Vaginal Birth—and Homebirth—after Cesarean Section


If you are family hopeful to have an HBAC, this essay may be helpful to you as you consider birth plans and engage in Informed Consent dialogue with your midwife.  You may also want to read the links below, under the heading of ‘Cesarean Birth and RCS  information–risks and benefits’ (ICAN and CIMS fact sheets).  The rest of the information is available to you as you may wish to review it.

Preface: after my comments are links to information that supports my points.   This essay is a general introduction to VBAC/HBAC, and is only a starting point–do look into all available information.  Also, to clarify: ‘vaginal birth’,  means having a baby vaginally, with or without pain relief or other medical help; ‘normal birth’ or ‘birthing normally’ refers to  the usual process of birth as naturally designed.  

VBAC General Information:  Vaginal birth after cesarean, for the majority of women and babies, is the safest way to birth because it has the most benefits and least risks for mothers and babies.  While VBAC has risks, repeated cesarean surgery also has risks—and the risks of surgery rise, as the number of surgeries rises.  For healthy moms and babies, though, the risks of VBAC get lower, the more times a woman gives birth vaginally after a cesarean.  These are the factors that are known to help make VBAC safest:

~  A woman who has had only 1 or 2 cesarean births, with uncomplicated healing;

~  A woman who has at least 18 months between cesarean and VBAC;

~  A woman who takes care of her health on all levels (diet, exercise, social/spiritual support);

~  A woman whose labor starts and continues naturally, not induced or augmented chemically;

~ A woman who can labor with abundant natural aids for the work of labor: food, fluids, movement, rest and emotional support;

~  A woman with competent birth care, who receives prenatal monitoring, support and information, along with attentive labor monitoring.

VBAC Risk:  Uterine rupture (UR), which happens very rarely in women who’ve never had uterine surgery, presents an elevated risk at birth when the uterus is scarred.  For reasonably healthy VBAC candidates, who start labor with low risk (defined above), the rate of UR is .5%–one of every 200 VBACs.  The scarred uterus can tear, at the scar or anywhere on the uterus, although usually it occurs on the scar.  This is because scar tissue is more rigid than unscarred tissues, and sometimes cannot stretch as much as needed during late pregnancy and birth.    UR very rarely happens during late pregnancy, when the uterus is stretched quickly by baby’s rapid growth; more often UR occurs during labor, under the stress of contractions.  The great majority of URs are very minor, bleeding very little and causing no problems for mother or baby.  This is ‘dehiscence’, sometimes only a thinning of tissues called a ‘window’ because the thinned uterus at that place is translucent; it may also occur as a small, partial separation of the scar.  Dehiscence rarely presents risk to mother or baby’s health; VBAC is usually successful.  Some ruptures, are moderate, and need timely medical assistance to remain safest for mother and baby.  An extremely small number of uterine ruptures are catastrophic, will bleed profusely and require immediate surgical intervention to preserve mother/baby’s lives and health.  While these outcomes are rare for otherwise healthy mother/babies, the primary risks of uterine rupture are infant death, and hysterectomy needed to save mother’s life; there is an extremely low risk of maternal death as well (slightly higher than the risk of death for any mother). 

Another risk for pregnant women with uterine scars is the placenta attaching to the scar—which sometimes leads to the placenta attaching too deeply into the uterine wall (placenta accreta or percreta).  This prevents the placenta from detaching following birth, causing postpartum hemorrhage; it could require surgical removal or possibly hysterectomy.  This depends on how much of the placenta is over-attached to the uterine wall, and how deeply attached into maternal tissues.  Both factors can vary greatly—from just a small part of the placenta to most of it being over-attached; from a minor accreta to the more deeply-imbedded increta and percreta.  While this can happen to anyone, it is more common for those with scars from any prior uterine surgery or infection.  This is a general risk of any pregnancy with uterine scarring; however, the risk of vbac with this issue is actually lower than its risks through RCS–because of the possibility with surgery of fatal bleeding for mothers.  For VBAC mothers, the main risk is postpartum hemorrhage, the potential need for surgical removal of the placenta, and sometimes, hysterectomy.

Repeat of Past Reasons for Cesarean: Some mothers fear they will encounter the same issue again, that prompted her earlier cesarean birth: Cephalo-Pelvic Disproportion (CPD: mother’s pelvic outlet is too small for passage of baby); breech presentation or twins; Failure to Progress; cord issues, fetal distress, infection and ‘other’.  Most often, these factors do not repeat, since every pregnancy and birth is different; many of these things are unusual or even rare, in the first place (see notes).  And it’s important to understand that the reasons for cesarean are often about ‘failures of birth care’, rather than any true problem or ‘’failure’ on a mother’s part.  Often, the reason given for a cesarean is only an assumption made by care providers, with no true diagnostic evidence.  If a woman has a large baby, she may be told she has (or is at risk for) CPD; if she labors without adequate food, fluids, movement, rest and emotional support, she may become fatigued enough to give up—or is pressured into a cesarean by care providers with no more time or skills to offer, or who may fear a lawsuit: this is ‘Failure to Progress’.  Breech and twins are often ‘automatic cesareans’ only because few medical providers receive training to assist these births vaginally.  Fetal distress is often misdiagnosed– and when it’s real, it is often caused by pitocin or other avoidable elements of medical birth care.  Families can help themselves greatly by exploring the reasons for their cesarean, and how to avoid those issues in future.  They can learn more about supporting optimal mother/baby health throughout pregnancy, and prepare themselves to work well with vbac.   They can learn more about different care-providers available, making choices that best support vaginal birth in future, in the ways that they believe are safest.

Birthing Normally after Cesarean:  Any family hoping to birth vaginally after cesarean needs to understand what makes VBAC different from other births— to know the risks of VBAC along with its benefits, as well as the benefits and risks of different types of birth care after cesarean.  VBAC families can review the information, and decide what is acceptable risk for them— knowing that however low their risk, it is real.  They should know, too, that any choice they make, including elective repeat cesarean (ERCS), carries its own risks.  We can’t entirely eliminate risk from any birth—just as we can’t eliminate risk from life in general.  VBAC families will make the best decisions by taking their whole situation into account—their factors favoring vaginal birth, and those that elevate their risk; the types of care available along with the care they feel safest receiving.  Yet it is just as important to know: in most ways, ‘having a vaginal birth after a cesarean’ is pure and simply ‘having a normal birth’. 

This is because same healthy processes of birth occur for the great majority of VBAC mother/babies, as for any birthing pair.  VBAC pregnancy is still pregnancy as we know it normally.  VBAC labor is labor as it is for all mother/babies, with the same natural mechanisms, needs and benefits for both.  All mothers support safe vaginal birth best by practicing healthy habits of physical, emotional and spiritual well-being throughout pregnancy.  For all mothers, the best birth care supports normal birth in all possible ways; finding the same positive, skilled support that helps any mother/baby, also helps a VBAC mother/baby.   With this in mind, VBAC families can benefit by also avoiding forms of care that hinder normal birth and tend to lead to complications.  When labor starts and continues naturally, and when laboring mothers can freely eat, drink, move and rest in an atmosphere where she feels safe and supported, VBAC most often proceeds just like any birth, and most often results in a safe vaginal birth.  When considering options for birth care following a cesarean, keeping those simple things foremost can help you learn what you need to know: so you can choose positive support for normal birth, as well as choosing to avoid interference known to lead to complicated, needlessly medicalized birth.

Homebirth After Cesarean (HBAC): For reasonably healthy women and babies, VBAC can be safest of all when mothers birth at home.  For some, homebirth is their first choice; home is where they feel best able to birth, maximizing their use of natural, gentle measures, and receiving appropriate support and care.  Some other VBAC families might not ordinarily choose homebirth, but they discover that home is the only place available to attempt to birth normally.  Local hospitals and care providers may refuse to support normal VBAC; so, giving birth at home is the only way to avoid the risks of medical over-management. 

Unfortunately, many hospitals actively ban VBAC and insist upon RCS for all mothers who’ve had a cesarean.  Even among the hospitals and OBs that allow VBAC, most have policies for VBAC mother/babies that directly interfere with normal birth: first they might restrict mothers’ intake of food and fluids, restrict her movement and disrupt any normal rest-periods she may take during labor; these things alone can lead to complications.  Further, most hospitals add risks to birth: requiring labor induction by a certain time, using Continuous Electronic Fetal Monitoring (CEFM), in-place IV, using pitocin or other labor stimulants, imposing time-limits on labor, frequent cervical dilation exams—none of these routines show evidence of general benefit and all of them are well-proven to increase the risk of problems for women and babies both (for all mother/babies, not just VBACs; but the risks may be greater for VBACs because VBAC mother/babies are already at a slightly elevated risk).  Because of these things, hospital VBAC is often less safe for mother/babies, generally, than homebirth.  In theory, VBAC should be safest in the hospital, where there is immediate access to medical technology if problems arise.  In reality for many families, home is the place where they have the most freedom and support for birthing normally and the best chance of achieving a safe vaginal birth. 

HBAC Risks: The 2 main risks of HBAC are the family’s distance from a hospital, and the abilities of their care provider to support normal birth, to detect signs of problems and to address them in a timely, competent way.  So, it is wise to carefully select HBAC assistance; most of the information you need is the same information about midwives that all families need with respect to a mdwife’s training, knowledge, and usual routines.  You should also ask about each available midwife’s knowledge and experience with HBAC.  If she has experience with UR, then discuss those births with her to discover if any of her routines might have contributed to UR.  For instance, some homebirth midwives induce labor with VBAC mothers, even though UR rates are higher with induction—you may want to avoid induction by any method.  Also, if UR occurs, time is of the essence in saving lives (and mother’s uterus).  Families who live more than several minutes from a maternity hospital may want to give birth somewhere closer  (a hotel or friend’s home), to increase their safety in case of  rupture or postpartum hemorrhage.  Further, having OB backup care during pregnancy, and being registered at the OB’s hospital prior to birth, can also help you get the quickest possible care in an emergency. 

HBAC has not been well-researched yet.  The rate of homebirth for all families is 1-2% in the US (with regional pockets up to about 5%, where homebirth is well supported in law and medicine); the occurrence of HBAC is surely well below 1%.   Because of the lack of research, I cannot provide confirmed evidence of HBAC safety, however: in discussions with hundreds of midwives since 2003, anecdotal evidence shows that HBAC is successful the vast majority of the time, with reported UR rates among low risk VBAC candidates being well below the .5% rate for hospital VBAC.  In my informal survey over those years, I only found one midwife with a UR rate of greater than 1%.  The details about these URs was not provided, but given what we know about UR and the fact that her UR rate is more than double national standards for hospital VBAC, then she is possibly  a) accepting high-risk women for HBAC care and/or b) introducing forms of care, such as labor induction, known to elevate UR risk.  

 WomynWise suggests HBAC for families when: the mother and her family will learn about pregnancy and birth health generally, and are pro-active in daily mother/baby health choices; when they are willing to participate actively in all preparations for HBAC; and when they have chosen HBAC with full knowledge of the risks, benefits and alternatives to HBAC in their particular situation.  While you may or may not want to have onboard OB backup, you will at least need to discuss the possibility of transferring care and know in advance which hospital you prefer along with which hospital is closest in case of emergency.  You might instead want to have a hospital VBAC, if your circumstances warrant closer medical attention due to greater risk factors present.  That is something to discuss with your chosen care providers and with each other as a couple, as you find your way.

Below are links to information about VBAC and HBAC.  If you have other links to contribute, please do so through the comment box on the main Choices page.

General VBAC and cesarean information:

http://www.ican-online.org/  The International Cesarean Awareness Network is the foremost authority on cesarean birth and VBAC.  It is also a leading supporter of informed choice in birth and cesarean prevention, with special attention to support for families seeking VBAC.   The ICAN website contains a huge amount of information and commentary on all aspects of cesarean and VBAC, including links to research; it also has links to local support groups and birth professionals who provide skilled VBAC care.  Here is the link to the St Louis area chapter, where you can find leaders and meeting times in the St Louis and metro-East region: http://stlouis.ican-online.org/

http://vbacfacts.com/ Another highly comprehensive and intensively research-supported website for all things favoring VBAC and shedding ight upon the risks and realities of cesarean birth and RCS.

http://www.mothering.com/discussions/forumdisplay.php?s=&daysprune=-1&f=213  This is a link to Mothering Magazine’s discussion forums, specifically the Birth and Beyond Forums.  2 subforums of interest on this page are Homebirth and VBAC; both have a lot of information about VBAC and HBAC, including links to research.  You can read posts without registering, but registration is free, no spamming, if you want to post queries or participate on the threads; I recommend it because this is also a great place for online VBAC/HBAC support.  There are also a great number of other forums available on the Mothering site.

http://www.motherfriendly.org/ The website for the Coalition for Improving Maternity Services (CIMS): “Our mission is to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs. This evidence-based mother-, baby-, and family-friendly model focuses on prevention and wellness…”  This site contains much information about birth, including but not limited to info on cesarean and VBAC.

Uterine Rupture information:

http://www.ican-online.org/vbac/uterine-rupture-a-10-year-population-based-study-uterine-rupture  One large, general study of UR, including UR with VBAC: “The incidence of uterine rupture … was complete rupture (3/1000) and dehiscence (5/1000). Induction or augmentation of labor with oxytocics [pitocin] was associated with 50% of complete ruptures and 25% of dehiscence. There were no maternal deaths, but 33% of patients with complete ruptures required blood transfusion. There was one neonatal death attributable to uterine rupture.   Induction and augmentation of labor are confirmed as risk factors for uterine rupture.

http://momstinfoilhat.wordpress.com/2009/09/08/update-on-uterine-rupture/ a look at comparative UR rates with different incisions.

Cesarean Birth and RCS  information–risks and benefits:

http://www.ican-online.org/pregnancy/cesarean-fact-sheet  General information on cesarean birth, including info on reasons cesarean may be truly necessary for some, and the short and longterm risks to mother/babies from surgery.

http://www.motherfriendly.org/pdf/TheRisksofCesareanSectionFebruary2010.pdf  Information from CIMS about the risks of cesarean, including risks of repeat cesarean.

http://vbacfacts.com/vbac/  Debunks the myths of VBAC risk, information about the risks of cesarean and RCS. 

CPD, breech, and other reasons for cesarean:

http://ican-online.org/ican-white-papers  This page has a variety of information linked, including articles about some reasons women have had cesareans that may be unnecessary in future

http://www.ican-online.org/vbac/cephalopelvic-disproportion-cpd  All about CPD, the facts and debunking the myths

http://www.ican-online.org/community/videos/laureen/question-cpd An excellent and moving video with many women birthing babies vaginally after cesarean for CPD (often with even larger babies than before).

Homebirth After Cesarean:

http://vbacfacts.com/hbac/  A long and very thoughful essay, with multiple links to various issues concerning HBAC.

Further Info about Various Related Issues:

Placenta Accreta, Increta and Percreta: http://www.americanpregnancy.org/pregnancycomplications/placentaaccreta.html

Still in process of linking info….

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