Vaginal Birth After Cesarean (VBAC): Dream or Reality?

Just yesterday, while reading through patient testimonies, I came across the moving story of a woman who gave birth vaginally after four previous cesarean deliveries. As an obstetrician-gynecologist, such a testimony immediately stirs mixed feelings: admiration for the mother’s strength, but also concern about the safety of such a choice.

The topic of VBAC has been at the center of passionate debate for decades. Should it be encouraged, restricted, or even discouraged? As so often in medicine, the answer lies in balancing risk and benefit—and, above all, in careful patient selection.

When is VBAC a reasonable option?

VBAC is considered a safe possibility under certain well-defined conditions:

• A single prior cesarean delivery with a low transverse uterine incision.

• A singleton pregnancy (one baby).

• A cephalic presentation (baby head-down).

• No major obstetric contraindications (placenta previa, proven cephalopelvic disproportion, etc.).

Under these circumstances, studies suggest a VBAC success rate of 60–80%.

What are the risks?

The main risk, and the one most feared, is uterine rupture at the site of the previous cesarean scar.

• Its incidence is estimated at 0.5–1% after a single cesarean.

• Consequences can be severe: maternal hemorrhage, acute fetal distress, need for emergency cesarean, or even hysterectomy.

Other risks exist—failed VBAC, complex lacerations, blood transfusions—but these are broadly comparable to those of an elective repeat cesarean.

What are the advantages of a successful VBAC?

A successful vaginal birth after cesarean offers many benefits for both mother and baby:

• Fewer surgical complications: no abdominal incision, lower risk of infection, hemorrhage, or visceral injury.

• Faster recovery: earlier mobility, shorter hospital stay, quicker return to daily activities.

• Fewer complications in future pregnancies: each additional cesarean increases the risk of adhesions, placenta previa or accreta, and surgical complications.

• Positive birth experience: for many women, the chance to give birth vaginally holds great psychological and emotional value.

  
  

What ensures safety?

The cornerstone of a safe VBAC is adequate obstetric care:

• Delivery in a hospital setting with an operating theater immediately available.

• A trained obstetric team present 24/7.

• Continuous fetal heart rate monitoring.

• Fully informed maternal consent after honest discussion of risks and benefits.

  
  

What do international guidelines say?

• ACOG (U.S.): recommends VBAC after one prior low transverse cesarean, provided immediate surgical capability is available. VBAC after two cesareans is possible in selected cases.

• RCOG (U.K.): encourages VBAC after one cesarean with strict monitoring; may be considered after two cesareans in favorable circumstances.

• HAS (France): advises systematically offering VBAC after a single cesarean, unless contraindicated.

• WHO: stresses the importance of reducing unnecessary cesarean deliveries. Safe VBAC is a key way to avoid repeated cesareans and their cumulative complications.

Most professional bodies do not recommend VBAC after more than two cesareans, due to lack of robust evidence and higher risk of uterine rupture.

Conclusion

VBAC is neither a utopian dream nor an unreasonable gamble. It is a valid and safe option for carefully selected women, provided that experienced teams and rapid intervention facilities are in place.

The story of this mother who gave birth vaginally after four cesareans is a powerful reminder of the resilience and surprises of childbirth. But as an obstetrician, I hold to one essential truth: every birth is unique, and the safety of mother and child must always guide our decisions.

Thank you for your attention.I remain at your disposal for any further discussion or questions, and I send you my warm regards.

Dr. Sandra Yene Amougui