April is Cesarean Awareness Month and 1 in every 3 women will give birth via cesarean. I am 1 in 3. My first child was born via cesarean and my provider at the time promptly informed me that “once a cesarean always a cesarean”. That was very discouraging to hear as I really wanted the opportunity to experience a vaginal birth. Fast forward about 4 years later and we were ready to begin the journey of conceiving our second child, it was then that I begin my VBAC (vaginal birth after cesarean) journey.
The American College of Obstetrics and Gynecology (ACOG) states that “VBAC is a safe and appropriate choice for most women who have had a prior cesarean section, including some who have had two previous cesareans”1 and that “candidates should be counseled and offered a trial of labor after cesarean”1. Between 2011-2012 approximately fifty percent of expecting women considered a VBAC, however, despite ACOG’s recommendation 46% of those women were denied care for their VBAC.5 88% of those providers preferred to schedule a repeat cesarean.5
Finding a VBAC supportive provider is not always that easy. More often than not providers are VBAC tolerant meaning that they will support a trial of labor after cesarean (TOLAC) as long as the pregnancy fits within their personal standard of care (what they are comfortable with.) When I began my VBAC journey, my provider seemed 100% supportive towards my VBAC until my 36-week appointment. Suddenly there were concerns of a “big baby” and he recommended scheduling a repeat cesarean for the safety of my baby. My provider did not choose to counsel me on the risks of a repeat cesarean or the risks of macrosomia (medical term for big baby) and VBAC. Yes, there are some risks when it comes to delivering a big baby3, however, macrosomia is not a contraindication for a VBAC1 and big babies are safely delivered vaginally every day. Weight estimates via ultrasound can be incorrect about 40% of the time and more often than not they lead to unnecessary medical interventions2. ACOG also discourages medical providers from using ultrasounds in the third trimester for the purpose of estimating a baby’s weight or recommending a cesarean due to suspicion of macrosomia.4
A provider may stipulate that you must go into labor by a certain gestation and that they will not induce you under any circumstances. ACOG states that while going beyond 40 weeks may decrease your chance of having a successful VBAC it does not exclude you from being allowed a trial of labor after cesarean (TOLAC).1 ACOG also notes that an induction of labor is an option for patients who are seeking a VBAC and the less than 3% chance of uterine rupture that may accompany a VBAC induction is not a reason to deny a you an opportunity to experience a trial of labor after cesarean (TOLAC).1
If you are pregnant with twins and are hoping to achieve your VBAC – shoot for the stars! ACOG notes that mothers pregnant with twins have a similar trial of labor after cesarean (TOLAC) success rate as that of a mother who is pregnant with a singleton.1
Being a plus size woman myself and being involved with members of the plus size birth community, I know that providers will frequently try to use weight as a reason to recommend a repeat cesarean. While being plus size does decrease the chances for a successful VBAC by about 24% (compared to women with a normal BMI) it does not deny us the opportunity to experience a trial of labor after cesarean (TOLAC).1
The type of incision made during previous cesarean is one of the most important considerations for providers when it comes to a VBAC. While a low-transverse incision is the most optimal incision for VBAC candidates, recent studies have determined that candidates with a low-vertical uterine incision have similar VBAC success rates and that any risks associated with uterine rupture or morbidity have not been consistent enough make a low-vertical incision a contraindication for a VBAC or TOLAC.1 If you are unsure what type a uterine incision was previously used that is not a contraindication for TOLAC unless the provider suspects a rare classical uterine incision that is reserved for very emergent situations.1
Some providers may even “require” you to have an epidural just in case you need a cesarean. ACOG says it is not necessary to require VBAC candidates to have an epidural1, so if you have your heart set on an unmedicated natural birth go for it!
Lastly, movement in labor is your friend and can help to increase your chances of having a successful VBAC. You can read more about the benefits of movement during labor from one of our earlier blog posts: https://www.dfwbirthresource.com/doula-support/movement-in-labor/.
Pregnancy and childbirth often comes with a wide variation of normal that may or may not fall in line with your provider’s standard of care. When providers become uncomfortable with a particular situation fear is often introduced into the conversation. The provider may be fearful that if something goes wrong they will be faced with a malpractice lawsuit therefore they begin to recommend (repeat) cesareans and other medical interventions “for your and you baby’s safety” because then they can better control the outcome.
Most women are candidates for a VBAC or trial of labor after cesarean (TOLAC), however, if you have experienced a previous uterine rupture, have a classical uterine incision or have a medical issue such as placenta previa that would be a contraindication of a vaginal birth. “Once a cesarean” does not always have to be a cesarean. Just because you are pregnant does not mean that you lose your rights to informed consent. If your provider is not counseling you on the risks of both a VBAC and a cesarean and is putting stipulations on your right to a trial of labor of cesarean (TOLAC) then they might not be the right provider for your VBAC journey. You are the patient, you hired your provider, they work for you not the other way around. If you feel that you are not getting the care that you deserve whether you are 6 weeks, 24 weeks, 36 weeks or even 41+ weeks it is never too late. Many women have changed providers days or even hours before they went into labor. You can do this, you have a right to a trial of labor after cesarean (TOLAC) and you deserve a provider who not only believes in your rights to informed consent but in your ability to birth your baby. Finding the right provider may not always be easy, but it is worth it! OB-GYN’s are not the only provider options for VBAC, be sure to research the midwives in your area – VBAC’s can take place at home, in birth centers or hospitals – you have options and do not let anyone deny you of those options!
Best Wishes on your VBAC journey!
P.S. It wasn’t easy but I did achieve a successful VBAC despite the opposition of my provider.
Also, be sure to check out the following resources: International Cesarean Awareness Network: https://www.ican-online.org/; https://www.vbac.com/; and the VBAC Education Project: https://icea.org/about/the-vbac-education-project/.