VBAC Birth Plan: Complete Guide to Vaginal Birth After Cesarean

Vaginal birth after cesarean (VBAC) is a safe, achievable goal for many women with previous c-sections. This comprehensive guide covers VBAC candidacy, success rates, risks and benefits, finding supportive providers, hospital policies, and creating an effective birth plan that addresses both VBAC and possible repeat cesarean.

Understanding VBAC and TOLAC

Let's start with important terminology:

VBAC (Vaginal Birth After Cesarean): Successfully delivering vaginally after having had one or more previous cesarean deliveries.

TOLAC (Trial of Labor After Cesarean): Attempting vaginal birth after prior cesarean. TOLAC is the attempt; VBAC is the successful outcome. About 60-80% of women who attempt TOLAC achieve VBAC, meaning 20-40% require repeat cesarean.

Elective Repeat Cesarean (ERCS): Choosing scheduled cesarean delivery rather than attempting VBAC.

Why Consider VBAC?

Women choose VBAC for various reasons:

• Desire for vaginal birth experience: Experience birth they missed with cesarean
• Faster recovery: Vaginal birth typically has shorter, easier recovery than repeat surgery
• Avoid surgical risks: No anesthesia complications, surgical infections, or blood clots
• Future pregnancy safety: Multiple cesareans increase risks of placenta problems
• Shorter hospital stay: Usually 24-48 hours vs. 3-4 days for cesarean
• Bonding and breastfeeding: Immediate skin-to-skin and nursing without surgery recovery
• Sibling care: Easier to care for older children after vaginal birth
• Cost savings: Vaginal birth costs significantly less than cesarean

Why Some Women Choose Repeat Cesarean

Elective repeat cesarean is also a valid choice:

• Certainty of planned birth date and time
• Avoiding labor altogether
• Concern about uterine rupture risk
• Previous traumatic labor experience
• Medical contraindications to VBAC
• Lack of VBAC-supportive hospital or provider
• Personal preference for cesarean

Neither choice is right or wrong—it's about what's best for your individual situation and values.

VBAC Candidacy: Are You a Good Candidate?

Not everyone is a candidate for VBAC. Factors affecting candidacy include:

Favorable Factors for VBAC

Best candidates typically have:

• One or two prior low transverse cesareans: Horizontal incision in lower uterus (most common type)
• Previous vaginal delivery: Especially prior successful VBAC—increases success to 85-90%
• Spontaneous labor: Going into labor naturally vs. induction
• Non-recurring reason for prior cesarean: Breech, placenta previa, or other one-time situation
• VBAC-supportive provider and hospital: Essential for success
• Normal pregnancy: No complications contraindicating vaginal birth
• Adequate pelvis: Previous cesarean wasn't for cephalopelvic disproportion (baby too big for pelvis)
• Appropriate infant size: Baby estimated under 9 pounds

Challenging But Possible Scenarios

These factors reduce but don't eliminate VBAC candidacy:

• Prior cesarean for failure to progress: Recurring issue but VBAC still possible, especially if baby is smaller
• Obesity: Reduces success rates but many obese women achieve VBAC
• Advanced maternal age: Lower success rates but not a contraindication
• Gestational diabetes: May affect baby size but doesn't preclude VBAC
• Short interval since cesarean: Less than 18 months increases rupture risk slightly
• Need for induction: Lower success rates than spontaneous labor but still possible

VBAC Contraindications

VBAC is not recommended if you have:

• Previous classical (vertical) uterine incision: High rupture risk (4-9%)
• Previous T-shaped or extensive uterine incision: High rupture risk
• Previous uterine rupture: Significantly increased risk of repeat rupture
• Three or more prior cesareans: Higher rupture risk, though some providers support VBAC
• Placenta previa or accreta: Cesarean necessary
• Other contraindications to vaginal birth: Active herpes outbreak, certain fetal positions, etc.

Important: Ask your previous surgeon about your uterine incision type. Your abdominal incision (skin) doesn't necessarily match your uterine incision. You need to know the uterine incision type to determine VBAC candidacy.

VBAC Success Rates

Understanding your likelihood of successful VBAC helps set realistic expectations:

Overall Statistics

• General VBAC success rate: 60-80% depending on individual factors
• With prior vaginal delivery: 85-90% success
• With prior successful VBAC: 85-90% success
• Spontaneous labor: 75-85% success
• Induced labor: 60% success (lower but still majority)
• Prior cesarean for breech: 85% success
• Prior cesarean for failure to progress: 60-67% success

Factors That Increase Success

• Previous vaginal birth (before or after cesarean)
• Spontaneous labor onset
• Cervical dilation at admission (more dilated = higher success)
• Non-recurring reason for prior cesarean
• Normal weight BMI
• Maternal age under 35
• Baby under 8 pounds, 13 ounces
• Short labor duration

Factors That Decrease Success

• No prior vaginal delivery
• Labor induction, especially without favorable cervix
• Prior cesarean for cephalopelvic disproportion or failure to progress
• Obesity (BMI over 30)
• Maternal age over 35
• Baby over 9 pounds
• Gestational age over 40 weeks
• Short stature (under 5 feet)
• Two or more prior cesareans

Use online VBAC calculators (like the MFMU calculator) to estimate your personal success probability based on your specific factors.

Understanding VBAC Risks

Making an informed decision requires understanding both VBAC risks and repeat cesarean risks:

Primary VBAC Risk: Uterine Rupture

The main concern with VBAC is uterine rupture—separation of the previous cesarean scar:

Incidence:

• With one prior low transverse cesarean: 0.5-0.9% (about 1 in 200)
• With two prior cesareans: 1.5% (about 1 in 67)
• With prior classical incision: 4-9% (much higher—VBAC not recommended)
• With labor induction using Pitocin: Slightly higher than spontaneous labor
• With labor induction using prostaglandins (Cytotec): Much higher—generally avoided

What happens during rupture:

• Most ruptures cause abnormal fetal heart rate requiring emergency cesarean
• Many ruptures are small separations managed successfully
• Rarely, rupture can cause severe maternal hemorrhage or fetal oxygen deprivation
• Maternal death from rupture is extremely rare (about 1 in 100,000 VBAC attempts)
• Serious fetal consequences occur in about 6% of ruptures

Important context: While uterine rupture sounds terrifying, keep perspective. The risk is less than 1%. Most ruptures are successfully managed. And repeat cesarean also carries serious risks.

Other VBAC-Related Risks

• Need for repeat cesarean: 20-40% likelihood
• Emergency cesarean complications: Higher risk than planned cesarean
• Labor duration: May be longer than first-time labor
• Emotional impact: If VBAC attempt results in repeat cesarean

Risks of Elective Repeat Cesarean

Repeat cesarean isn't risk-free either:

• Surgical risks: Infection, hemorrhage, blood clots, anesthesia complications
• Adhesions: Scar tissue making surgery more difficult and risky
• Injury to bladder or bowel: Risk increases with each cesarean
• Longer recovery: 6-8 weeks vs. 2-4 weeks for vaginal birth
• Future pregnancy risks: Placenta previa, placenta accreta, uterine rupture in subsequent pregnancies
• Hysterectomy risk: Increases with number of cesareans
• Baby's risks: Respiratory issues, accidental surgical cuts, no labor hormones

The safety comparison: For women with one prior low transverse cesarean, VBAC and repeat cesarean have similar overall safety profiles, with different risk profiles. VBAC has very small uterine rupture risk, while repeat cesarean has surgical risks and future pregnancy complications.

Finding VBAC-Supportive Providers and Hospitals

Provider and hospital support dramatically affects VBAC success:

Choosing a VBAC-Supportive Provider

Questions to ask prospective providers:

• "What is your VBAC rate?" (Look for 60% or higher)
• "What percentage of your TOLAC patients achieve VBAC vs. repeat cesarean?"
• "Under what circumstances do you recommend against VBAC?"
• "What is your approach to labor management for VBAC?"
• "How long do you allow VBAC labor to progress before recommending cesarean?"
• "What are your policies on VBAC induction?"
• "Do you support water birth for VBAC?" (if desired)
• "What interventions do you routinely use during VBAC?"
• "Will you be the one attending my birth, or could it be a partner/on-call doctor?"
• "Have you had experience with successful VBACs?"

Provider types to consider:

• OB/GYNs: Vary widely in VBAC support; some are very supportive, others push repeat cesarean
• Midwives: Generally more VBAC-supportive; can only attend in hospitals or birth centers with physician backup
• Family practice doctors: Some are trained in VBAC attendance
• Maternal-fetal medicine specialists: For high-risk VBAC candidates

Red flags: Providers who seem hesitant, focus only on risks without mentioning benefits, have very low VBAC rates, or make you feel your desire for VBAC is unreasonable.

Hospital Policies and VBAC

Hospital policy can make or break your VBAC attempt:

What to ask hospitals:

• "Do you allow VBAC?" (Some have outright bans)
• "What is your VBAC rate?"
• "What restrictions do you have on VBAC?" (Induction? Epidural? Continuous monitoring?)
• "Do you have 24/7 anesthesia and surgical team availability?"
• "What is your policy on VBAC induction?"
• "Can I use hydrotherapy/birth tub for VBAC?"
• "What monitoring is required for VBAC?"
• "Can I eat and drink during VBAC labor?"
• "How long can I labor before you recommend cesarean?"

VBAC-friendly hospital characteristics:

• VBAC rate of 30% or higher (of women with prior cesarean)
• 24/7 immediate cesarean capability
• Supportive policies (allows induction if needed, intermittent monitoring option, mobility)
• Staff trained and experienced in VBAC
• Birth tub availability for VBAC (bonus)

Alternative Birth Locations

Birth centers: Some birth centers accept VBAC candidates, especially those with previous vaginal birth. Requires physician backup and nearby hospital for transfer if needed.

Home birth: Controversial for VBAC due to uterine rupture risk. Some midwives attend home VBAC (HBAC), but it requires careful risk assessment and clear transfer plan. ACOG doesn't recommend home VBAC, but some women choose it when hospital VBAC isn't available or has unacceptable restrictions.

Creating Your VBAC Birth Plan

A VBAC birth plan addresses both your ideal VBAC scenario and preferences for possible repeat cesarean:

Part 1: VBAC Labor Preferences

Monitoring:

• "I understand continuous fetal monitoring is recommended for VBAC to watch for signs of uterine rupture"
• "I request wireless/telemetry monitoring if available so I can remain mobile"
• "If continuous monitoring is required and wireless unavailable, please help me change positions frequently"
• "I'd like intermittent monitoring if my labor is progressing well and baby is tolerating labor" (some hospitals may allow this)

IV Access:

• "I understand IV access is recommended for VBAC for emergency access if needed"
• "I prefer saline lock over continuous IV fluids if acceptable"
• "I'd like to stay hydrated with oral fluids"

Mobility and Movement:

• "I'd like to remain mobile and change positions throughout labor"
• "Please support my use of birth ball, squatting bar, and different positions even with continuous monitoring"
• "I'd like access to shower for hydrotherapy"
• "I'd like to use the birth tub for labor if available and permitted for VBAC at this hospital"

Pain Management:

• "I plan to use natural pain management techniques (breathing, movement, hydrotherapy)"
• "I'm open to epidural if labor becomes very long or challenging"
• "Please don't offer pain medication—I'll request it if wanted"
• (Or: "I plan to request epidural during active labor")

Note: Epidural doesn't increase uterine rupture risk or decrease VBAC success. Choose based on your pain management preferences, not VBAC concerns.

Labor Augmentation:

• "Please allow my labor to start spontaneously if possible"
• "If induction becomes medically necessary, I prefer [method]"
• "I'm open to Pitocin augmentation if my labor stalls, starting with low doses"
• "Please avoid prostaglandins (Cytotec) due to increased rupture risk"
• "Please explain why any intervention is being recommended before proceeding"

Other Interventions:

• "Please allow my membranes to rupture naturally unless there's a medical reason to break them"
• "I prefer minimal vaginal exams—only when necessary to assess progress"
• "I'd like to eat light foods and drink fluids during early labor"
• "Please keep me informed about my progress and baby's status"

Duration of Labor:

• "I understand VBAC labor may progress differently than first-time labor"
• "If my labor is progressing and baby is tolerating it well, I'd like to continue laboring even if it's slow"
• "Please discuss with me before recommending cesarean, explaining the medical reason"
• "I'm committed to VBAC but understand cesarean may become necessary for safety"

Pushing and Delivery:

• "I'd like to push in positions that feel right to me"
• "I prefer spontaneous pushing following my body's urges"
• "Please support my perineum to reduce tearing"
• "Please avoid episiotomy unless absolutely necessary"
• "Delayed cord clamping until cord stops pulsing"
• "Immediate skin-to-skin contact with baby"

Part 2: Backup Plan for Repeat Cesarean

Since 20-40% of VBAC attempts end in cesarean, address this possibility:

Decision-Making:

• "Please explain clearly why cesarean is being recommended"
• "If it's not an emergency, I'd like time to discuss the decision with my partner"
• "I'd like to understand what we could try first before proceeding to cesarean"
• "If cesarean becomes necessary, I request the following preferences:"

Cesarean Preferences (see our complete c-section guide for details):

• Partner present in OR
• Gentle cesarean techniques if possible
• Screen lowered to watch birth
• Immediate skin-to-skin contact
• Delayed cord clamping
• Explanation of what's happening
• Calm, quiet atmosphere

Part 3: Immediate Postpartum (Both Scenarios)

• "Immediate and uninterrupted skin-to-skin contact for at least first hour"
• "Support for breastfeeding initiation within first hour"
• "Delay non-urgent newborn procedures until after bonding time"
• "Baby rooms-in with us 24/7"
• "Please no pacifiers or formula without discussing with me first"
• "Lactation consultant support"

Preparing for Your VBAC

Physical Preparation

• Exercise regularly: Walking, prenatal yoga, swimming build stamina
• Optimal fetal positioning: Encourage baby into good position through posture and movement
• Nutrition: Maintain healthy weight gain, balanced diet
• Perineal massage: May reduce tearing risk (starting at 34 weeks)
• Rest: Build up energy reserves for labor

Mental and Emotional Preparation

• Process your previous cesarean: Work through any trauma or disappointment
• Educate yourself: Take VBAC-specific childbirth classes if available
• Address fears: Work through anxiety about labor, pain, or potential rupture
• Visualize success: Practice seeing yourself achieving VBAC
• Join VBAC support groups: Online or in-person communities
• Read positive VBAC stories: Build confidence through others' successes
• Practice relaxation: Hypnobirthing, meditation, breathing techniques
• Prepare for both outcomes: Hope for VBAC but make peace with possibility of repeat cesarean

Logistical Preparation

• Tour VBAC-friendly hospital: Understand policies and environment
• Meet backup providers: Know who might attend if your provider isn't available
• Hire a VBAC-experienced doula: Continuous support increases success
• Prepare your partner: Discuss birth plan, comfort measures, advocacy role
• Arrange childcare: For older children during labor
• Pack hospital bags: For both vaginal birth and cesarean scenarios

Labor and Delivery: What to Expect

Early Labor at Home

• Labor at home as long as comfortable and safe
• Rest, stay hydrated, eat light foods
• Use comfort measures: breathing, movement, shower
• Time contractions to know when to go to hospital
• Trust your body's ability to labor

Hospital Admission

• Arrive when contractions are regular and strong (or per your provider's instructions)
• Cervical exam to assess dilation
• IV placement (saline lock or continuous IV per hospital policy)
• Continuous fetal monitoring will likely be required
• Give copy of your birth plan to admitting nurse
• Discuss any policy restrictions you weren't aware of

Active Labor

• Continue changing positions despite monitoring
• Use pain management techniques
• Request epidural if desired (doesn't affect VBAC success)
• Stay focused and positive
• Trust your support team
• Communicate your needs

Signs of Potential Uterine Rupture

Rare but important to recognize:

• Abnormal fetal heart rate pattern (most common sign)
• Sudden severe abdominal pain between contractions
• Loss of contraction strength
• Vaginal bleeding
• Referred shoulder pain

Continuous monitoring is designed to catch abnormal heart rate patterns immediately, allowing for prompt cesarean delivery. This is why most providers require continuous monitoring for VBAC.

Pushing and Birth

• Push in positions that feel effective
• Follow your body's urges
• Remember this is the final stage—you're about to meet your baby!
• Celebrate achieving VBAC!

If Repeat Cesarean Becomes Necessary

• Understand why it's being recommended
• Know that laboring before cesarean isn't "failing"—you gave it your full effort
• Advocate for your cesarean preferences
• Focus on meeting your baby safely
• Allow yourself to grieve if needed, but also celebrate your baby

After Your VBAC or Repeat Cesarean

If You Achieve VBAC

• Celebrate! You worked hard for this
• Enjoy typically faster recovery than cesarean
• Process the experience—it may bring up feelings about your previous cesarean
• Share your positive story to encourage other VBAC hopefuls
• Know that future VBACs have even higher success rates

If You Have Repeat Cesarean

• Allow yourself to feel disappointed while also celebrating your baby
• Understand that TOLAC itself has benefits even if it didn't end in VBAC
• Debrief with your provider about why cesarean was necessary
• Seek support for processing the experience
• Know your feelings are valid
• Consider therapy if birth was traumatic
• Remember: you're not a failure—you made the right decision for you and your baby

VBAC After Multiple Cesareans (VBA2C, VBA3C)

VBAC is possible after two or even three previous cesareans, though success rates and risks differ:

VBA2C (Vaginal Birth After 2 Cesareans):

• Success rate: 70% (similar to one prior cesarean)
• Uterine rupture risk: 1.5% (slightly higher than one cesarean)
• Many providers support VBA2C
• May be harder to find supportive hospital

VBA3C (Vaginal Birth After 3+ Cesareans):

• Limited data on safety and success
• Rupture risk likely higher
• Very few providers and hospitals support this
• Requires careful individualized risk assessment

Frequently Asked Questions

The Bottom Line

VBAC is a safe, achievable goal for many women with previous cesareans. With proper candidate selection, supportive providers, appropriate monitoring, and preparation for both possible outcomes, the majority of women attempting VBAC succeed.

The decision between VBAC and repeat cesarean is deeply personal. Both options carry risks and benefits. Educate yourself thoroughly, discuss your individual situation with your provider, find supportive care, and trust yourself to make the right choice for your family.

If you choose VBAC, go into it informed and prepared, with realistic expectations and a backup plan. Remember that even if you need a repeat cesarean, laboring first often has benefits, and you should feel proud of your effort.

Ultimately, whether you achieve VBAC or have a repeat cesarean, what matters most is that you, your baby, and your family are healthy and that you feel supported, informed, and respected throughout your birth experience.