Great Tips to Increase a Successful VBAC

The greatest social changes usually begin at the grassroots and works its way up. Based on growing dissent regarding limited options for VBACS, a panel of the National Institute of Child Health Development (NICHD) met in March of this year to determine why VBACs were declining. Between 2006 and 2008, 20% of obstetricians stopped offering VBAC as an option. In 2006, the numbers were even higher at a rate of 26%. The NICHD panel concluded that a trial of labor is a reasonable option for many women with a prior cesarean delivery (see “Vaginal Birth After Cesarean: New Insights”). So, why all the fuss and resistance? Because there is a small risk of uterine rupture (less than 1%) and most hospitals require a physician to be in the hospital to manage a laboring VBAC patient. Dr. George Macones was interviewed in a recent ob-gyn newspaper and I’d like to share some of his observations and comments. Macones is a maternal fetal medicine specialist and the ob-gyn chair at Washington University in St. Louis.

According to Macones, there are no scientific models that can predict who will succeed and who will fail a trial of labor after cesarean section but he did offer these helpful insights:

  1. A VBAC candidate who has had a previous vaginal delivery has an 89% success rate for a VBAC and fewer complications as opposed to a woman who has never had a vaginal delivery. It is therefore not appropriate to ask  women who’ve had successful vaginal deliveries to have repeat c. sections based on “hospital policy.”
  2. Women who have spontaneous labors have more successful VBACs than women who are induced in labor.
  3. Doses of oxytocin or Pitocin greater than 20 mu/min increase the risk of uterine rupture
  4. Intrauterine pressure catheters do NOT accurately predict uterine rupture and should not be used for that purpose.
  5. VBAC candidates who need more than one medication to induce labor are at an increased risk of uterine rupture
  6. If a VBAC candidate has an epidural and still feels significant pain or needs frequent doses of the epidural anesthetic, there is a significant risk that there might be a uterine rupture.

Performing repeat c. sections in women who have had previous vaginal deliveries is morally wrong. Patient safety should always take precedence over physician convenience.

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32 thoughts on “Great Tips to Increase a Successful VBAC

  1. Pingback: Tweets that mention Great Tips to Increase a Successful VBAC « Dr. Linda Burke-Galloway --

  2. Thanks for the topic. The best way to prepare for a vbac is educated yourself. When planning my first vbac, I interviewed SIX ob’s before I found one that was up to date on the vbac research. One doctor told me I had a 4% chance of having a ur (not true in any study w/ low transverse incision). Another doctor told me I could never vbac a big baby (I did vbac a posterior 9lb4oz baby). Another doctor told me I had to progress one cm every hour or it was straight to the or bc of rur (when asked for a study, bc truly I love my baby more than she does and wanted to prevent a ur more than she did) It did end up that I arrived at the hospital at 9 cm and didn’t get to 10 for 4 more hours …I could go on. It is truly shocking how little ob’s are up to date on vbac literature. No wonder they push a rcs. By now, I’ve read thousands of vbac and cs stories. What doctors do to moms is criminal.
    I got involved w/ ICAN, the international Cesarean awareness network that works to improve maternal/fetal health through education. To any pregnant mom out there, find an ican chapter meeting and learn as much as you can! It was amazing what I learned.

    • i had an aweful experience with my son, i had my water broken at 8am progressed and was a 7 at 5pm. my doctor was not on call and wanted to deliver the baby so she pushed a c-section on me. i went from 8-5 with no epidural and then had my little one via c-section at 7:04. i did not see my doctor again until the day i left the hospital. SHE wanted to go home!!! i did not need a c-section so i am very upset!!!!

  3. Pingback: Vaginal Birth After Cesarean New Guidelines

  4. I’m very glad I found your blog, and am reading through all the older posts. I am currently pregnant with my second child, and with my first child it was “very strongly recommended” to me by my OB that I have a primary elective CS simply because my son was measuring large on 3rd trimester in-office US. He was perfectly positioned and I went into labor spontaneously, but was taken to the OR. I have found a different OB and am planning a TOL with this baby, and hoping for successful VBAC. However, I am a pediatrician at an academic medical center and as such my patients are primarily children with severe medical problems, including profound developmental delays, neurologic conditions, etc. Of course only a small percentage of these cases have birth-related trauma as the etiology of their neuro status, but it is still very sobering to see these cases daily. As such I am really trying to gain insights from other OBs as well, and I appreciate your input. I have read the entire NIH report and while I appreciate the data, it is entirely retrospective (which makes sense, as a prospective RCT could never be done…imagine randomizing women to CS vs VBAC). The truth is that I am scared to death either way…but reading the story of Abbie Dorn in the paper this morning reminded me that CS isn’t without risks either. Sorry for being long-winded…I appreciate your blog and will continue to read throughout my pregnancy.

    • Beth, thanks so much for your comments. Quite honestly, the reason you probably had the first c/section was because you’re a physician and your OB wasn’t going to risk any mishaps with your first child/pregnancy. It would be helpful to know the weight of the first baby to determine whether you’re a successful candidate for a VBAC. As long as you’re in an institution where an OR is readily available should you need to have a c/s, you should be fine. If you’re being induced, the L&D nurses should follow strict protocol regarding the use of Cervidil and not give you more than the prescribed dose. Of course, the baby should be monitored and you should have pain relief including a possible epidural. Your physician should be no more than 15 minutes from the hospital. I encourage you to read my book, The Smart Mother’s Guide to a Better Pregnancy for more tips but I think you’ll be fine. I’m on Facebook so you can always contact me should you need additional information.

      May you have a healthy and blessed delivery.

  5. i am 28 weeks pregnant and am absolutely sure that i want to have a vbac. I have not disscussed any birthing plans with my doctor previously because he said its too early. I am scared i dont want to be preasured in to a repeat cs. I would also want more tips on what i can do to help increase my chances of a vbac.

  6. I had a C-section nearly 8 months ago with my first baby. My doctor wasn’t very clear as to why a C-section was necessary but all I know is during a whole 36 hours of induced labor I only dialated to 5 cm. My C-section was and is one of the biggest reasons for my PPD. I felt like I failed as a women. I’m hoping in the future I will be able to have a successful VBAC.

    • Hi Ashley. Thanks for your comments. Please don’t feel like you’re a failure because you had a c. section. It seems like you had an arrest of labor which means the cervix dilated to 5 cm and could not dilate further. I’m assuming you had a healthy baby. That’s what’s important. I used to think I was failure because I had infertility and then God blessed me with two awesome sons through the gift of adoption. I now realize I’m no less of a woman than someone who had a biological child. You might be able to have a VBAC in the future but whether you do or you don’t . . . you’re still a mom. Thanks for sharing.

  7. Glad I found this…I had a c-section with my first due to breech position and cord around the neck. I really struggled with the decision of a repeat c-section or a VBAC with my second. I chose VBAC and it was the most rewarding experience of my life. I wish more doctors would encourage this route. Our bodies are made for this. If you want to read my story you can see it here on my blog.

  8. “Performing repeat c. sections in women who have had previous vaginal deliveries is morally wrong.”

    I love this. I had a c-section with my third, and ended up with a classical incision. But given my previous history if uncomplicated vaginal births, I knew I could VBAC. I searched far and wide and found a supportive team, and had a wonderful VBAC, despite my classical scar.

  9. Just now reading this i too have dealt with a lot regarding my c-section idk if it was my bodys failure or the dr.’s failure to wait. I know a lot of ob/gyns have families to but sometimes they forget that its their job and what they signed up for but all i know is she said my cervix was swelling and the swelling stayed the same which i wasnt sure if i could deliever or not im hoping to get a better dr. next time but thanks for the article, It offers me comfort and hopefully when we get ready for our next child we can have a vbac or at least if theres a rcs then maybe theyll let me see the baby come out :) thanks again for the article

  10. I am 28 weeks and asked my dr about trying vbac or letting me labor for a while because i have a deep desire to try a vbac. My first pregnancy the baby was in distress and his heart rate was dropping with each contraction and i hadn’t even made it to 1cm. With my son, we had gotten into a minor fender bender 3 weeks before he was born, never try to drive to the hospital on a snowy icy day and go down a hill, anyway, i was put on a fetal monitor but given no ultrasound. so 3 weeks later i started having very slight cramping which my grandmother said was contractions, i didn’t belive her because they did not hurt. i was 37 weeks and 1 day. i got really sick that night and my husband took me to the hospital where they said i was indeed having contractions and was dehydrated from being so sick. shortly after, they took me in for an emergency c section and said the placenta was calcified in spots and the cord broke without being cut.. Not sure why… no tests were run. Anyway, we waited a few years and got pregnant again, miscarried immediately. waited one cycle conceived again, miscarried immediately again. didn’t wait the required 2 cycles and conceived again, now i’m 28 weeks pregnant with an extremely healthy baby and an easy pregnancy so far. I have a bikini line c section scar but no way of knowing what type of incision was used on the inside but i know i desperately want to try vbac. Any comments? My dr has said to prepare emotionally for another csection but if my body starts laboring on its own, we’ll see..

    • Hi Jo-el,
      Thanks for your comment. You can find out what type of uterine incision you have by requesting the operative reports from your previous c/s. This can be obtained from the medical records department at the hospital(s) where your children were born. You then need to discuss the reports with your doctor. If the uterus is transverse (meaning it goes in a straight line) rather than vertical (up and down), you might be a candidate for a VBAC however, there are several conditions that must be met. Your hospital would have to approve them. Believe it or not, some labor rooms don’t allow them. You would need to have am ultrasound to determine the weight of the baby. If it’s greater than 10 pounds, you wouldn’t be allowed to have a VBAC.

      Understand that you’ve had 2 previous c/s so again, you should speak with your doctor. If you’re doctor says not, ask him or her to explain the reason(s) in terms that you can understand.

      Keep in touch and let me know how things turn out.

      • I have only have one previous c/s. Would I need to possibly research hospitals in my area to find out if any of them are equipped to handle vbac? I’ve been pregnant a total now of 4 times. The first one resulted in an emergency c/s. The second 2 were miscarriages that ended naturally and this is the 4th pregnancy with no complications.

      • Yes, if you can. Make sure that they are in your insurance company’s plan if possible. Most hospitals require that a physician be present while you’re in labor if you want a VBAC. Check to see if this is a requirement and then ask your physician if he or she would be willing to do that. The best of luck to you.

  11. I have enjoyed your article, thank you very much for posting. I am currently 27 weeks pregnant with my second child. My first child was “too big” at a 38 week ultrasound and I was induced at 39 weeks pregnant for fear that he would be over 9lb. Myself and my mother were both 8lb 12oz babies and vaginal birth was not an issue in either case but the doctor was concerned. Since my mother was induced at 41 weeks, and delivered fine, I allowed the OB to induce me. After 7 hours of agonizing full blown pitocin labor, an epidural at a fingertip dilation, and stalling out at 2cm, I delivered via cs, a 8lb 4oz baby boy. I have found that in order to prepare myself for this birth, that I have to know that I can and I will VBAC. My body is made for this. CS was the reason I had PPD and why I am dealing with depression during my pregnancy now. I have found a very supportive midwife in my state who will deliver a VBAC baby in the hospital setting and has even pushed my due date out 6 days from the original date to give me more time to go into spontaneous labor. She has given me reading material as well as coached me on my diet. I would love to have a home water birth but the state I live in (Alabama) does not allow home delivery except in the event of an emergency.

    • Hi Amanda,
      Thanks for your comment. I’m not sure what you mean by your midwife “pushing your due date back” but be very careful of changing due dates. The most reliable dating occurs with a 1st trimester ultrasound, something known as the “crown-rump length.” Accurate dating based on early ultrasound is the only reason your due date should change. Also ask your midwife about doing kick counts and getting another ultrasound during the late last 3rd trimester to make sure there’s enough fluid around the baby and that the placenta is not too old. Best wishes for a safe and healthy delivery.

      • That is exactly the reason it was moved back. I know my ovulation date and my lmp date but due to 1st trimester ultrasound (13 weeks) they moved the date 6 days. Ice been advised by several midwives including my own not to have a 3rd trimester ultrasound because that was the reason i ended up induced with my soon a week early… The ultrasound tech overestimated the weight. My friend who is an l&d charge nurse says the ultrasound can be off by up to 2lbs that late in pregnancy

      • Hi Amanda,
        The thing I was always concerned about with my patients was decreased fluid or potential problems of the baby not seen in an early ultrasound. I have reviewed several malpractice cases where, had a third trimester u/s been done, the problem would have been detected early. To be forewarned is to be forearmed. If the fluid is low (less than 5 centimeters), the baby has to be delivered because it’s umbilical cord will be squeezed, cutting off oxygen to the baby during labor. No one should wheel you into an operating room to do a c/s because of the weight detected on an ultrasound alone. There has to be other criteria. The ultimate choice regarding c/s is always yours, as is getting an ultrasound.

  12. Hello Dr. Burke-Galloway,
    I just came across your blog and all of the questions/responses above and they have been so helpful. I am currently 29 weeks pregnant and planning on going for VBAC. I found a midwife practice this time and they are very supportive of me going for VBAC; they also work in partnership with OBs who are supportive of VBAC too, all working out of the same hospital.
    The reason for my first CS was that I was induced 10 days past due date (date chosen by my OB at the time, I didn’t fight it). Was given prostaglandin gel, my body overreacted immediately and I went into intense labor – irregular contractions and severe pain. I was in labor for 4 hours total and still only ended up 1 cm dilated. By that point, my son’s heartbeat started falling and he was in distress, plus my BP shot up. They wheeled me into the OR for an emergency CS.
    Based on the research I’ve been doing, I am a decent candidate for VBAC but maybe not the best because of my reasons for having the CS – fetal distress, basically no dilation, etc. My midwife says that those same issues may or may not present themselves again, but the chances that they might have me worried. As does the chance of me having a uterine rupture. My scar by the way is a low transverse.
    I appreciate any feedback you may have or what insight you have on women going for VBAC depending on the circumstances that dictated the previous CS.
    Thank you so much for this blog and your advice, extremely helpful and supportive information!
    – Jennifer

    • Hi Jennifer,
      Thanks so much for your great question. It would be helpful to know how much your baby weighed and how tall you are. From your description, you sound like a good candidate for a VBAC but short women and women with big babies might have an increased risk of requiring a c/s. The fact that you have midwives who are backed up by obstetricians who support VBAC is a profound benefit. You now have a team. I recommend that patients under the care of a midwife meet the back-up OB to establish a relationship and to get a sense of the OB’s philosophy. Is everyone on the same page regarding expectations of your delivery?

      Hopefully, you’ll go into to labor on your own without the need for an induction. I always tell patients that each pregnancy is different: same uterus but different baby. Not having pain is a great benefit. If the patient has pain, the body can’t relax nor can the cervix dilate. Don’t be afraid to ask for pain meds and discuss this with your midwife. The risk of uterine rupture is approximately 1% and it occurs under very specific conditions. My philosophy is that “whatever you think about expands.” Therefore focus on this beautiful baby that you’re carrying and even when there was a problem with your first pregnancy, everything turned out well. From what you’ve described, you’re in very capable hands. I hope this helps. I encourage you to please “like” my Facebook page and read the Chapters 12 and 13 (Preparing for the Hospital and Labor Room Problems) in The Smart Mother’s Guide. You’ll find them very helpful.

      Best of luck with your VBAC.

      • Thank you so much for your prompt reply! Well, I am 5’6″ and my son weighed only 6 lb 10 oz, even after being 10 days overdue. So very small in my opinion. So far the midwives say I am measuring okay, so I guess that means that the baby isn’t too big, at least not at this point.
        I will ask about meeting the back-up OB and make sure that we are all on the same page in terms of expectations.
        Another thing that I have to do is choose a “just-in-case” CS date, in case I do not go into labor naturally. They will not induce for anyone who’s already had a CS, which is fine by me because my induction was so awful last time that I swore I’d never do it again. They will let me go up to 42 weeks, however the most I am comfortable with is maximum 41. From what I read, the further you get past your due date, the chances go down for having a successful VBAC. I am not sure how accurate that is. And also, as in your previous replies to others, I would worry about the amniotic fluid and the baby size if I waited too long.

      • Your height and baby’s weight certainly don’t suggest anything that would prevent a VBAC but again, I’m not providing “official” medical advice. I commend you for not going beyond 41 weeks and after 40 weeks, I would request a biophysical profile (BPP) to document fetal well being. The ultrasound performed as part of the BPP would not be used to determine an estimated fetal weight but to measure the fluid. Late ultrasounds are not accurate for dating and have statistical variation in terms of estimating weight so don’t think that having an ultrasound increases your risk for a repeat C. Section. I commend you for being an informed patient and thank you for “liking” my FB page. Please keep in touch and let me know how things go.

  13. I’m so happy to find some kind of information that talks about women that have previously had vaginal deliveries before a Cesarean. I’ve had two uncomplicated vaginal births (9lbs11oz after a 50 hour labour and 8lbs3oz after an 8 hour labour), and am currently 34 weeks with di/di breech twins. Given the health risks involved with delivering breech twins (and assuming baby A doesn’t flip between now and 37 weeks) I’ll be having a Cesarean. I can’t seem to find any information ANYWHERE about what I should be discussing with my doctor about another pregnancy/VBAC after this pregnancy – everything is directed for people having a Cesarean with their first labour/delivery! Thank you for this informative post!

  14. the only reason for my 1st c section was my son was measuring 10lbs 9 oz on the growth sonogram at 40 weeks. my son was 9lbs 10oz 21 inches and i am 5’7 i went into labor on my own , i was 100 % effaced and dilated to 4cm .. i assume i am a good candidate for a vbac ..unless the new baby is measuring 10 plus pounds as well? is it very likely to have another big baby ?

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