Doc Talk: Choosing a VBAC with Ariel Herron, CNM
If a pregnant patient has already had a Cesarean section in the past, it is still possible to have a vaginal birth after Cesarean (VBAC). Although riskier than a first-time vaginal birth, research has indicated that VBACs can be a very safe alternative to repeat C-sections. Fewer complications, shorter recovery time, and more participation at the birth are just a few of the benefits.
What is a TOLAC or VBAC?
When a woman has had a C-section in the past but decides to attempt to deliver vaginally, it’s referred to as trial of labor after a Cesarean (TOLAC). It is newer medical terminology than VBAC. A VBAC is also a retrospective diagnosis, we say the patient delivered and had a successful VBAC. However, you may see both of these terms used in readings and discussions.
What is your practice’s approach to VBAC?
As healthcare providers, we neither push for nor deny our patients the opportunity to attempt a trial of labor after a Cesarean (TOLAC). When I start this particular conversation during an OB visit, I often ask "have you thought about how you would like to birth this time around?" Then we go on to investigate each patient’s feelings, preferences, and expectations before arriving at a decision together.
At Women’s Health Connecticut, we believe that patients must be at the center of decision making when it comes to their health care. We know that offering women unbiased education and respecting their decisions leads to better outcomes and empowered patients.
In your practice, when do you recommend a VBAC and when do you advise against it?
Our care is individualized, and decision making is patient-centered. Once major risks have been ruled out, the factors for success and failure are reviewed with each patient based on her specific situation. One birthing person might be a great candidate for a successful VBAC but choose not to attempt a trial of labor, and that is ok. Another woman might really want to try even though she doesn't look like the best candidate on paper.
What are some of the benefits of having a VBAC?
We support a trial of labor after a Cesarean because the evidence supports the many benefits to both mom and baby when a successful VBAC is achieved.
Some of the benefits of a successful VBAC include:
- Avoiding abdominal surgery which carries the risk for infection, hemorrhage, or injury to internal organs.
- A quicker and less painful recovery
- Lower risks for future pregnancies
- Higher success for future vaginal births
- Benefits to the baby, such as lower rates of respiratory distress and immediate skin to skin contact with mom.
How can an expectant mother prepare ahead of time for a VBAC?
The number one thing a woman can do to prepare for any labor is to take care of her body. This means making good dietary choices, getting out in the fresh air and sunshine, engaging in light exercise and self-care, and staying as positive as possible. Birth is out of our control, so being in a good space physically, mentally, and emotionally is really important. She can also educate herself on what to expect in labor and consider a labor and birth doula. Evidence suggests that having a doula may improve rates of successful vaginal birth.
How do your patients generally feel after proceeding with a VBAC?
The vast majority of my patients are really happy when they have a successful VBAC. One of my patients recently shared her experience of feeling "on top of the world" after her TOLAC ended in a beautiful birth with the use of nitrous oxide.
However, women shouldn’t feel bad if a TOLAC doesn’t proceed as planned, resulting in a C-section. Mothers can still have a very rewarding birth experience – bonding with baby, breastfeeding immediately, and experiencing skin to skin contact.
Many first time moms-to-be are worried by the thought of having an episiotomy or experiencing tearing during childbirth. Is this a valid reason to have a C-section?
Some patients have expressed this concern. Episiotomies are out of favor, and all available evidence supports the abolishment of performing a routine episiotomy. Only in certain circumstances is this procedure ever recommended. I reassure women that most tears are minor and that the risks of a C-section are greater than the baseline risk of a vaginal laceration. We review the real data and ways to avoid deep lacerations, and go from there. Elective C-sections are allowed, however the patient needs to be educated on what they are requesting, just as with TOLAC or any other procedure.
Why are there federal goals surrounding VBAC rates?
Avoiding an unnecessary C-section in a first-time mom is one of the most important things that can be done for women having a baby in 2020. From a public health perspective, reducing C-sections saves millions of healthcare dollars and prevents thousands of post-op complications. It also drives down the maternal morbidity and mortality rate.
Though a VBAC isn’t recommended for all pregnancies, with success rates ranging from 60-80%, it is an option worth considering. An expectant mother should consult with her Women’s Health Connecticut provider to determine what is best for her and her family.
Resources for patients who are interested in learning more about VBAC: