Ask a Midwife is a blog series from Adriatica Women’s Health. Hear directly from midwives on topics like reducing c-section risk, considering a VBAC, and discussing the spectrum of pain management options available during labor. This conversation about considering a VBAC is with Holly Costello, a Certified Nurse-Midwife and Family Nurse Practitioner who feels there is no profession more rewarding than supporting women through the journey to motherhood.
Stephanie: Today we’re talking about VBACs. Let’s start with the basics. What is a VBAC?
Holly: A VBAC refers to a successful vaginal birth after a c-section. For women interested in the medical terms surrounding a VBAC, if someone wants to attempt a VBAC, we call it a trial of labor after c-section, or a TOLAC. I often refer to it simply as a “trial of labor.”
S: It’s good to know all the medical terms! What motivated you to discuss this topic?
H: For a long time, we didn’t give women a lot of options for delivery after they’d had a c-section. If you had a c-section, you just had more c-sections. In recent years we’ve realized that risk to moms is greater when we keep doing major surgery, and a c-section is major surgery. I want women to know that the research supports VBACs as a safe option, and they should be considered.
S: Why have vaginal births been avoided for women with a history of c-sections?
H: The scariest thing that can happen when a woman has a c-section and wants to attempt vaginal birth is uterine rupture, which is a serious threat to mother and baby. But what we see is that the risk of uterine rupture isn’t as high as we thought. If you’ve had one c-section, your risk for uterine rupture is about 1%. If you’ve had two c-sections, that bumps up to about 2%. If you go up to three or more c-sections, the risk increases, so we don’t recommend a trial of labor to attempt a VBAC.
S: If a woman is interested in attempting a VBAC, what steps should she take to set herself up for success?
H: The first and most important thing is a careful choice of your provider, whether that’s a midwife or an obstetrician. Ask the hard questions. “What are your successful rates of VBAC? What criteria do I have to meet to have a trial of labor?” Picking a provider that is really VBAC supportive is an important thing. Find someone who parallels what you’re hoping for.
Your provider should have questions for you as well. The first thing I do is talk about why you had your first c-section. We want to review your records and make sure it’s safe to attempt a trial of labor. So much about your health and medical history will help us decide whether you’re a good candidate for a trial of labor after c-section.
There are other factors to consider as well. Doulas can help success rates and so can birth classes that help you prepare for labor. Knowledge is so powerful. Knowing what to expect and getting mentally prepared for that labor and birth process strongly benefits women.
What does the labor and birthing process look like for an attempted VBAC?
For someone who has had a prior c-section, we don’t feel it’s safe to intermittently monitor the baby, so we continuously monitor the baby’s heart rate. That means we can’t offer as many of the same freedoms to the mother. There are also medications we can’t give. But otherwise, it looks like a very normal labor, we just monitor baby more closely.
S: These can feel like difficult and sometimes scary choices for women to make. What do you say to women who are hesitant?
H: Everything we do and say as medical professionals is supported by evidence. As providers continue to follow the evidence, the outcomes for mothers improve. Be your own advocate. Ask questions and do research until you feel comfortable with your plan.