Should I Try for VBAC Again?
One of the most difficult dilemmas CBAC moms face is whether or not to have more children, and if they do, whether to schedule an Elective Repeat Cesarean Section (ERCS) or try for a VBAC again.
There is no one right answer to this. Different mothers will choose different things, and this is perfectly fine. One woman's answer does not have to be your answer, nor will your answer suit every woman.
Some mothers will decide to end their family at its current size rather than risk going through another cesarean, either planned or during labor. For some, it's just too emotionally painful to go through pregnancy and another cesarean again.
Some will decide to go ahead and have another child, but will choose a repeat cesarean so they don't have to risk ending up with another CBAC. For them, a CBAC is so emotionally devastating that they don't want to even chance it again. It may feel emotionally safer to just choose a planned cesarean from the get-go.
Others may have trouble finding a provider that supports VBAC after 2 Cesareans (VBA2C) and so may not have a choice, even though the American Congress of Obstetricians and Gynecologists (ACOG) supports VBA2C as an option. Others will have trouble finding a provider that supports VBAC after more than 2 prior cesareans (VBAC after Multiple Cesareans, or VBAMC). Although these can be hard to find, it's important to know that there ARE care providers who still support higher-order VBAMCs.
On the other hand, many CBAC moms decide to go for a VBAC again. They want more children and would rather avoid the substantial risks of repeated cesareans, which include an increasing chance of surgical injury, hemorrhage, hysterectomy, cesarean scar pregnancy, and placental disorders like previa, abruption, and accreta (Silver 2006, Rosen 2008).
Many CBAC mothers may want to avoid the pain of yet another surgical recovery, especially with other children in the house who need active mothering. Although they have managed to deal with unwelcome cesareans before and could again if need be, they would like to avoid having to do so if possible, and so choose to go for a VBAC again.
All of these decisions have been chosen by CBAC mothers in the past, and all are perfectly legitimate choices. Only you can figure out which is the right one for you.
Should CBAC Mothers Have Another Opportunity to VBAC?
One of the most pressing questions for many CBAC women is whether they will be "allowed" to try for a VBAC again. In this hostile birth climate where even many first-time VBAC candidates cannot find support, it is even harder to find support for VBAC after CBAC.
At this time, many hospitals do not support VBAMC of any kind, but because ACOG revised its VBAC guidelines to support a VBAC after 2 prior cesareans, more CBAC mothers now will have the option to try. And there are some providers out there who will support higher-order VBACs as well.
Sadly, many will face roadblocks from doctors who tell them that they are no longer a "good candidate" for a trial of labor (TOL) because they had a CBAC. Yet this is based more on the care provider's biases than on actual facts.
Because of the increased morbidity associated with a "failed trial of labor," many researchers have tried to invent a model that can accurately predict who will and won’t have a VBAC. Although it is possible to predict with some precision who will have a successful VBAC, most research has found it very difficult to predict accurately who will not have a VBAC (Dinsmoor and Brock, 2004; Grobman et al., 2007). Other authors (Eden 2010) reviewed a number of VBAC prediction models and concluded:
Current scored models provide reasonable predictability for VBAC, but none provides consistent ability to identify
women at risk for failed trial of labor.
In other words, care providers cannot predict accurately who will not have a VBAC.
Prediction models can help care providers tell you if you have characteristics that give a high probability of having a VBAC (for example, a prior vaginal birth, a non-recurring prior indication for cesarean like breech, fetal distress, etc.), but they cannot accurately tell you who should not have a trial of labor because they are unlikely to have a VBAC.
Many women have had very low scores in VBAC prediction models and still ended up having a VBAC.
VBAC prediction models are one more piece of information to consider in decision-making, but the poor performance of these prediction models mean that their use must be treated with great caution when denying women the right to a TOL.
Although women with a "failed" TOL have a higher rate of complications (El-Sayed 2007, Hibbard 2001, Durnwald and Mercer 2004), researchers have found that they are not able to predict which women will experience major morbidity (Scifres 2011). Therefore, these morbidity prediction models should also not be used to deny women the right to a TOL.
Many doctors assume that once you've had a “failed” VBAC, it means you truly can’t give birth vaginally. However, Phelan (1989) found that many women with CBACs were able to go on and have VBACs with another attempt. In their study, 53% of women who had a primary labor cesarean and then a TOL CBAC went on to have a VBA2C anyhow. They also found that 56% of women who had 2 cesareans for "cephalopelvic disproportion" or "failure to progress" during labor (in a primary c-section and then a CBAC) went on to have a VBA2C.
Anecdotally, many CBAC mothers in ICAN have gone on to have VBACs in later pregnancies.
So although some care providers may try to tell you that your CBAC disqualifies you from another TOL, this is not necessarily true. You might have to search long and hard for a provider who will attend you, but a CBAC mother can indeed go on to have another TOL, and many do succeed in having a VBAC. A TOL remains a viable option for those CBAC mothers who want it.
Only you should get to decide your childbearing plans. They should not be dictated by care providers, other family members, birth politics, or members of the greater community.
Only you get to decide whether or not to have more children. It's very normal after a CBAC to consider yourself "done" and ready to end your family because of the disappointment of the CBAC and the physical recovery of yet another cesarean. It's also very common for husbands/partners to pressure women to be "done" after a CBAC because they are loathe to see the woman they love risk such a difficult journey again. Yet it's important not to take permanent birth control measures too soon after a CBAC; many women who think they are "done" afterwards go on to change their minds with time. Wait at least a year or two (and preferably longer) before you make any permanent decisions.
If you do decide to have more children, you are the one who should decide whether or not to go for another VBAC. This is a very personal decision and should not be made because of birth politics or unsupportive care providers. It should come from both a clear understanding of the risks and benefits of both choices and a deep inner knowing of what's right for you.
Some women have complications or circumstances that make another TOL unwise. Obviously, a repeat cesarean in this situation is the best choice, but it's perfectly fine to have ambivalent feelings about it. And there are ways to plan even an unwanted cesarean to make it feel more empowering and family-centered.
Some women cannot face the disappointment of the possibility of another CBAC and so choose a repeat cesarean. There is nothing wrong with this choice. There can be healing in this choice too.
Some women choose to go for a VBAC again. Because a “failed” TOL cannot be predicted accurately, because maternal morbidity cannot be predicted accurately, and because what little research we have on the topic suggests that more than half of women who try for another VBAC will get one, another TOL can be a legitimate choice too. Although many providers will discourage this, there are doctors and midwives who will attend VBAC after a CBAC. Many women in ICAN have had multiple TOLs, and many have gone on to have a VBAC in time.
Perhaps you are not sure what choice is right for you. Many CBAC mothers enter another pregnancy not knowing whether or not they want to make another VBAC attempt or have a repeat cesarean. It's perfectly normal to not be sure, or to waver in your decision at times during your pregnancy.
Nearly every CBAC mother second-guesses her decision at some point in the pregnancy, even if she was sure of her choice at the start. If you are not sure what to do, ask yourself which decision would give you the most peace in the long term, looking back at it after many years. "Try on" each decision for several days or weeks and see how it makes you feel. In the end, your heart will lead you to the decision that is right for you.
Whatever a woman's decision, whether for a repeat cesarean or another VBAC attempt, her choice should be respected. In the end, the decision should be up to the mother.
http://www.childbirthconnection.org/article.asp?ck=10212 - excellent evidence-based summary of the benefits and risks of birth choice after a previous cesarean
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El-Sayed YY, Watkins MM, Fix M, Druzin ML, Pullen KKM, Caughey AB. Perinatal outcomes after successful and failed trials of labor after cesarean delivery. American Journal of Obstetrics and Gynecology 2007 Jun;196(6):583.e1-5; discussion 583.e5. PMID: 17547905
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Durnwald C and Mercer B. Vaginal birth after Cesarean delivery: predicting success, risks of failure. J Matern Fetal Neonatal Med 2004 Jun;15(6):388-93. PMID: 15280110
Scifres CM, Rohn A, Odibo A, Stamilio D, Macones GA. Predicting significant maternal morbidity in women attempting vaginal birth after cesarean section. Am J Perinatol 2011 Mar;28(3):181-6. PMID: 20842616
Phelan J et al. Twice a cesarean, always a cesarean? Obstetrics and Gynecology 1989 Feb;73(2):161-5. PMID: 2911420