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VBAC Protocols

With repeat cesarean births accounting for 1/3 of America's c-section rate, doctors are under pressure to allow more women the chance to have a vaginal birth after cesarean (VBAC). Doctors and hospitals, leery of adverse outcomes and potential lawsuits, tend to follow a standard protocol for evaluating the eligibility of a VBAC patient and managing a VBAC labor. While usually no single factor should preclude a determined woman from attempting a VBAC, women should expect to encounter certain provider requirements.

  1. Type of Incision

    • The option of a VBAC is usually presented only to women with a low transverse ("bikini") incision. A doctor generally will not work with a woman who had a classical or T-shaped incision. These types of incisions, however, are increasingly rare. Women interested in a VBAC may request the operative records of their previous delivery.

    History of Uterine Surgery

    • Many doctors insist on a repeat c-section for women who had uterine surgery, such as a myomectomy, the surgical removal of fibroids. Depending on the placement of the surgery scar, however, a VBAC could be possible. Again, surgical notes could come in handy.

    Time Between Deliveries

    • Doctors typically recommend at least 18 to 24 months between deliveries. They believe that a cesarean scar will be stronger, and less likely to tear open, if it has at least 18 months to heal.

    Number of Previous Cesareans

    • Women seeking a vaginal birth after multiple cesareans (VBAMC) should know that while it is certainly possible, finding a provider is significantly more difficult. Most doctors will not consider VBAC an option after two cesareans unless the woman also had a successful vaginal birth.

    Reason for Previous Cesarean

    • One of the first questions a doctor asks a woman seeking a VBAC is what prompted her previous cesarean. While a breech birth or placenta previa (when the placenta covers the cervix) can be considered non-repeating events, doctors might look at a diagnosis of small pelvis or failure to progress as an indication that an underlying problem in the woman's body makes her unlikely to have a successful VBAC.

    Other Health Issues

    • Most doctors rule out a VBAC in cases of gestational diabetes, hypertension, congenital defect of the fetus or other health issues. They also tend to recommend a repeat cesarean in cases of breech position (in which the baby is not head down in the uterus) and when a woman is giving birth to twins or other multiple babies.

    Spontaneous Labor Necessary

    • VBACs have a reputation for being risky because of the possibility of a uterine rupture. A uterine rupture is a potentially catastrophic tear in the uterus. In the case of a VBAC, the cesarean scar is considered weaker than a non-scarred uterus. Because the risk of uterine rupture has been found to be much higher when doctors used artificial means of inducing labor, it is generally best that a woman attempting a VBAC go into labor on her own. Because inductions are contraindicated, and doctors do not typically want to allow a gestation to pass 42 weeks, a woman giving birth by VBAC should expect her doctor to attempt to impose a time line of 40 to 42 weeks, after which the doctor would want to schedule a c-section.

    Fetal Monitoring

    • Doctors attending a VBAC often insist on continuous fetal heart monitoring. Many doctors think that monitoring decelerations in the baby's heart rate is the most effective way to detect a uterine rupture.

    Epidural

    • Some doctors require that a woman who is in labor and attempting a VBAC receive an epidural immediately upon admission to a hospital. They reason that performing an emergency c-section is much faster if an anesthesia is already in place.

    ACOG Guidelines

    • In 1999, the American College of Obstetricians and Gynecologists (ACOG) issued a recommendation that VBACs should be permitted only in institutions able to provide immediately available emergency c-sections. Many doctors and hospitals interpreted this to mean that a dedicated anesthesiologist and surgical team had to be available for each VBAC patient. This led to widespread VBAC bans and a decrease in VBAC rates. In 2010, ACOG updated its guidelines, loosening VBAC restrictions.

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