“I am contemplating having one more child [after two c-sections]. I have moved to Utah, where I know I can easily find a doula or birthing center that would support a vbac. After 2 though, I don’t really know all the risks. I have friends that say don’t try it, too dangerous. I’m not pregnant. I just want to have some dialogue about it. I want to know what’s possible.”
I received this in an email from a follower last week.
Her story is one of frustration and stuggle. VBA2C and VBAMC can be a confusing and very misunderstood topic.
What are the risks? How do I find a supportive provider? What are the FACTS?
Below I will share five things about VBA2C that you didn’t know that can help guide your journey!
P.S. Did you know, my business partner, Meagan, had a VBA2C? Her story is found here. Look at this picture of her and her VBA2C baby, aren’t they just gorgeous?!
1. Your chances of a successful VBA2C are similar to those of VBAC after just one cesarean.
On page four of ACOG Practice Bulletin 184, two large studies are referenced. These studies had sample sizes large enough to account for small variances that might influence the results.
It is significant for ACOG (American College of Obstetrics and Gynecology) to recognize studies like this as credible. In other words, the fact that they are even cited there is AWESOME! The results of those two studies, referenced in the bulletin, concluded that the success rates vary by 2% or less, depending on which study you look at.
2. ACOG recommends VBA2C as a safe option.
Speaking of ACOG… Since 2010 , their stance on VBA2C is that it is “…reasonable to consider women with two previous low-transverse cesarean deliveries to be candidates for TOLAC and to counsel them based on the combination of other factors that affect their probability of achieving a successful VBAC.”
More importantly to note is that there is no mention of a requirement to have had a prior vaginal delivery to be considered. If you are going for VBA2C, this bulletin is very important to have in your back pocket as you work with your provider to determine your care.
3. Choosing a repeat cesarean does NOT eliminate your chance of rupture.
We often only talk about uterine rupture during TOLAC (Trial of Labor After Cesarean, aka attempting VBAC), and by choosing elective repeat cesarean, you can eliminate any chance of uterine rupture.
Although focus is usually on uterine rupture during labor, it is possible for uterine ruptures to occur before labor begins. These types of uterine rupture are usually more devastating, and can cause serious health complications or worse in mother and baby.
It is NOT true that deciding against a VBAC means that you won’t have any risk of uterine rupture. In fact, occasional studies have even found a higher rate of rupture in the elective repeat cesarean groups! So keep in mind that it is the PREVIOUS CESAREAN that puts you at risk for uterine rupture.
4. There are things you can do to minimize uterine rupture risks.
There is so much information and studies linked in the first source listed at the bottom of this blog.
The conclusions of these studies indicate there are many things you can to do reduce the risk of rupture and increase success for VBA2C. See them below, then check out that source for all the data behind these recommendations.
- Stay away from induction unless absolutely necessary.
- Avoid augmentation of labor (using something to stimulate contractions, usually pitocin).
- Avoid excessive pitocin, and upping the dose too fast.
- Avoid Cytotec (misoprostal) COMPLETELY.
- Avoid providers who aggressively intervene with and manage labor.
- Stay mobile. Walk, change position and posture when in active labor.
- In early labor and if labor stalls, rest or sleep.
- Do EVERYTHING you can to make sure your baby is in the most optimal position BEFORE labor begins.
- IF baby is not in a great position and labor stalls or, you have back labor; try spinning babies, MILES circuit, abdominal lifting, side lying, or get on hands and knees to try and help baby settle into a better position.
- Avoid rupturing membranes if baby is not in optimal position if possible.
- Avoid an epidural if possible.
- Have attentive labor support with you ALL THE TIME.
- Be aware of typical labor patterns. Any stalls in labor is usually indicative that something needs to change (emotional processing, baby position, rest/sleep, and even pitocin in some instances). Figure out what needs to change and fix it if you can. A long stall combined with high doses of pitocin is a prime scenario for uterine rupture.
- HONOR YOUR INTUITION!!! If you feel that something is not quite right or if baby’s movement is significantly decreased insist that your provider or their staff pay attention to you. In many instances uterine rupture occurs when a mother knows something is wrong intuitively before providers pay sufficient attention.
5. The risk for rupture is still incredibly low, maybe even the same as VBAC.
The limit of most VBA2+C research is that almost no studies have controls for pitocin/other drug use, and this may well be a significant factor.
Although there is still some debate, uterine rupture rates may be somewhat higher in VBA2C when pitocin or multiple induction agents are used. Nearly all VBA2C studies analyzed aggressively used pitocin etc. for 50% or more of their participants.
So, it is impossible to know for sure what the true underlying rate of rupture in VBA2C may be.
Although hard data is lacking, it seems likely that the average VBA2C rupture rate of 1.4% found in the ACOG bulletin could probably be drastically reduced by inducing less, inducing only when the cervix is ripe when induction is truly necessary, and using drugs and interventions a lot less (and much more judiciously when they are used).
So, with all this information, should I attempt (TOLAC) a VBA2C?
This is a decision that each family must make for themselves. Take a look at your desires and fears and what motivates YOU. Weigh the benefits and risks based on your specific needs and circumstances.
Listen to the advice of your providers, but remember that each provider differs, sometimes drastically, in their support, knowledge, and how they approach VBA2C so, they may not be up to date with current recommendations and guidelines.
Moving forward, seek out the current recommendations and research, talk to several providers and get their opinions until you find one whose knowledge and philosophy align with yours, weigh the potential risks and benefits, and check your own intuition to decide what is best for YOU and YOUR family.
Sources and where to find even more info:
Plus Size Pregnancy’s article on VBA2C is robust, and beefy, and full of SO. Much. Goodness!! It is applicable to women of all sizes.
You will find links and analysis and how to interpret dozens of studies related to the topic. There is a LOT of info, sure to keep an analytical mind busy for hours. They even dig a LOT into VBAC after 3+ cesarean.
Check out episode 2 of our podcast all about Meagan’s VBA2C journey and then find more VBA2C birth stories as you continue to listen.
Are you over the VBAC myths and want solid data to back up the facts? Grab your FREE VBAC MythBusters guide here.
The Best Induction Method for VBAC