Vaginal Birth After Cesarean (VBAC): Evidence, Risks, and How to Decide

Ashley Strengholt
Oct 16
5 min read

Many women who have experienced a prior cesarean birth wonder whether a vaginal birth after cesarean (VBAC) is possible - and whether it’s safe. The short answer: for most women with one previous low-transverse cesarean, a trial of labor after cesarean (TOLAC) can be a safe and reasonable option when carefully planned and monitored (American College of Obstetricians and Gynecologists [ACOG], 2021; Royal College of Obstetricians and Gynaecologists [RCOG], 2022). For others, a repeat cesarean may be safer depending on personal and medical factors. This article summarizes current research, risks, and benefits to help you make an informed decision with your provider.

What Is a VBAC?

A VBAC occurs when a woman gives birth vaginally after a previous cesarean delivery. The process leading up to this is known as a trial of labor after cesarean (TOLAC) - an attempt to labor with the goal of vaginal birth. If the trial succeeds, the outcome is a VBAC; if not, it ends in a repeat cesarean.

How Likely Is a Successful VBAC?

Success rates vary, but studies consistently report that 60–80% of women who attempt a TOLAC achieve a VBAC (ACOG, 2021; Landon et al., 2004). Predictors of success include a prior vaginal birth (especially a previous successful VBAC), spontaneous (non-induced) labor, and a prior cesarean for non-recurrent causes such as breech presentation (RCOG, 2022). Factors that lower success rates include induction of labor, higher body mass index, older maternal age, or a cesarean done previously for failure to progress (Tahseen & Griffiths, 2010).

The Benefits of VBAC

A successful VBAC offers both short-term and long-term advantages compared with a repeat cesarean:

Shorter recovery: Vaginal births typically involve less postoperative pain, lower infection rates, and faster hospital discharge (Guise et al., 2010).
Reduced surgical risks: Avoiding another abdominal surgery lowers the risk of hemorrhage, transfusion, and anesthesia complications.
Fewer complications in future pregnancies: Each repeat cesarean increases the risk of placenta accreta spectrum and other implantation disorders (Silver et al., 2006).
Emotional and psychological satisfaction: For many mothers, achieving a VBAC can be an empowering experience and a source of healing after a difficult prior birth.

Given the rising rate of cesarean deliveries worldwide, major health organizations now encourage offering VBAC to eligible women as a way to reduce overall cesarean rates and related complications (World Health Organization, 2018).

The Risks of TOLAC

While most women who attempt VBAC have healthy outcomes, TOLAC carries distinct risks.The most serious is uterine rupture, when the scar from the previous cesarean opens during labor. Although rare, this complication can lead to severe maternal bleeding, need for hysterectomy, or neonatal distress.

The risk of complete uterine rupture after a single low-transverse incision is approximately 0.5–0.9% (Landon et al., 2004; RCOG, 2022).
The risk increases with induction or augmentation of labor, particularly when prostaglandins are used (Harper et al., 2012).
A prior classical (vertical) incision carries a much higher rupture risk (4–9%), making VBAC generally contraindicated in those cases (ACOG, 2021).

If a uterine rupture occurs, an emergency cesarean is required immediately - hence the importance of laboring in a facility capable of performing an urgent surgical delivery.

An unsuccessful TOLAC (one that ends in cesarean) also carries higher maternal morbidity - mainly infection, hemorrhage, or transfusion - than a planned repeat cesarean (Guise et al., 2010). Therefore, individual assessment is crucial.

VBAC vs. Elective Repeat Cesarean: What the Evidence Shows

Systematic reviews and national guidelines consistently conclude that both planned VBAC and planned repeat cesarean are safe choices when managed appropriately, each with its own risk profile (Dodd et al., 2013; ACOG, 2021). TOLAC carries a slightly higher risk of rare, acute complications (such as uterine rupture or emergent surgery), whereas elective repeat cesarean carries cumulative risks from surgery and future pregnancies.

A Cochrane review comparing planned VBAC and planned repeat cesarean found no significant difference in serious long-term maternal outcomes but emphasized that successful VBAC offers a faster recovery and avoids surgical risks (Dodd et al., 2013). Because randomized trials in this area are limited, most recommendations rely on observational data, making shared decision-making essential.

Who Is a Good Candidate for VBAC?

According to ACOG (2021) and RCOG (2022), the best candidates for VBAC are those who:

Have one previous low-transverse cesarean incision
Have no other uterine scars or history of rupture
Are carrying a single fetus in a head-down position
Have no contraindications to vaginal birth (e.g., placenta previa)
Are giving birth in a facility with staff capable of performing an emergency cesarean and continuous fetal monitoring

Women with two prior low-transverse cesareans may also be candidates in selected settings, though risks are slightly higher (Tahseen & Griffiths, 2010).

Labor Induction and VBAC

Labor induction is sometimes necessary, but it must be approached with caution in VBAC candidates. Oxytocin (Pitocin) can be used judiciously, but prostaglandin agents (especially misoprostol) are linked with higher rupture rates and are generally avoided (Harper et al., 2012). Mechanical methods such as the Foley balloon are considered safer alternatives (RCOG, 2022).

If induction is needed, discuss which methods your provider uses, what monitoring protocols are in place, and what thresholds would prompt a cesarean.

Making the Decision: Steps for Shared Decision-Making

Review your prior surgical records. Your provider can confirm your incision type and whether your prior cesarean was for a recurrent reason.
Discuss your individual success rate. Some hospitals use VBAC prediction calculators, though ACOG cautions these tools should supplement - not replace - personalized counseling (ACOG, 2021).
Understand your hospital’s readiness. Confirm that a surgical team, anesthesia, and continuous fetal monitoring are available 24/7.
Clarify your values. Some mothers prioritize avoiding surgery; others focus on minimizing any risk of emergency situations.
Develop a flexible birth plan. Prepare emotionally and logistically for both possibilities - a successful VBAC or a necessary repeat cesarean.

Faith and Emotional Considerations

For many families, birth choices hold deep emotional and spiritual meaning. If your previous birth was difficult, considering a VBAC can be part of a redemptive and healing experience. Surround yourself with supportive providers, a knowledgeable doula, and prayer partners who respect both your faith and your safety. Philippians 4:6-7 reminds us, “Do not be anxious about anything, but in everything by prayer and supplication with thanksgiving let your requests be made known to God.” Finding peace in whichever path your birth takes is part of that preparation.

The Bottom Line

VBAC is a safe and realistic option for most women with one previous low-transverse cesarean, boasting success rates of 60–80% when carefully selected and managed (Landon et al., 2004; ACOG, 2021). It offers meaningful benefits - shorter recovery, fewer surgical risks, and lower future pregnancy complications - while carrying a small but serious risk of uterine rupture. The decision between VBAC and repeat cesarean is deeply personal and should balance clinical evidence, hospital capabilities, and your own values and goals. With good preparation and open communication, many families find VBAC to be a safe and empowering birth experience.

References

American College of Obstetricians and Gynecologists. (2021). Vaginal Birth After Cesarean Delivery (Practice Bulletin No. 205).
Dodd, J. M., Crowther, C. A., Huertas, E., Guise, J.-M., & Horey, D. (2013). Elective repeat cesarean section versus induction of labour for women with a previous cesarean birth. Cochrane Database of Systematic Reviews, (12), CD004906.
Guise, J.-M., et al. (2010). Safety of vaginal birth after cesarean: A systematic review. Obstetrics & Gynecology, 115(6), 1267–1278.
Harper, L. M., Cahill, A. G., Boslaugh, S. E., & Stamilio, D. M. (2012). Association of induction of labor and uterine rupture in women attempting VBAC. American Journal of Obstetrics & Gynecology, 206(1), 65.e1-65.e9.
Landon, M. B., et al. (2004). Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. New England Journal of Medicine, 351(25), 2581–2589.
Royal College of Obstetricians and Gynaecologists. (2022). Birth after previous caesarean birth (Green-top Guideline No. 45).
Silver, R. M., et al. (2006). Maternal morbidity associated with multiple repeat cesarean deliveries. Obstetrics & Gynecology, 107(6), 1226–1232.
Tahseen, S., & Griffiths, M. (2010). Vaginal birth after two caesarean sections (VBAC-2): A systematic review with meta-analysis. BJOG, 117(1), 5–19.
World Health Organization. (2018). WHO recommendations: Non-clinical interventions to reduce unnecessary caesarean sections.