The decision to attempt a vaginal birth after cesarean (VBAC) was never one I thought I’d have to make. Having worked as Women’s Health Nurse Practitioner and doula for several years prior to beginning my own motherhood journey, I was well informed about the various birthing options. When I found out I was pregnant with my now 16-month-old son, I opted for a homebirth with a Certified Professional Midwife. Although I felt well prepared, one of the greatest lessons from my experience is that while you can take steps to ready your body and mind, birth itself is not something you can control. You can read more about our birth story here, but long story short, my son was born via cesarean and was in the NICU for the first 5 days of his life.
In some scenarios a c-section is a very necessary and potentially live saving intervention for either mom, baby, or both. However, while the World Health organization (WHO) recommends a cesarean birth rate of no more than 15%, in the United States the rate is greater than 30%. Here in Tennessee the rate is nearly 34%, and we have just an 11.43% VBAC rate. Although I didn’t have the birth I’d hoped for, I can honestly say every intervention my son and I underwent was medically necessary, which is unfortunately not always the case. In fact, many c-sections result from “failed” inductions, which are often done without any true medical indication.
For many women, the choice to try for a VBAC can be daunting. Despite the latest recommendations from ACOG (The American Congress of Obstetricians and Gynecologists, a professional organization) which state “attempting a VBAC is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans” many providers are still reluctant to offer them. The challenge then becomes finding a provider and a facility that is willing to support a trial of labor after cesarean (TOLAC).
The ACOG practice guidelines also state:
“Restrictive VBAC policies should not be used to force a woman to undergo a repeat cesarean delivery against her will” and “if, during prenatal care, a physician is uncomfortable with a patient’s desire to undergo VBAC, it is appropriate to refer her to another physician or center.”
The argument against VBACs is the potential risk of a uterine rupture at the site of the previous cesarean scar. However, according to ACOG this occurs in just 0.7%-0.9% of cases. It should be noted that if rupture does occur, it is a medical emergency, but I find it unfortunate that so many providers would prefer to subject women to the risks of repeat surgery rather than allow them to attempt a vaginal delivery.
So let’s review some of risks of a repeat cesarean: for one, it is a major abdominal surgery with a greater likelihood of hemorrhage and infection than a vaginal delivery, and these risks increase with subsequent births. If a woman plans future pregnancies, her risk of bowel and bladder injury and abnormal placental conditions increases with each surgical delivery (ACOG, 2010).
I don’t intend to imply that TOLACs are without risks, and in fact most maternal injury occurs when a repeat cesarean becomes necessary after failed TOLAC, but a vaginal delivery regardless of c-section history is safest (in most cases) for both mom and baby.
After my son was born I knew almost immediately that I wanted to attempt a VBAC with my next baby, I just didn’t realize it would be quite so soon. At 9 months postpartum, finding out I was pregnant was overwhelming to say the least. I wasn’t sure where I wanted to birth, but after consulting with my midwife and several trusted providers, I again felt a homebirth was the right decision for us. I realize there are many who don’t agree with this decision but having fully considered the potential risks and benefits, and assembling a highly capable birth team, I feel confident in my decision. For me it comes down to the fact that I want to be able to move freely and labor without excessive monitoring. With my first birth I dilated to 9cm before any intervention became necessary, and from that experience I know that being in the water really helped me cope with the pain. In the hospital setting, women who are attempting a TOLAC are typically not able to get in the water because most facilities require continuous monitoring. Additionally, I want to be able to eat and drink without restriction (another “no-no” in the hospital setting) and be in a place where I feel most safe and secure.
Today, at 30 weeks, I had an appointment with a midwife friend who is collaborating with my primary midwife (told ya I have an awesome team!) She too had a cesarean with her first baby and has since had two successful VBACs at home. Her encouragement and support has been invaluable, and today she recommended that I spend some time doing a “fear releasing” practice to mentally prepare for this birth. With just a couple months left in this pregnancy I can definitely feel some anxiety building, especially after going into my first birth with so much confidence. I want to let go of my previous experience and approach this one with a beginner’s mind. I truly believe any woman preparing for birth (especially a VBAC) will greatly benefit from a mindfulness practice.
When considering a VBAC it is essential for women to discuss their personal history and risk factors with their provider so they can make the most informed choice. Additionally I would encourage any woman who does not feel at peace with her providers’ recommendations to seek a second opinion. Mamas, this is your birth experience and I encourage you to base your decision to try for a VBAC on facts rather than fears.
Women’s health Nurse Practitioner