realities are not necessarily the ones we hear as
unavoidable solutions.”
“We women need to have our say because we are
the people most immediately affected by birth.”
Hélène Vadeboncoeur. (2011). Birthing normally after a
cesarean or two: A guide for pregnant women, exploring
reasons and practicalities for VBAC. Chester-le-Street,
England: Fresh Heart.
Key Points to Review:
VBAC is a reasonable option for women who do not
need or want a repeat cesarean.
The majority of women who labor for a VBAC
ultimately have a vaginal birth.
If you labor for a VBAC, it’s possible that you may
need a cesarean.
Having a VBAC helps mothers and babies avoid the
complications of surgery.
Having a VBAC helps mothers avoid complications in a
future pregnancy.
With a VBAC, babies are more likely to begin and
successfully continue to breastfeed.
Checklist for Parents:
What information do you have now that you did not already know?
What additional information would you like to have?
If you are pregnant, have you started talking with your caregiver about your
options?
Make a list of questions or concerns you would like to discuss with your
caregiver.
Look at the additional resources in this section and discuss them with your
partner and caregiver.
Resources
Thinking About VBAC: Birth Options After VBAC Basics
Deciding What Is Right a Cesarean
For Me