When Breanna Jay was pregnant with her first son, she expected a vaginal delivery. But when she was 38 weeks pregnant, she learned her son’s feet were facing downward, what’s known as breech. Doctors said they could try to turn the baby to allow for a vaginal birth. But, the doctors just couldn’t get the baby to budge and she needed a cesarean section to deliver him.
“I was prepped for a C-section essentially,” the 36-year-old social worker in Pittsburgh told TODAY. “I was pretty devastated about the C-section. I was crying through the whole thing.”
While her birth class mentioned that sometimes C-sections happened, Jay had an idea of what birth would be like and a major surgery isn't what she imagined.
“I really had not taken the time to think about what a C-section would look like or didn't really even know very much about it,” she said. “To be honest, I was woefully unprepared.”
What’s more, her son experienced respiratory distress and needed to stay in the neonatal intensive care unit. She struggled with the pain of recovering from a major surgery, coping with a son in the NICU and then caring for an infant.
When she became pregnant again, the midwives at her birthing center told her she was a candidate for a trial of labor, which if successful is called a vaginal birth after cesarean (VBAC).
“A vaginal birth after cesarean is an option that a woman can decide on after she had a cesarean delivery,” Dr. Francine Hippolyte, an OB-GYN and vice chair of clinical operations at Long Island Jewish Medical Center, who did not treat Jay, told TODAY. “A woman may opt to birth by a vaginal delivery approach and not undergo a repeat cesarean section.”
Jay was excited to try for a vaginal delivery.
“I have nothing but positive memories,” she said.
Amanda Bacon — who had a picture of her in mesh maternity underwear after her VBAC go viral in 2016 — also preferred vaginal delivery compared to the C-section she had with her first child.
“It was wonderful. I remember feeling like I was on cloud nine … I didn't know that after you have a C-section you get wheeled into recovery and they separate you from the baby,” the 31-year-old from Wilmington, North Carolina told TODAY. “Immediately getting my son put on my chest after delivering him vaginally was the best feeling.”
Who qualifies for a VBAC?
Women who have a transverse scar or a bikini incision, a low horizontal incision, qualify to try a trial of labor.
“In general, we quote anywhere from 60 to 80% success rate for women who decide to undergo a VBAC, understanding there may be some exceptions,” Hippolyte said.
Women who had a “classical cesarean,” which is an incision that is vertical on the abdomen, cannot have a VBAC.
“If said incision is up and down on the uterus through the main, muscular portion of the stomach, that has up to a 12% risk of rupture if a person labors,” Dr. Christine Greves, an OB-GYN in Orlando told TODAY. “That woman would not be a candidate.”
Other conditions that might exclude a woman from trial of labor include:
- Breech babies.
- Having had uterine surgery that cuts through the muscle.
- Placenta previa, where the placenta covers the cervix.
- Some birth defects, especially ones that impact the neural tube, such as spina bifida.
“If it's somebody for whom we would normally let them have a vaginal delivery then we would likely let them have a VBAC,” Dr. Katherine Economy, a maternal fetal medicine doctor in the department of obstetrics and gynecology at Brigham and Women’s Hospital in Boston, told TODAY. “When thinking about talking to women about whether or not they want to have a VBAC the first (consideration) is: Are they a candidate, so, is it a safe choice for them?”
The number of C-sections a woman has had might play a role in considering a VBAC. It is possible that a woman who had two C-sections could try a trial of labor.
“It might be that your risk of uterine rupture or scar separation is a little higher than it is after just one C-section. But for most hospitals that offer trial of labor as a possibility for women, I think they wouldn't necessarily exclude you because you had two,” Economy explained. “There is not any substance of data on three prior C-sections (and trial of labor).”
But Economy stresses the need for doctors to work with their patients to find what’s most comfortable.
“It's just really important to have very patient-centered individual counseling about what is best for them,” she said.
A trial of labor does come with risks. Women who do not progress with labor might have to have a C-section, for example. In fewer than 1% of VBACs women experience uterine ruptures, according to a practice bulletin in the journal Obstetrics and Gynecology. A uterine rupture describes when the incision separates causing a tear in the uterus. This can put mom and baby at risk and, in some cases, could result in a hysterectomy.
“There is a range,” Economy explained. “There’s what we consider catastrophic uterine rupture.”
When this occurs both mom and baby might experience weakened vital signs that require a quick C-section. The damage to the uterus could be so severe that a hysterectomy is required.
While doctors and midwives want to make sure their patients understand the risks, hearing about uterine rupture caused Jay to worry. Jay had midwives who partnered with doctors so that they could be there in case of a C-section.
“It is very anxiety-producing to be honest,” she said. “The midwives do mood counseling throughout the pregnancy … that was very helpful to address my anxiety related to having a VBAC.”
Can you have a VBAC at home or a birthing center?
It’s not recommended for women to attempt a VBAC at home or in a birthing center, Economy said. That’s to protect mom and baby if the trial of labor results in a C-section.
“The reason that we don't endorse letting women have home birth with C-section scars is that there is a certain percentage of scar separation and uterine rupture and those can be very devastating outcomes for mother and baby, if you don't have immediate access to cesarean delivery,” Economy said.
The benefits of a VBAC
Bacon suffered a fourth-degree tear in her perineum after her VBAC. Even still, she felt recovery was much quicker.
“It was so much easier,” she said. “Right on my feet after obviously. In that picture I was eating donuts because I had gestational diabetes and I couldn’t eat anything sweet … The second he came out I was like, ‘Get me on my feet and give me some donuts.'”
Jay agrees. After her first VBAC in 2017, she was at the grocery store two days later. She had her second VBAC in 2020 while she had COVID-19.
“Even with COVID (it was better),” she said.
The experts say VBAC recovery is often easier.
“Recovery with the cesarean sections is a little bit more, regarding pain and also regarding (walking) for some women,” Hippolyte said. “We can anticipate more bleeding or higher blood loss with a cesarean section.”