VBAC: Know the pros and cons

Many people who have given birth by C-section in an earlier pregnancy can try to have a vaginal birth after cesarean, also called VBAC. Trying to give birth in this way is referred to as a trial of labor after cesarean. You also might hear it called TOLAC.

The overall success rate for people in the U.S. who try to have a vaginal birth after one C-section is about 70%. The success rate is higher for some people, such as those who have given birth vaginally before. The success rate is lower for people with certain risk factors. For example, your chance of success is lower if you had a C-section in an earlier delivery because labor didn’t progress. That’s called labor dystocia.

The choice to try for a VBAC or to schedule another C-section can be hard. Here’s helpful information to know as you think about your options.

Why consider trying for a VBAC?

Compared with having another C-section, a vaginal delivery has a number of benefits, including:

• No surgery on the belly.
• Lower risk of infection and serious blood loss.
• Lower risk that a baby will have breathing problems after birth.
• A shorter hospital stay.
• A faster return to daily activities.

For people who plan to have more pregnancies, a VBAC might help avoid the risks that can come with more than one C-section. These risks include problems with the placenta growing too deeply into the wall of the uterus, a condition called placenta accreta, or scar tissue raising the likelihood of problems during a C-section.

What are the risks of attempting a VBAC?

A successful VBAC is linked with fewer health concerns than having another C-section. But an unsuccessful VBAC attempt is linked with more health concerns. They include the possibility of serious bleeding and uterine rupture. There’s also a higher risk of problems happening during a C-section that’s done after labor has started.

Uterine rupture is rare. It happens in less than 1% of people who try for a VBAC. But uterine rupture can be life-threatening to both the pregnant person and the baby. During a uterine rupture, the C-section scar on the uterus breaks open. An emergency C-section is needed to prevent serious health issues. Treatment might involve surgery to remove the uterus. That procedure is called a hysterectomy. If you have your uterus removed, you cannot get pregnant again.

Who can try to have a VBAC?

Whether someone can attempt a VBAC depends on many factors, including the following.

• Type of earlier C-section incision Most C-sections use a low sideways cut on the uterus, called a transverse incision. People who have had a low transverse incision typically can try to have a VBAC. But those who had a high vertical incision, also called a classical incision, typically cannot attempt a VBAC. That’s because a high vertical incision raises the risk of uterine rupture.
• History of uterine rupture People who have had a uterine rupture before typically cannot try to have a VBAC.
• Other surgery on the uterus Trying to have a VBAC often isn’t advised for people who have had other uterine surgeries, such as surgery to remove fibroids. The scars from those surgeries raise the risk of a uterine rupture.
• Other vaginal deliveries At least one vaginal delivery before or after an earlier C-section raises the chances of having a successful VBAC.
• The number of other C-sections Having two or more C-sections can raise the risk of some health concerns linked to attempting a VBAC. But depending on your health history, it may be possible to try for a VBAC in this situation.
• Pregnancy spacing The risk of uterine rupture is higher for people who try to have a VBAC less than 18 months after giving birth in an earlier pregnancy.
• Other health concerns A VBAC attempt may not be advised for people who have health concerns that could affect a vaginal delivery. Examples include:
  • Problems with the placenta.
  • The fetus being in a position that makes a vaginal delivery hard.
  • Carrying triplets or a higher number of multiples.
  • The need to have labor induced.
• Location of the delivery Attempts to have a VBAC need to be done at a hospital or other healthcare facility that can handle an emergency C-section. A home birth isn’t appropriate.

How does labor and delivery during a VBAC attempt differ from labor and delivery during other vaginal births?

When pregnant people who try to have a VBAC go into labor, they typically follow a process similar to that used for any vaginal delivery. But it’s likely the baby’s heart rate will be watched continuously throughout labor and delivery. The healthcare team also likely will be prepared to do a C-section if needed.

What else should a person thinking about VBAC know?

When considering trying to have a VBAC, it’s important to talk with a healthcare professional about it early in pregnancy. Discuss the risks and benefits, as well as your expectations and concerns. Make sure your healthcare team knows your complete medical history. That includes records of your earlier C-section and any other uterine surgeries. The information can help your healthcare professional guide you as you decide whether to attempt a vaginal delivery.

If you decide to try for a VBAC, it’s important to talk with your healthcare team about where you want to deliver and how that facility would handle an emergency C-section if you need one. Continue talking about the risks and benefits with your healthcare team throughout pregnancy.

And as your pregnancy goes forward, try to stay flexible. It’s possible that the way your labor happens will make trying a VBAC a clear choice. Or you and your care team might decide that another C-section would be best after all.