Did you have a C-section with your first child? Are you planning to have a second child? Are you team VBAC or C-section? Here is your guide to your second pregnancy, giving you everything you need to know about your birth options and whether you are team VBAC or team C-Section?
V-B-A-C. VBAC. VBAC stands for Vaginal Birth After Cesarean section. It is a state when the birth person, who has had a previous cesarean section, is now in their next pregnancy and has to decide on the plan for birth. In most cases, most birthing people have the option of having a vaginal birth after a prior cesarean or having a repeat cesarean section the second time around.
In most cases, you can plan for both. There are a few situations where it may be better or more favourable to have one or the other. One can plan to have a TOLEC, also known as a trial of labour, with the goal of having a vaginal birth after a c-section. It is always recommended to talk about having a backup plan, that is, you have a plan A and a plan B for your pregnancy goals.
So, both are pretty good options and it is dependent on the particular situation or case. For most women, both are reasonable options in the sense that the risks are fairly equal for each option. However, it is worth discussing what the pros and cons of each birth option would be for that particular person.
Both birth options have their own set of risks and potential complications, and the level of risk is dependent on many factors.
Let's start with the repeats of the cesarean section. Anytime someone has had a previous C-section, their option is to plan ahead and schedule a repeat cesarean section. For some people, it is what they want and it's more convenient for them. They know exactly what's coming up, they can arrange for childcare for their other child, carries fewer unknowns, and has more predictability. This is a very attractive feature for a lot of people, especially if their first cesarean was fairly straightforward, they had a good recovery, and there were no complications.
A lot of birthing people like that option, but then of course there's always the surgical risks that are involved for that person. Having a second surgery is usually has more potential for risks. These could include more infection risks, more bleeding risks. Another thing to keep in mind is that the recovery after surgery, compared to a straightforward vaginal birth, is usually longer and there is more pain involved. We have to also think about subsequent pregnancies. After having two cesarean sections, you're committed to having repeat cesarean sections and that in itself carries other risks of long-term things like placenta previa.
💡 Placenta previa is when a pregnant person's placenta blocks the opening to the cervix. If the placenta only partially covers the cervix in mid-pregnancy, it may resolve on its own by term, allowing vaginal birth. If it covers the cervix completely, the birth must be by Caesarean section.
Source: https://www.ontariofetalcentre.ca/conditions/placenta/placenta-praevia/
Now let's talk about the risks associated with a vaginal birth. Even with a goal of having a vaginal birth, the potential for needing a cesarean section is still there. If they decided to go down the road of labour, just like the first time, there is an 80% chance that it may end up with vaginal birth, but there is that 20% chance that they may still need a C-section. This could be for multiple reasons, including labour-related or baby health reasons. Again, each person will have their own unique birth plan and no birth is the same.
You are considered a good candidate for a VBAC if:
Factors that can result in a higher chance of having a VBAC would be if they had an average size baby, they went into labour on their own, and their labour was progressing without any intervention or medical help. In terms of past history, if they had their first cesarean section because, for example, they were pre-term and the baby was in a breech position or they had the placenta previa. Things that are not necessarily recurring, meaning the chances of that happening the second time around this is a lot lower, then they are a reasonable candidate to have a TOLEC or a trial of labour.
Things that would make someone not be the ideal candidate would be if they had a vertical, up and down scar on their uterus, usually called the classical cesarean section. If they've had multiple surgeries, they've had two c-sections before, they have hypertension or other complications in the pregnancy, or they are needing to be induced. The main reason that they're not the ideal candidate is that the risks are slightly higher than the average risk, or if their chance of having a vaginal birth is lower than the average person going into labour.
When pregnant, one should definitely educate themselves on the pros and cons of a VBAC vs. a repeat C-Section, and the risks associated with each. It is recommended that you speak with your care provider about your specific situation, your pregnancies, and whether your birthplace has emergency services in place in the event that you do require an urgent C-section.
If you want a VBAC, you need to consider all the risks associated with this labour. The main risk that we talk about is that of uterine rupture. It is when the scar on the uterus is weak, this can cause the area to potentially open up during labour contractions. If that area opens up, it can lead to serious consequences, such as major bleeding. It could affect the blood flow or oxygen flow to the baby and potentially cause serious health concerns for the baby. In that situation, a birth person would usually need an urgent cesarean section.
During this process, because of that risk of uterine rupture, we always want to monitor two things, once their labour progresses. Your care provider will want to make sure that the birth person is going through the birth process in an ideal manner, meaning their cervix is changing and the baby's coming down. The other important piece is that we are monitoring the baby's heart rate pattern because that reflects how the baby's handling labour.
Without regard to specific circumstances around the baby size, the birth persons' height and weight, the gestational age, and overall the chance for someone having a vaginal birth 70-80%. This is actually the same rate of someone with their first pregnancy going to labour, between 70-80%. As mentioned above, it is always a good idea to have a plan B, that way families are not setting themselves up for disappointment because the reality is that a lot of things are beyond our control.
Based on what we know about labour and VBAC and uterine rupture risk, the chance of experiencing a uterine rupture risk is very, very low. However, if it does happen, things can change really quickly. Ideally, the recommendations are to have ongoing continuous monitoring of the fetal heart rate. It is often the first sign that something is going wrong. In that setting, if there was an indication that things aren't going well, you want to be in a situation where you have the ability to go to an urgent cesarean section, meaning having an operating room and the operating team there as fast as possible.
That is a very common situation and the common reasons that someone may need to be induced in this setting would be if they go past their due date or if they're water breaks and they haven't gone to labour. An artificial rupture of membranes would be offered to someone wanting a VBAC. Artificial rupture of membranes (ARM) is used when your water does not break naturally. Your doctor or midwife will insert a small hook-like instrument through your vagina to make a hole in the membrane sac that is holding the amniotic fluid. This will get the labour started by increasing the pressure of your baby's head on your cervix, some birth people may also need oxytocin to start their contractions.
The main message is that both VBACs and C-sections are good options. There is never a one-size-fits-all when it comes to birth. If someone was motivated, they want to try labour and have a vaginal birth, absolutely discuss this with your healthcare provider! Talk about how you can optimize your outcome, but also for women who are wanting to have a repeat cesarean section, there's nothing wrong with that as well. You have to figure out and plan for what's right for you and your situation.
WATCH THE FULL CONVERSATION WITH DR. JESSICA DY ON OUR YOUTUBE CHANNEL
Dr. Jessica Dy has a passion for practicing both medicine and surgery. Dr. Dy is the Medical Director of The Maternal Newborn and Women’s Health Program at The Ottawa Hospital. Her research interests are in labour management, induction of labour, Cesarean section and VBAC. She is here today to answer some of the questions about repeat C-sections and VBACs.
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