What Is Vaginal Birth After Cesarean?

Vaginal birth after cesarean is when a woman who has previously given birth by cesarean delivers her baby vaginally in a subsequent pregnancy. This type of birth is abbreviated as VBAC. In English medical sources, the term VBAC, meaning “Vaginal Birth After Cesarean,” is used [1][2].

When VBAC is planned, the expectant mother goes into labor and vaginal birth is aimed for. In medical literature, this process is called a trial of labor after cesarean, or TOLAC. If TOLAC is successful, the birth occurs vaginally, and this is called VBAC [1][5].

Vaginal birth after cesarean is not suitable for every expectant mother. The type of uterine incision made in the previous cesarean, previous birth history, the course of the current pregnancy, the baby’s position, the mother’s general health condition, and the emergency intervention capacity of the birth center should be evaluated together [1][2][3].

In suitable candidates, VBAC may provide advantages such as a shorter recovery period compared with repeat cesarean, fewer surgical complications, and reduced risks related to repeated cesareans in future pregnancies [1][2][4]. However, because of rare but serious risks such as uterine rupture, the decision must be made together with an obstetrician and gynecologist [1][2].

Benefits of Vaginal Birth After Cesarean

Vaginal birth after cesarean may provide some important advantages in suitable candidates. ACOG states that a successful VBAC may be associated with lower maternal morbidity and fewer complications compared with repeat cesarean [1]. RCOG also emphasizes that recovery after vaginal birth is generally faster and the length of hospital stay may be shorter [2].

Possible benefits of VBAC include:

• A repeat abdominal surgery is avoided.
• The recovery period may be shorter compared with cesarean [2].
• The length of hospital stay may decrease.
• The risk of blood loss, infection, and surgical wound complications may be lower [1][2].
• The mother may return to daily life in a shorter time.
• Placental problems and surgical difficulties related to repeated cesareans in future pregnancies may decrease [1][4].
• It may be an option under suitable conditions for expectant mothers who wish to experience vaginal birth.

However, these benefits are valid only when appropriate patient selection is made and the birth is monitored by an experienced team. If VBAC is unsuccessful, an emergency cesarean may be required, and in this case some risks may increase compared with a planned cesarean [1][2].

Vaginal Birth After Cesarean (VBAC)

Vaginal Birth After Cesarean (VBAC) is when a woman who has previously given birth by cesarean has a vaginal birth in a subsequent pregnancy. This method is often wondered about by expectant mothers who do not want to have another cesarean or who wish to experience vaginal birth under suitable conditions [1][2].

The most important point for VBAC is that the expectant mother’s suitability for this type of birth should be evaluated by the physician following the pregnancy. Especially if the uterine incision in the previous cesarean was a low transverse incision and there are no other risk factors, the VBAC option can be evaluated more easily [1][2][5].

According to NCBI/StatPearls data, the success rate in VBAC attempts is generally reported to be approximately 60-80% [5]. However, this rate may vary depending on whether the mother has previously had a vaginal birth, whether labor begins spontaneously, the baby’s weight, the mother’s body mass index, and the reason for the previous cesarean [1][2][5].

Advantages of VBAC

The advantages of VBAC become more evident when a successful vaginal birth occurs. Since repeat cesarean is a surgical procedure, it may carry risks such as bleeding, infection, adhesions, and bladder or bowel injury. As the number of repeated cesareans increases, future pregnancy risks such as placental attachment disorders may also increase [1][4].

1. Natural Birth Experience

VBAC allows suitable candidates to experience the vaginal birth process. The expectant mother can actively participate in labor, feel the baby’s birth process, and the postpartum recovery period may be shorter compared with cesarean [2][5].

2. Shorter Recovery Period

Recovery after vaginal birth is generally faster than after cesarean. Since there is no abdominal incision, wound care, movement restriction, and surgical pain may be less. This may support the mother in caring for her baby earlier and returning to daily life more comfortably [2].

3. Lower Risk of Surgical Complications

In a successful VBAC, cesarean-related surgical complications can be avoided because repeat abdominal surgery is not performed. ACOG states that successful VBAC may be associated with less blood loss, a lower risk of infection, and a shorter recovery period [1].

4. May Provide Advantages for Future Pregnancies

As the number of repeated cesareans increases, risks such as placenta previa, placenta accreta spectrum, intra-abdominal adhesions, and surgical injury may increase [1][4]. Therefore, in suitable patients who plan more than one pregnancy in the future, VBAC may be an important option in terms of long-term birth planning.

Factors Affecting Failure in Vaginal Birth After Cesarean

VBAC may not always result successfully. Emergency cesarean may be needed for reasons such as failure of labor to progress, deterioration in the baby’s heartbeat, suspicion of uterine rupture, or the development of risk in the condition of the mother or baby [1][2].

Factors that may reduce VBAC success include:

• Never having had a vaginal birth before [1][2]
• The previous cesarean having been performed because labor did not progress
• Advanced maternal age
• High body mass index
• High estimated fetal weight
• Pregnancy continuing beyond 40-41 weeks
• Labor not starting spontaneously and induction being required [1][2]
• Cervical dilation not progressing appropriately

The presence of these factors does not mean that VBAC will definitely fail. However, they may reduce the chance of success and should be taken into account when making a birth plan [1][5].

In Which Situations Can Vaginal Birth After Cesarean Not Be Performed?

VBAC is not recommended or is considered high risk in some situations. Planned repeat cesarean may be safer, especially in conditions that increase the risk of uterine rupture [1][2][3].

Situations in which VBAC may not be suitable include:

• A vertical or classical incision having been made in the uterus during the previous cesarean [1][2]
• A previous history of uterine rupture [1][2]
• Having undergone certain uterine surgeries that deeply affect the uterine wall
• Placental placement problems that prevent vaginal birth, such as placenta previa [3]
• The baby being in a position unsuitable for vaginal birth
• A medical condition developing in the mother or baby that requires emergency cesarean
• The birth center not having the possibility of emergency cesarean and blood transfusion [1][2]
• Uncontrolled serious maternal diseases or severe pregnancy-related complications

Diseases such as diabetes or hypertension are not always absolute barriers on their own. However, the severity of the disease, the baby’s condition, the course of pregnancy, and the conditions of the birth center should be evaluated together [1][2][3].

Is VBAC Risky?

VBAC may be a safe option in suitable candidates; however, it is not completely risk-free. The most important risk is uterine rupture, which is tearing of the uterine wall at the site of the previous cesarean scar [1][2][5].

Uterine rupture is rare; however, because it may lead to serious consequences for both mother and baby, close monitoring is required in births planned as VBAC. ACOG states that it is important for centers where TOLAC is attempted to have a team and facilities capable of performing emergency cesarean [1]. RCOG also emphasizes that birth should be planned in a hospital with appropriate equipment [2].

Possible risks that should be monitored during VBAC include:

• Uterine rupture
• Need for emergency cesarean
• Bleeding
• Infection
• Deterioration in the baby’s heartbeat
• Failure of labor to progress
• Need for intensive monitoring for the mother or baby

On the other hand, planned repeat cesarean also has surgical risks. Therefore, when choosing between VBAC and repeat cesarean, the benefits and risks of both options should be discussed individually [1][2][3].

What Are the Requirements for VBAC?

The most important requirement for VBAC is that the expectant mother is medically suitable for this type of birth. ACOG and RCOG state that the previous cesarean incision, gestational week, baby’s position, mother’s birth history, and hospital conditions should be taken into account when planning VBAC [1][2].

General eligibility criteria for VBAC include:

• The uterine incision in the previous cesarean should be a low transverse incision [1][2]
• The mother and baby should generally be healthy
• The baby should be in head-down presentation
• There should be no placental or fetal position problem preventing vaginal birth
• There should be no history of additional uterine surgery increasing the risk of uterine rupture
• The birth center should have emergency cesarean capability [1][2]
• The mother and baby should be closely monitored throughout labor

The decision on suitability should be made individually for each expectant mother. A VBAC plan that is suitable for one person may not be safe for another [1][3].

When Can Vaginal Birth After Cesarean Be Planned?

VBAC is generally evaluated after the 37th week of birth in the current pregnancy. However, the decision is not made only according to gestational week. The time elapsed since the previous cesarean, the type of uterine incision, the mother’s birth history, the baby’s development, and the risks that arise during pregnancy are considered together [1][2].

A very short interval between the previous cesarean and the new pregnancy has been associated with an increased risk of uterine rupture in some studies. Therefore, the birth interval is also taken into account in VBAC evaluation [1][5].

Spontaneous onset of labor may increase VBAC success. When labor induction or artificial oxytocin stimulation is required, the risks and chance of success should be re-evaluated [1][2].

Differences Between VBAC and Repeat Cesarean

There are two main options in pregnancy after a previous cesarean: a VBAC attempt or planned repeat cesarean. Both options have advantages and risks [1][2][3].

If VBAC is successful, abdominal surgery is not performed, recovery may be shorter, and the risks of repeated cesareans in future pregnancies may decrease [1][2]. However, during a VBAC attempt, there are risks such as uterine rupture or the need for emergency cesarean [1][5].

In planned repeat cesarean, the timing of birth may be more predictable, and the risk of uterine rupture is lower because labor is not entered. However, cesarean is a surgical procedure; it carries risks such as infection, bleeding, adhesions, organ injury, and placental problems in future pregnancies [1][3][4].

Common Misconceptions About VBAC

There is a lot of misinformation about VBAC in society. This misinformation may negatively affect expectant mothers’ decision-making process.

"Everyone who has had one cesarean must have another cesarean."
No. In suitable patients, the option of vaginal birth after cesarean can be evaluated [1][2].

"VBAC is completely risk-free."
No. VBAC may be safe in suitable candidates; however, it carries risks such as uterine rupture and emergency cesarean [1][2][5].

"VBAC will definitely be successful."
No. The success rate of VBAC varies from person to person. Previous vaginal birth history, spontaneous onset of labor, and the mother’s general condition affect success [1][5].

"If there is diabetes or hypertension, VBAC definitely cannot be performed."
These conditions are not always absolute barriers on their own. Disease control, the course of pregnancy, and maternal-infant health should be evaluated together [1][3].

"VBAC can only be performed at home or in natural birth centers."
No. VBAC should be planned in appropriate healthcare facilities where emergency cesarean can be performed [1][2].

Comments From Those Who Had Vaginal Birth After Cesarean

The experiences of mothers who have had VBAC vary from person to person. Some mothers state that they recovered faster because they were able to give birth vaginally, could care for their babies earlier, and actively participated in the birth process. Some mothers, however, may experience the process as more stressful because the trial of labor ended in emergency cesarean.

"My first birth was a cesarean. In my second pregnancy, after discussing all the risks with my doctor, we decided to try VBAC. The birth process was closely monitored, and because I was able to have a vaginal birth, my recovery was easier."

"VBAC was a powerful experience for me, but the most important thing in the decision-making process was that my doctor clearly explained both the benefits and the risks to me."

"My trial of labor started, but due to the baby’s heartbeat, we switched to cesarean. Although I was upset at first, I later understood that the safest birth was the right decision."

Patient comments may provide insight during the decision-making process; however, the decision for VBAC should be made not according to personal experiences, but according to the medical evaluation of the mother and baby [1][2].

Frequently Asked Questions

References

1. American College of Obstetricians and Gynecologists (ACOG). Vaginal Birth After Cesarean Delivery. (https://www.acog.org)
2. Royal College of Obstetricians and Gynaecologists (RCOG). Birth after previous caesarean. (https://www.rcog.org.uk)
3. NICE. Caesarean birth guideline NG192. (https://www.nice.org.uk)
4. FIGO. Good practice recommendations for vaginal birth after cesarean. (https://obgyn.onlinelibrary.wiley.com)
5. NCBI Bookshelf / StatPearls. Vaginal Birth After Cesarean Delivery. (https://www.ncbi.nlm.nih.gov)