September 16, 2020

VBAC Birth Preparation

What exactly is a VBAC? VBAC stands for vaginal birth after cesarean and is a delivery option for mothers who have had a cesarean delivery prior to their current pregnancy. While vaginal birth after cesarean was not always thought of as a safe option for moms, the most recent research shows that VBAC can be a great option when the patient is an appropriate candidate.

What exactly is a VBAC anyway? VBAC stands for vaginal birth after cesarean and is an option for mothers who birthed via a Cesarean section prior to their current pregnancy. While vaginal birth after cesarean was not always thought of as a safe option for moms, the most recent research shows that VBAC can be a great option when the patient is an appropriate candidate.

Why VBAC?

So why choose a VBAC over a repeat cesarean, and what makes a patient an appropriate candidate? There are MANY reasons one might chose a VBAC over repeat cesarean, but below are some of the more common reasons.

  • Their first or most recent delivery was an unplanned cesarean and they want the opportunity to experience a vaginal delivery.

  • Cesarean births require major abdominal surgery and therefore can have longer recovery times and sometimes more difficult recoveries.

  • Cesareans require an epidural and some women may not tolerate anesthesia well.

  • Repeat cesareans come with a risk of increased scarring along the incision which can lead to difficulty with bowel and bladder function, low back pain, pain with intercourse, and infertility. This risk increases to 24.5% for a second cesarean and 46.1% for a third cesarean.

  •  Cesarean births are 4x more likely to cause blood clots than a vaginal delivery.

It should be noted that risk of uterine rupture was cited as the largest anticipated complication and risk of attempting a VBAC. However, recent research has shown that the risk of uterine rupture is only 0.2% – 0.4% in women who have a bikini cut incision and have at least 2 years between deliveries. It should also be noted that there is a 60 – 80% success rate with attempted VBAC (Mayo Clinic).

VBAC: Not a one size fits all approach

So what criteria make a patient a good candidate for VBAC? Those criteria are not limited to, but include the below. (It should also be noted that no one component alone will make a patient an ideal or non-ideal candidate for VBAC, and to have a successful VBAC there should be great consideration into the patient’s history, desired experience, and presentation at the time of delivery).

  • Low risk pregnancy

  • Low-transverse (bikini cut) incision from prior cesarean

  • Single delivery ( i.e. not twins)

  • 2 cesarean deliveries or less prior to attempted VBAC

  • 2 years or more between deliveries

  • Spontaneous labor versus induction

  • Familiarity of medical team with VBAC deliveries

Some things that might make a patient a non-ideal candidate for VBAC are:

  • Placenta Previa

  • High risk pregnancy

  • Multiple birth (twins)

  • Breech position of the baby

  • Fetal distress

  • Medical care team with limited knowledge or experience with VBAC

  • Gestation longer than 40 weeks

So, you’ve decided to give VBAC a try… now what? 

Believe it or not, there are things you can do to prepare your body for a vaginal birth after cesarean. One of the first things I would recommend is having a lengthy discussion with your OB/GYN or midwife. Discuss their comfort level in attempting a VBAC and what you can do for VBAC preparation. Ask if they have experience with vaginal delivery after cesarean, and make sure the facility you plan to give birth at has experience with VBAC deliveries. Ask your healthcare provider about the risks associated with VBAC and what that looks like for you specifically. Discuss the reasons for your prior cesarean delivery and ask if that will impact your ability to safely attempt a VBAC for this delivery. Bottom line, make sure you and your healthcare provider are on the same page. If you are hiring a doula, I would recommend including them in the care plan as well so they can advocate for you if need be. Once you feel confident in the care plan you and your birth team have established, you can start working on the physical preparation for VBAC attempt.

Pelvic PT for the win! 

Yup that’s right, pelvic PT can be hugely beneficial in helping prepare your body for a VBAC. Pelvic PTs can help assess the muscles of your pelvic floor to ensure there is no overactivity present that may hinder effective pushing during delivery. We can also assess and treat any residual scar tissue along your cesarean scar and in the surrounding tissues of your abdomen. This can help improve pelvic floor function and motor control as the pelvic floor muscles are tied closely to the function of the transverse abdominis (deep abdominals).  Lastly, we can help instruct you on how to effectively push without excessive strain on your pelvic floor. This typically includes education on the phases of labor, proper timing for an epidural, positioning to assist with cervical dilation and engaging of the baby, and an internal exam to improve the effectiveness of your pushing without placing unwanted strain on the muscles of your pelvic floor and perineum.

Your uterus PUshes your baby OUT

One of the key factors to remember during delivery is that your pelvic floor does not push your baby out, your uterus does. That’s right, your uterus is doing most of the work during delivery and your pelvic floor is just there to assist. So all that breath holding, straining, and excessive pushing you see in the movies… yeah that’s not right. What we really need to happen is for your pelvic floor to eccentrically load (lengthen in a controlled manner like slowly lowering your arm out of a bicep curl) during delivery. We also want to release any pressure that has built up in your abdomen as this is happening. That means NO breath holding. To prevent this, you should slowly exhale as you push. This will reduce the pressure in your abdomen and limit excessive strain on the pelvic floor muscles and perineum.

Allowing yourself to move for as long as possible can also be helpful in progressing labor and limiting the need for excessive intervention. Movement can help the baby engage into the birth canal and ultimately help progress cervical dilation. Therefore, it is often best to wait until you are between 5 and 6 cm dilated before you receive the epidural. This will ensure you are in the active phase of labor, and will most likely continue to progress without added intervention.

Whichever way baby arrives…

Ultimately, you want to choose the birth plan that brings you the most comfort and helps you stay the most relaxed. If that happens to be a VBAC, great. If that happens to be a repeat cesarean, great. There are cases in which the birthing momma’s anatomy just does not allow for the baby to drop down into the birth canal, no matter what you try. In those cases, the baby’s gotta come out of the sunroof (aka tummy), and that’s okay.

If you do have a repeat cesarean birth, many hospitals have begun offering a family-centered Cesarean. This allows a clear shield to allow mom to view baby’s arrival along with immediate skin-to-skin with the baby, which can be beneficial for both momma and baby. And remember, pelvic floor physical therapists specialize in postpartum treatment to help you recover from ALL types of birth experiences. So whether you have a VBAC or repeat cesarean, be sure to find a pelvic PT in your area to help with your recovery or we offer offer virtual consultations that can be hugely beneficial. If you’re local to NOLA, come see us at NOLA Pelvic Health between 4-6 weeks postpartum for a check.

Lastly, be sure to check out our recommended product list for all the postpartum recovery goodies for both vaginal and cesarean deliveries. Happy birthing to all!

Emily McElrath PT, DPT, MTC, CIDN is an orthopedic and pelvic health physical therapist with a passion for helping women achieve optimal sports performance. She is an avid runner and Crossfitter and has personal experience modifying these activities during pregnancy and postpartum. She is certified in manual therapy and dry needling. When not working, Emily enjoys time with her husband and two kids.

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