Can I Have Vaginal Delivery After Cesarean Section? (VBAC)

When I was in medical school 45 years ago, the mantra when it came to the management of pregnant women who underwent one or more C-sections was “Once a C-section, always a C-section.”.  

During my third year as a medical student, I witnessed a woman deliver by C-section even when her cervix was 9 cm dilated, or almost complete. The only reason she underwent a C-section at this late stage in her delivery was that she had had a previous C-section. As a student, this emergency approach made no sense to me. After all, she and her baby had survived the worst part of her labor. So what was the emergency requiring a C-section?  

Fast forward to 1981. When I arrived at my first practice, I met an OB doctor who was open to the notion that VBACs were a reasonable alternative to repeated C-sections. I read various studies of VBACs from different countries where the VBAC had proved safe and successful. We agreed that we would offer them. However, the prevailing practice at that time restricted the use of VBACs by requiring there was no induction and offer VBACs to women who had had at least one vaginal birth before their C-section.  

We observed our patients underwent VBACs without any problems.  

Are VBACs Dangerous? 

According to medical journals, VBAC can actually be a health advantage for women by avoiding major abdominal surgery. In the U.S., C-sections are the most common surgical procedure done in hospitals today. When I started practicing in Crookston, the C-section rate was about 15 percent. Today, it’s 34 percent. 

The risk of infection, damaging internal organs, and damage to your baby is greater with a C-section than with a VBAC after a previous C-section. 

Is Induction with VBAC Safe? 

This fear of induction with VBAC has been around for a long time. Today, the American College of Obstetricians and Gynecologists (ACOG) has a lot of information on it’s website about VBACs. Today, ACOG says induction with Pitocin is not a contra-indication for a VBAC.  

I personally prefer low dose (25 mcg) of Cytotec (misoprostol) to initiate prodromal labor (the earliest signs of labor). However, ACOG is not fond of Cytotec.  

In my years of experience and in my study of the research, bad outcomes only happen when excessive dosing with Cytotec (50 or more mcgs) is used. This is why in my practice; I would only administer 25 mcgs (and rarely a second dose within 24 hours). I avoided Pitocin for all inductions because there have been no studies done on the effect of Pitosin on the baby. Yes, that’s right. Hard to believe, isn’t it? 

Is Having a VBAC After Multiple C-sections More Dangerous? 

Over the years, I became known as the VBAC doctor. I once had a patient who’d had four previous C-sections with no vaginal births. She came to me wanting a VBAC; She had a successful labor and delivery, and a healthy baby. So no, a VBAC is not necessarily any more dangerous than any other method of delivery, even after several C-sections.  

Are Some Pelvises Too Small for Vaginal Delivery? 

The pelvis naturally expands during labor. But there is a condition called cephalopelvic disproportion (CPD) where a baby is too big for the mother’s pelvis. I offered these women VBACs because we found that the condition did not reoccur. It was thought these women would have CPD again, but most did not. 

How Do Insurance Companies Feel About VBACs? 

There is this awful incentive pay structure where insurance companies pay the most for the method of delivery we should be trying to avoid. C-sections are the easiest, the quickest, and most heavily reimbursed delivery procedure. On the other hand, VBACs which take more time and thought are reimbursed at the same leval as a vaginal birth. 

VBACs are one way of bringing down the absurd high rate of C-sections. From my perspective, VBACs are safe for both mother and baby. I have performed and supervised countless VBACs with no maternal or neonatal mortalities. VBACs are less invasive and have a lower maternal mortality rate than C-sections.  

Books

Dr. Alan Lindemann

Obstetrician-Gynecologist (OB/GYN)​

He is an obstetrician and maternal mortality expert with 4 decades of medical practice beginning in Minnesota and presently in North Dakota. He has delivered around 6,000 babies with zero maternal deaths.