1. VBAC should be encouraged in patients with one previous Cesarean Section (C/S) and considered in patients with two previous Cesarean Section (C/S) as long as there are no other contraindications.
2. The benefits of a VBAC are significant as compared to the potential complications associated with a repeat C/S.
3. The recommendation of "once a cesarean, always a cesarean" is not valid and is not supported by the literature.
4. The risk of an Uterine Rupture, which is one of the most serious complications of a failed VBAC, occurs between 0.5-1%.
5. The risk of materal death associated with a uterine rupture is extremely low, reaching almost 0%.
6. The risk of fetal death associated with a uterine rupture is between 3-6%.
7. Current hospital policies either banning VBAC outright or restricting VBAC to a single previous C/S is not supported by the literature and can compromise both the health and well-being of both mother and baby.
8. Current hospital policies requiring a physician to be "immediately available" or "in-house" (in the hospital) during the entire labor process has not been shown to improve the overall outcome of the VBAC delivery and has instead lead to the reduction of routine VBAC deliveries to less than 10%.
9. Proper Informed Consent regarding the VBAC requires that your physician provide information regarding the most current recommendations on VBAC from institutions such as the National Institutes of Health (NIH), the Centers for Disease Control (CDC), the United States Department of Health and Human Services, and the American Congress of Obstetricians and Gynecologists (ACOG).
10. Each repeat C/S increases risks of complications, especially after four C/S and should be discussed especially in women considering having large families.

1. National Institutes of Health (NIH):
   "Given the available evidence, trial of labor is a reasonable option for many pregnant women with one prior low transverse uterine incision."
   http://consensus.nih.gov
2. U.S. Department of Health and Human Services (HHS), Agency for Healthcare Research and Quality (AHRQ):
   "VBAC is a reasonable and safe choice for the majority of women with prior caesarean and that there is emerging evidence of serious harms relating to multiple caesareans."
   http://www.ahrq.gov
3. American Congress of Obstetricians and Gynecologists (ACOG):
   "Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans."
   http://www.acog.org/

1. Augmentation of Labor - the intentional increase in contraction frequency or intensity when contractions are already present or dilation of the cervix is occurring in order to hasten the process of labor with the goal of achieving a vaginal delivery.
2. Cesarean Section (C/S) - the delivery of a baby by making a surgical incision through the abdomen and the uterus, thus allowing for the delivery of the baby through these incisions and not through a vaginal approach.
3. Elective repeat Cesarean Section (ERCS) - Planned cesarean delivery in a woman who has had one or more prior cesarean deliveries. The delivery may or may not be scheduled.
4. Home Birth After Cesarean Section (HBAC) - the delivery of a baby vaginally at a home, private residence or domicile, after having delivered previously by C/S.
   • HBAnC - (n) representing the number of previous C/S. ie. If a patient had 3 previous C/S, then HBA3C.
5. Induction of Labor - the provoking or intentional production of uterine contractions in a previously non-contracting uterus in order to cause or "induce" labor with the goal of achieving a vaginal delivery.
6. Labor - physiologic process during which the products of conception (ie, the fetus, membranes, umbilical cord, and placenta) are expelled outside of the uterus.
7. Nulliparous - a woman who has never had a pregnancy go beyond 20 weeks or given birth to a viable, or live, infant.
8. Preterm Labor - the presence of uterine contractions of sufficient frequency and intensity to cause progressive effacement and dilation of the cervix prior to term gestation (between 20 and 37 wk).
9. Preterm Pregnancy - estimated gestational age of a baby below 37 weeks.
10. Placenta previa - a complication of pregnancy in which the placenta grows in the lowest part of the uterus and covers all or part of the opening to the cervix. The risk of placenta previa in the general population is 1/200 pregnancies but more common in women with previous C/S. There are three types of placenta previa:
    • Marginal - The placenta is next to cervix but does not cover the opening.
    • Partial - The placenta covers part of the cervical opening.
    • Complete - The placenta covers all of the cervical opening.
11. Placenta accreta - is a general term used to describe a complication of pregnancy in which there is an abnormally deep attachment of the placenta through the endometrium and into the myometrium (muscle of the uterus). This invasion of the placenta then becomes...
12. Placenta increta - a variant of placenta accreta with deeper penetration into the myometrium than placenta accreta.
13. Placenta percreta - a variant of placenta accreta with complete penetration through the myometrium to the serosa and/or adjacent organs to the uterus.
14. Postterm Pregnancy - estimated gestational age of a baby 42 weeks and beyond.
15. Term Pregnancy - estimated gestational age of a baby between 37-42 weeks.
16. Trial of Labor after Cesarean Section (TOLAC) - term used when a patient attempts a vaginal delivery after a previous C/S. It can either be associated with spontaneous labor or with an induction of labor.
    • TOLAC is the term used when the patient is attempting the Vaginal Birth after Cesarean Section (VBAC).
    • Therefore, a VBAC is a successful TOLAC.
17. Unsuccessful trial of labor - Delivery by Cesarean Section in a woman who has had a trial of labor; sometimes referred to as a "failed" TOLAC.
18. Vaginal Delivery - the delivery of a baby through the vagina, either spontaneously or with the assistance of instruments such as a vacuum or forceps.
19. Vaginal Birth after Cesarean Section (VBAC) - the delivery of a baby vaginally after having had a previous C/S. Also known as a successful TOLAC.
    • VBAnC - (n) representing the number of previous C/S. ie. If a patient had 3 previous C/S, then VBA3C.
20. Water Birth After Cesarean Section (WBAC) - the delivery of a baby vaginally in a water pool or tub after having had a previous C/S.
    • WBAnC - (n) representing the number of previous C/S. ie. If a patient had 3 previous C/S, then WBA3C.

In 1916, Dr. E.B. Cragin delivered an address entitled "Conservatism in Obstetrics" to the Eastern Medical Society of New York in which he coined the phrase "Once a caesarean, always a caesarean."

For most of the twentieth century, doctors followed this dogma believing that once a woman delivered by C/S she should deliver all future pregnancies by repeat C/S. Clinical studies starting the 1960s, however, concluded that this practice was not always necessary.

In 1980, the National Institutes of Health (NIH) Consensus Development Conference Panel questioned the necessity of routine repeat Cesarean Section. After extensive research, the panel made recommendations regarding the VBAC. Their recommendations gave support to the practice of the TOLAC and successful VBAC with a significant rise in the number of attempted VBAC from the 1980s through 1996.

A major turning point occurred in 1996 with a study published in The New England Journal of Medicine (MacMahon et al, 1996) which concluded that a vaginal delivery after previous C/S (VBAC) was associated with an increased maternal complications as compared to the Elective Repeat Cesarean Section (ERCS).

The American College of Obstetrics and Gynecology (ACOG) subsequently issued guidelines in its 1999 Practice Bulletin which recommended that "VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care." (ACOG, 1999) This practice bulletin also recommended that a physician "capable of monitoring labor and performing an emergency cesarean delivery" be "immediately available throughout active labor," and that anesthesia and personnel for an emergency cesarean be "available."

Logistical and professional liability issues led many hospitals to restrict or prohibit the practice of VBAC. As a result, the rate at which VBAC was attempted fell from 26% in the early 1990s to less than 10% today.

Figure 1. Rates of Total Cesarean Deliveries, Primary Cesarean Deliveries, and Vaginal Birth After Cesarean (VBAC), 1989 to 2007. Data from the National Center for Health Statistics.

Figure 2. Increasing Rates of Cesarean Section, 1991 to 2007. Data from the US Department of Health and Human Services.

Figure 3. Cesarean delivery rates by age of mother. United States, 1998, 2000 & 2007. Data from the US Department of Health and Human Services.

In March 2010, the National Institutes of Health (NIH) hosted its Consensus Development Conference on the subject of VBAC and concluded, "Given the available evidence, trial of labor is a reasonable option for many pregnant women with one prior low transverse uterine incision.".

Also in March 2010, the U.S. Department of Health and Human Services (HHS), Agency for Healthcare Research and Quality (AHRQ) reported that VBAC is a reasonable and safe choice for the majority of women with a history of prior C/S and that there is emerging evidence of serious harm relating to multiple Cesarean Sections.

In July 2010, The American Congress of Obstetricians and Gynecologists (ACOG) similarly revised their own guidelines to be less restrictive of VBAC, stating, "Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans."