What are the advantages of a Vaginal Birth After Cesarean (VBAC) over a repeat cesarean section?

Why VBAC is Advantageous Over Repeat Cesarean Section

For most women with one or two previous cesarean deliveries, VBAC should be the preferred approach because it provides better short-term maternal outcomes and significantly reduces long-term risks of abnormal placentation, hysterectomy, and surgical complications in future pregnancies. 1

Short-Term Maternal Benefits

Successful VBAC delivers equal or superior short-term maternal outcomes compared to repeat cesarean delivery. 2, 1 The immediate advantages include:

• Lower bleeding rates and reduced transfusion requirements compared to cesarean section 1
• Avoidance of major abdominal surgery with its associated risks of infection, thromboembolism, and anesthetic complications 3, 4
• Faster recovery time allowing earlier return to normal activities and infant care
• Decreased maternal morbidity at the individual level 3, 4, 5

Critical Long-Term Advantages for Future Pregnancies

This is where VBAC demonstrates its most compelling advantage. Repeat cesarean delivery progressively increases catastrophic risks with each subsequent pregnancy: 1

• Abnormal placentation risk escalates dramatically: After one cesarean, placenta accreta occurs in 12.9 per 10,000 births; after two cesareans, this jumps to 41.3 per 10,000 6
• Placenta previa incidence rises with each cesarean: 9 per 1,000 after one cesarean, 17 per 1,000 after two, and 30 per 1,000 after three or more 6
• Hysterectomy risk increases with multiple cesarean deliveries 2, 1
• Surgical complications accumulate with each repeat procedure, including adhesions, bowel and bladder injury 2, 1
• Loss of future VBAC options as the number of cesarean deliveries increases 6

Success Rates and Patient Autonomy

Approximately 74% of U.S. women who attempt VBAC achieve successful vaginal delivery, making it a realistic goal for most candidates. 2, 1, 7 This high success rate means:

• Most women can fulfill their preference for vaginal delivery 3, 4
• Previous vaginal delivery is the single strongest predictor of VBAC success, with even higher rates in women who have had a prior successful VBAC 1, 7
• Women maintain reproductive autonomy and avoid the "once a cesarean, always a cesarean" cascade 3, 4

Population-Level Impact

At the population level, VBAC decreases the overall cesarean delivery rate, which has broader public health implications for reducing surgical morbidity across obstetric care. 3, 4, 5

Important Caveats About Risk Trade-offs

While VBAC offers substantial maternal benefits, perinatal mortality is slightly higher with trial of labor after cesarean compared to elective repeat cesarean delivery. 2, 1, 7 This represents the primary trade-off that must be discussed during counseling. However, this must be weighed against:

• The cumulative maternal risks of multiple cesarean deliveries over a woman's reproductive lifetime 1, 6
• The individual woman's plans for future childbearing 2
• The absolute risk difference, which remains small in appropriately selected candidates 1

When VBAC is Most Advantageous

The American College of Cardiology recommends TOLAC as the preferred approach for women with one previous low transverse cesarean section, particularly when: 1

• The woman has had any previous vaginal delivery (before or after the cesarean) 1, 7
• She plans future pregnancies and wants to minimize cumulative surgical risks 2, 6
• She presents in spontaneous labor with favorable cervical examination 2, 7
• She desires to avoid major surgery and its recovery 1

Early prenatal counseling should address these advantages, allowing women to make informed decisions based on their individual risk factors, values, and future reproductive plans. 2, 1