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VBAC or cesarean? A nurse midwife can help women decide

Even if a mother’s last baby was delivered by cesarean section, her next baby may not need to be born the same way. For many women, a vaginal birth after cesarean (VBAC) is not only possible—it’s recommended. That’s because VBACs are extremely safe and allow women to recover quickly.

As recently as 2006, just 16 percent of mothers who had a previous C-section attempted a trial of labor after cesarean (TOLAC). Hospitals and providers declined to offer TOLACs as an option because of fear of adverse consequences and malpractice claims. But their concern helped lead to more C-sections, which carry their own set of risks. In 2010, the American College of American College of Obstetrics and Gynecology (ACOG) recognized this and updated its guidelines to better support VBACs, stating that they are “a safe and appropriate choice for most women who have had a prior cesarean delivery.”

Why women consider VBACs

Because each person is unique, it’s important for a woman to talk to her provider about which birth option will be healthiest for her and her baby. However, expecting mothers have a lot of reasons to be excited that VBACs are back in style. VBACs enable women to:

  • Avoid major abdominal surgery: C-sections are an invasive procedure requiring a significant recuperation period. They also carry common surgery risks such as hemorrhage, infection, and injury to other organs. Women giving birth vaginally tend to recover faster, experience less pain, and have a lower risk of infection.
  • Prevent future pregnancy complications: The risk of placenta accreta, an abnormal implantation of the placenta that prevents it from easily detaching from the uterine wall, increases with each C-section due to additional scarring. Avoiding a C-section is particularly important for moms who plan on having more children.
  • Hold baby immediately: A mom giving birth vaginally can gather her newborn into her arms right away and can start nursing at the first sign of rooting.

While VBACs offer significant benefits, no type of birth is without risks. Vaginal birth carries potential complications including lacerations, infection of the uterine lining, and hemorrhage. Women laboring after a previous C-section have a higher risk of uterine rupture compared with women undergoing a repeat C-section.

In some cases a C-section is truly the best option. In those moments, I am particularly thankful for the knowledge and skills of our OBGYN doctors, nurses, and hospital staff. As a nurse midwife, I stay with patients should they be transferred into the operation room and work as a surgery assistant to our physicians. Encouragingly, many hospitals are working to improve the C-section experience by offering a “gentle cesarean,” which allows parents to see their baby being born and to experience skin-to-skin contact in the operating room.

Signs a VBAC will be successful

A women can find out if she is a candidate for a VBAC by talking with her certified nurse midwife, who will use a calculation tool to estimate the probability of having a successful VBAC. Signs that a VBAC is recommended include:

  • Successful previous vaginal delivery
  • Previous C-section with a low transverse incision
  • Baby who is positioned head-down after a previous breech baby

Women who have had a premature baby via C-section or an emergency C-section are less likely to be candidates because they may have a different kind of scar on their uterus. The size of a woman’s pelvis and the estimated weight of the baby she is carrying also matter.

Midwives shine during VBACs

A nurse midwife can be a great ally for women attempting a VBAC. Midwives are experts in supporting women through physiologic birth and believe the body has an innate wisdom allowing it to bring babies into the world. For women who are fearful, or who had an operative delivery before, a midwife can provide a safe environment and reassure them throughout the process.

Providers do take some specific precautions during all TOLACs, including continuous fetal monitoring during labor. Remote monitoring is available so that women who want to move around during labor and do not have an epidural can still do so. Additionally, patients who have had a previous C-section are limited to certain induction methods that do not increase the risk of uterine rupture.

Attempting a VBAC does not change a woman’s pain-management options. Women may choose an unmedicated delivery, IV pain medication, inhaled nitrous oxide, or epidural.

Delivery is a woman’s choice

When both a C-section and VBAC are safe delivery options for a woman, she can count on having the full support of her nurse midwife, no matter which route she chooses. Midwives’ calling is to listen to women, help them make informed choices, and enable them to achieve the birth experience they want. Whatever decision a woman makes, a midwife will respect her choice. At the end of a birth, every mother should feel empowered by the experience.

Debra Silberstein is a certified nurse midwife at Vancouver Clinic and holds a master of science in nursing with a specialization in OBGYN and midwifery care from the University of California. She became a midwife to be able to offer women choices in childbirth.