Ep 229: Vaginal Birth After Cesarean (VBAC)

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If you’re considering VBAC (vaginal birth after cesarean), this episode is a must listen! Most individuals with one (or two!) prior low transverse cesareans can consider VBAC. But you MUST bring it up early with your healthcare provider to be sure they will support your wishes, because not all doctors support it and some are not forthcoming about that. With VBAC, you avoid major surgery and the recovery time can be quicker but it’s not the appropriate option for everyone and there are risks. You can weigh the risks and benefits and decide if it’s the right choice for you. And if you decide to try for a VBAC, this episode will set you up for success!

In this Episode, You’ll Learn About:

  • What a vaginal birth after cesarean entails
  • Who is and is not a candidate
  • What’s the most important thing to do if you’re interested in trying for a vaginal birth
  • What the risks and benefits are
  • Which factors are associated with a successful trial of labor after cesarean (TOLAC)
  • Which scenarios make doctors uncomfortable with the procedure and what the evidence-based recommendations are for management
  • What a low-intervention TOLAC looks like

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Transcript

Dr. Nicole (00:00): In this episode, you are going to learn all about vaginal birth after Cesarean or vbac. Welcome to the All about Pregnancy and birth podcast. I'm Dr. Nicole Callaway, Rankins, a board certified OBGYN, who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now, let's get to it.

(00:51): Hello there. Welcome to another episode of the podcast. This is episode number 229, whether you are a new listener or a returning listener, thank you, thank you, thank you for spending some of your time with me today. So in today's episode of the podcast, you are going to learn all about VBAC vaginal birth after cesarean. So you'll start with learning some terminology. We'll talk about VBAC versus tolac. You will learn who and who is not a candidate for a tolac or trial of labor After cesarean, you'll learn what's the most important thing you need to do if you're interested in a vbac, the benefits and risk of VBAC factors that are associated with the successful vbac, and then factors that decrease your chances of success with a vbac. We'll also cover some scenarios that sometimes make doctors uncomfortable with VBAC and what the actual evidence-based recommendations are for management.

(01:53): And then we will end with what a low intervention VBAC may look like. This episode is jam packed with all the things you need to know if you're thinking about a vbac. So I know that you are going to find it useful. Now, before we get into the episode, let me take a second and do a listener shout out. This is from Saa309 and she left me this review in Apple podcast and the title says my go-to pregnancy resource. The review says, I love this podcast. It is truly an invaluable educational resource for me as I progress along my first pregnancy. Not only can you rely on Dr. Nicole for sound evidence-based information, but she has such a calm, nurturing manner in which she educates. I love the mix of informational guest episodes as well as the birth stories. I know I will be calm, confident and empowered as I head into my birth because of Dr. Nicole. Thank you for all that you do. Well, thank you so much for that lovely, lovely kind review. I so appreciate you taking the time

(02:59): To leave that and I appreciate your kind words. Everything you said is exactly what's in my heart to do for pregnant folks. I especially have a soft spot for first time moms to be. So thank you for doing that and if you too are a listener of this podcast and you enjoy it, then I would love it if you too would leave a five star review in Apple podcast as well. I also would love to hear what you think about the show. Alright, so let's get into this conversation about vbac. So first thing we're going to cover is a little bit of terminology. So the term VBAC is commonly used, which is vaginal birth after cesarean. However, it is not actually a VBAC until after you have the vaginal birth. So when we speak in the medical field about vbac, what we actually use is the term tolac.

(03:52): So that is trial of labor cesarean, and actually every pregnancy is technically a trial of labor and it's not a vaginal birth until after the vaginal birth happens. So we use the term trial of labor after cesarean, and then once the tolac is successful, then it is a vbac. That may seem a little nitpicky, but I wanted to explain that to you because you may hear your doctor or you will hear your doctor use the term tolac. And I'm going to use both terms tolac and VBAC interchangeably throughout this podcast episode. Know that I mean the same thing in general. So let's get into who and who is not a candidate for a VBAC or tolac. First thing I want you to know and I want you to hear is that most women are candidates, okay? Most people are candidates for having a tolac. Now, definitely you are a candidate if you have one or two prior low transverse cesarean births, and I'm going to explain what a low transverse cesarean birth means in just a moment.

(05:02): Also, ideally, there should be 18 months between the cesarean birth and then when you get pregnant again, the next conception, okay? So ideally 18 months between when the cesarean happened and when the next pregnancy is conceived. And the reason for that is because even though we put the uterus back together at the time of a cesarean birth, we cannot put it back together as strong as it was natively, as strong as it was at birth before we put that incision in there. So we want to give that incision time to heal, and that's what that 18 months is for. So ideally 18 months between the cesarean and conception. Now who is not a candidate for a tolac or vbac, if you had a previous classical or T incision, then you are not a candidate. And I'll explain what a classical is in just a minute.

(05:58): In short, it's an up and down incision in the uterus. If you had a prior uterine rupture, you are not a candidate. So if you had a prior cesarean or a prior uterine rupture in general, then you are not a candidate for a vaginal birth because that's going to greatly increase the risk of having another uterine rupture. If you've had extensive uterine surgery like a myomectomy or removal of fibroids, especially in what's called the contractile portion of the uterus, then you are not a candidate to have a vaginal birth after cesarean. And the reason those things are the case are because if when we do a low transverse cesarean and low transverse is just the incision is in the lower part of the uterus, so the incision that we make in the uterus in order to get the baby out, that incision is made in an area of the uterus that is the non contractile portion of the uterus.

(06:55): So it's not the part of the uterus that's doing the squeezing. If you've had a prior uterine rupture uterine surgery or a classical uterine incision that goes up into the contractile portion of the uterus, then that would mean as you're having contractions, then that old incision is being squeezed on, squeezed on, squeezed on, or where you had those fibroids removed is being squeezed on, squeezed on. And that is dangerous. That increases the risk or possibility that the uterus blows open through those old incisions that are in the contractile portion, and that can be potentially catastrophic. So that's why you are not a candidate, an appropriate candidate because it's just not considered safe. You're also not a candidate for VBAC or tolac if you have a contraindication to vaginal birth like placenta previa. Placenta previa is when the placenta covers the opening of the cervix and it is not safe to have a vaginal birth in that instance because it increases the chance of significant bleeding, particularly bleeding from the baby.

(07:55): So that is not appropriate to try for VBAC if you have a contraindication to vaginal birth like placenta premium. Also, if you have three or more prior cesareans, you are generally not considered a candidate for vaginal birth because of the increased risk for uterine rupture. Now granted, we don't have a lot of data in order to support that because just not a lot of people have a vaginal birth after three prior cesareans, but you will be hard pressed to find a physician who will support doing a VBAC when you've had three or more prior cesareans.

(08:31): All right, let's move into what is the most important thing you need to do If you had a cesarean birth before and you want to try for a vaginal birth this time, the most important thing that you need to do is discuss it with your doctor early. You need to know as soon as possible whether or not your doctor and the hospital where they practice support vbac. Alright? Sadly, there are unfortunately doctors who don't support vbac. Sometimes they don't support it because of prior experience or they don't support it because it makes it difficult for them in terms of how they have to be there for the labor. And sometimes some hospitals don't support it because it should require that you have almost immediate access or within 30 minutes access to anesthesia. And some hospitals don't have anesthesiologists in the hospital because that can be expensive or they're in a smaller environment.

(09:38): So some doctors and hospitals do not support vbac. And the sadder part, and the unfortunate part is that sometimes not all practices are upfront about that. I have unfortunately heard stories from women who haven't found out until the third trimester that their doctor or hospital doesn't support vbac and then they feel stuck at that point. So you really, really, really, really, really got to ask early. I'm talking about at your first visit or as soon as you are even thinking about a vbac, ask if they support it and if they don't support it or say that they can talk about it later, we can move it into another conversation. You really need to consider going to another provider if you really strongly want that option. Okay? So definitely, definitely, definitely ask early. If you don't take away anything else from this conversation, take that away.

(10:31): So what are some of the benefits of vbac? Well, folks who have a VBAC do avoid having a major abdominal surgery. Yes, cesarean birth is done routinely, but it is still a major surgery. So if you can avoid it, then that's ideal. All also women who have a VBAC have a lower rate of bleeding of developing blood clots in the legs. They have lower rates of infection compared to having a cesarean birth. And typically the recovery is shorter if you have a VBAC compared to those who have an elective repeat cesarean. And that's related to the fact that, again, cesarean is a major surgery. So typically if you have a vaginal birth, the recovery is going to be shorter. Now, that's not always guaranteed. I've certainly heard people say that the recovery was challenging with a vbac, but in general it's going to be shorter.

(11:23): And then the final thing is if you're considering future pregnancies, a VBAC can decrease the risk of problems related to having multiple cesarean births. So the more cesareans that you have, there's an increased risk of hysterectomy with each subsequent cesarean. There's an increased risk of bowel injury, there's an increased risk of bladder injury. There's the increased risk of blood transfusion, infection, and problems with the placenta and planting abnormally around those old incisions in the uterus. So if you have a vbac, then you are decreasing the chances of things happening from having multiple repeat cesarean births. So I think that conversation is especially important if you plan to have a large family. Now everything has risk and benefits. There are risk to VBAC as well. The biggest risk is of course, the risk of uterine rupture. Uterine rupture is when the incision in your uterus from the prior cesarean opens up.

(12:16): Thankfully, it is not a common occurrence. Studies show that the rate of uterine rupture is less than 1%. The reason we get so concerned about uterine rupture though is because when it does happen, it can be really catastrophic. There can be potentially devastating consequences for mom and baby including hysterectomy, including death of the baby, including brain damage for the baby. Again, not common, but those things do happen. I've seen uterine rupture happen a handful of times in my career. Fortunately, it did not turn out to be catastrophic. I have not, knock on wood, ever had to do with hysterectomy related to uterine rupture, but it can be challenging to repair and put the uterus back together. So it definitely can be a big concern, and you need to understand that the risk of uterine rupture when we talk about the risk is specific to having had a prior low transverse uterine incision.

(13:08): And that means that the incision on your uterus was on the lower part of your uterus and goes from side to side or transverse. That is the most common type of uterine incision that is performed. Please understand that you cannot know the type of uterine incision from the incision based on your skin. You can have a side to side incision on your skin, what's called a bikini cut, and still have a different type of incision on your uterus. So it's not related to the incision on your skin. This is about the incision on your uterus. Most often we do do a low transverse uterine incision. Occasionally, however, we have to do different types of incision on the uterus to remove the baby. That up and down incision is called a classical incision, and that goes up into the contractile portion, the squeezy portion of the uterus as I mentioned earlier.

(14:04): So for any other incision other than a low transverse uterine incision, the risk of uterine rupture is considered unacceptably high, and that's where vaginal birth should not be attempted. Alright, and then some of the other increased risk related to tolac actually occur when a repeat cesarean becomes necessary during the trial of labor. So some of the increased risk of infection or blood transfusion or hysterectomy, those are related to having had a cesarean after going through labor. So VBAC is associated with fewer complications than an elective repeat cesarean birth. So meaning VBAC is fewer complications than if you decided to have a scheduled repeat cesarean, whereas a failed tolac, and I don't like the word failed, but an unsuccessful tolac is actually associated with more complications than if you just decided to have a scheduled repeat cesarean birth. So let's talk about some of the symptoms of uterine rupture because this is important to know.

(15:16): In the things that we look out for to be concerned about uterine rupture. The first and most common thing that we will see when a uterine rupture is suspected is an abnormal fetal heart rate. The baby will start to show us signs that they are in distress when there is a concern about a uterine rupture. So the first sign is going to be an abnormal fetal heart rate. The next most common symptom of uterine rupture is going to be abdominal pain, abdominal pain, and it can feel out of proportion to what we would expect with labor. It can also be a more constant pain. So whereas contraction pain comes and goes, the abdominal pain from a uterine rupture is different. It tends to be more constant and it can also be in different places in the belly depending on where things are. All right. So abdominal pain is going to be the second most common symptom.

(16:20): Now, some of the literature reports rates of 14 to 33% of patients with the uterine rupture undergo hysterectomy. That is high. In my experience. I have not seen numbers that are that high. I've also seen the literature quoted that the death rate for babies associated with uterine rupture ranges from five to 26%. I'm not discounting these numbers, I'm just telling you that in my own personal experience it has not been that high. But again, the reason we get concerned about uterine rupture is because the outcomes can be catastrophic even though it is a rare occurrence. So why don't more doctors in hospitals support VBAC or tolac? Well, one of the reasons is that ACOG came out with a statement saying that ideally you need to be able to do a cesarean birth within about 30 minutes if you suspect a uterine rupture. So that generally requires that the doctor has to be in the hospital and not all doctors can be in the hospital all the time while someone is in labor.

(17:20): In some practices, the Dr. May be in the office or the Dr. May be at home overnight. There may not be an OB G Y N in the hospital. So some doctors are not willing to do that. Same thing for anesthesia availability. As I mentioned earlier, the anesthesiologist has to be in the hospital. So that can be a concern also if the hospital is smaller and doesn't have resources like a blood bank because there's an increased risk of blood transfusion. If there's a uterine rupture, the hospital may not feel comfortable supporting vbac. There's also the possibility of doctors not wanting to support it because of fear from a prior bad outcome. If you've had a prior bad outcome when you tried for a vbac, then that makes some doctors hesitant to do it in the future. So this is why you just need to ask very clearly ahead of time whether or not your doctor and hospital supported and what the options are.

(18:16): What are some factors to consider when you are trying to understand how successful your chances of VBAC will be? The first thing I want you to hear is that most published series that look at women attempting a tolac have demonstrated a vaginal birth rate of 60 to 80%, 60 to 80%. So I want you to know that the most likely thing is that you will be successful is that your vbac, your tolac attempt, will be successful and will result in a vaginal birth. So I want you to hold on to that when you're thinking about whether or not you want to go for a tolac. Now, there are some things that can increase your chances of success. If your first cesarean was performed for a reason that is not likely to recur. So for example, if your first C-section was because your baby was breach or because there was a drop in the baby's heart rate and the baby had to be delivered soon, then these are reasons or things that are not likely to recur.

(19:27): So in that instance, you have a higher chance of having a successful feedback. So if the reason for your first cesarean is not likely to recur, you have a higher chance of success. Also, if you had a vaginal birth before the C-section, that greatly increases your chances of having a successful V back. So if you had a vaginal birth, then you had a C-section. If you want to try for a vaginal birth, again, you have a greatly increased chance of having a successful V back because you've had that prior vaginal birth before. There are some factors that may decrease your chances of having a successful vbac. If your labor is induced or augmented, then that does decrease your chances of having a successful vbac. There are some other factors that can negatively influence the likelihood of VBAC increasing maternal age. If you have a higher body mass index or carry more weight, that decreases your chances of success.

(20:25): If the estimated birth weight is high, that decreases the chances of success and being more than 40 weeks can decrease the chances of success. Now again, those things are not absolutes, but they are things that you need to be aware of that you may have a decreased chance of success if you have those factors present. Now, some folks are numbers people, and you may want to have a specific estimate of your chances of success. If you Google, you may find things called VBAC calculators. VBAC calculators. Take into account your age, your height, your weight, any previous vaginal births, the reason for your prior cesarean, and they give you a predicted chance of successful vbac. Now, I personally think VBAC calculators are trash because they're not an exact science. I can't tell you how many times that I have seen someone have a low predicted chance for success with a VBAC calculator and actually have a successful vbac.

(21:23): Or on the flip side, someone predicted to have a high successful chance and then not have it. So they may be good for discussion, but they shouldn't be taken as an exact science, and I don't want those numbers to get into your head for you to think about what your chances are success are. There are no models that have been shown to improve outcomes. So I personally don't find VBAC calculators useful. The only way to know is to try and take into your own unique circumstances into account. So that's my 2 cents about VBAC calculators. So the next thing I want to do is discuss some scenarios that maybe can throw a little monkey wrench into the plan to have a vbac. These are circumstances that sometimes make some doctors less likely to support a tolac. Alright, so I'm going to go through each of the scenarios and what the current evidence-based recommendations are for management.

(22:24): The first one is what if I've had more than one prior cesarean? So in this case, the risk of uterine rupture goes up. As I've mentioned, we can't ever put the uterus back together as strong as it was before. So the reported rates of uterine rupture after having one prior cesarean, those rates range between 0.9 and 3.7%. So the overall risk is still quite low, but it is higher than with one prior C-section. Studies however, do show that the likelihood of having a successful VBAC is similar for women with one prior cesarean and with more than one prior cesarean. Now the caveat is that the data is pretty limited because there just are not a lot of women who attempt vaginal birth after two cesareans. So most of the data we have is similar for one prior cesarean and two prior cesareans. We don't have a lot of data for those who have more than two C-sections. So acog, the American College of Obstetricians and Gynecologists, that is the organization that helps set some of the standards for care within OB G Y N. Their exact statement on tolac is given the overall data, it is reasonable to consider women with two previous low transverse cesarean deliveries to be candidates for tolac and to counsel them based on the combination of other factors that affect their probability of achieving a successful vbac. So ACOG is definitely in support of women with two prior C-sections of attempting a vbac.

(24:23): You may have a hard time finding a doctor who supports that, I'm going to be honest, and there are many and I think more of us are getting more comfortable with that. But you will not find a doctor who is supportive of trying for a VBAC after three or more prior cesareans a doctor or a hospital. That's just going to be difficult to find. All right, but ACOG does support if you've had two, one or two prior C-sections attempting to vba. Alright, so the next scenario is what if it is suspected that my baby is big? Well, if you are attempting a tolac and you have a baby that's suspected to be big, and let's clarify what I mean by big. So that's greater than 4,000 grams. That's eight pounds, 13 ounces or 4,500 grams, nine pounds, 14 ounces depending on whether or not you have diabetes.

(25:19): So if you have diabetes, then greater than 4,000 grams is considered big. If you don't have diabetes, then greater than 4,500 grams is considered big. Women who have a suspected big baby do have a lower likelihood of successful VBAC compared to women who are attempting bebac who don't have a big baby. That is especially the case if the baby is bigger than the last baby that didn't fit or if you haven't had a vaginal birth before. Now with that being said, you can certainly still try for a vaginal birth if that's what you want to do. We don't know if a baby will be born vaginally until we see what happens during labor. I can say that if we suspect that the baby's big, we're not going to be aggressive with things like Pitocin or things like that. It's either going to happen or it's not going to happen, and there are some increased risk that come with having a big baby, whether it's a VBAC or not, including shoulder dystocia.

(26:17): There's an increased risk of injury to mom or baby, an increased risk of postpartum bleeding. Those risks are small, but you do need to be aware of those risks. Next scenario we need to talk about is what if you are past your due date? Now the good news is that there is not an increased risk of uterine rupture if you go past your due date. However, there is a decreased likelihood of successful vbac. The failure rate increases the further along you get in pregnancy. So there's a 22% chance that it won't be successful before 40 weeks and then after 41 weeks, that goes up to 35% of VBACs will not be successful. Now that again, doesn't mean that you won't be successful and still the most likely thing is that you will be successful, but the further along you get in your pregnancy, the chances of having a successful VBAC start to go down.

(27:18): This does bring the question, if I have a better chance of having a vaginal birth earlier than should I be induced? Well, the data shows that the answer is no. It's better to wait for spontaneous labor rather to be induced, and that is to avoid the increased risk of uterine rupture that is associated with being induced. Now, sometimes induction is recommended for other reasons though. So what happens if it's recommended that you be induced? Well, even though there is an increased risk of uterine rupture with induction, that doesn't mean that it cannot be done. Induction with a tolac is still definitely an option. We are just limited in what agents we can use. We avoid prostaglandins. Prostaglandins are a group of hormone like substances that have a lot of functions in the body, including the contraction and relaxation of smooth muscle like the muscles in the uterus and prostaglandins are frequently used in labor induction, but prostaglandins have a higher risk of uterine rupture when they're used in labor induction and then even without prostaglandins, there is a slightly higher risk of uterine rupture when labor is induced during a tolac.

(28:31): So an large study of about 20,000 women attempting vbac, the rate of uterine rupture was 0.52% for spontaneous labor and 0.77% for induced labor. So increased, but still very small and similar results were found in another study of 33,000 women. The rates for uterine rupture were 0.4% with spontaneous labor and 1.1% when Pitocin was used for induction. So slightly higher but still very low. So induction can still happen in the setting of tolac. And then the final scenario I want to address is what happens if you don't know what type of incision you had on your uterus for your cesarean? I mentioned earlier that in order to have a vbac, you should have had a low transverse incision on your uterus and with any other type of uterine incision, the risk of uterine rupture is considered unacceptably high. So if you dunno the type of uterine incision you had, then we really try and request a copy of your operative report from the hospital or practice where you gave birth.

(29:44): You can't tell from looking at the incision on your skin that has nothing to do with the one on your uterus. You have to have the operative report if you don't know. Now, if for whatever reason the operative report cannot be located, you still should be fine to try for a vbac. The reason being because the vast majority of C-section incisions are low transverse incisions, there are only a few circumstances where we do anything different. ACOG's position on this is women with one previous cesarean delivery with an unknown uterine scar type may be candidates for tolac unless there is a high clinical suspicion of a previous classical uterine incision such as cesarean delivery performed at an extremely preterm gestational age. So if your c-section was a typical full-term C-section that you should be fine to try for a vbac even if we don't know your prior uterine incision.

(30:39): Usually a classical incision is only done that up and down incision if it's a really, really preterm like 24, 25 under 28 weeks. So typically you should be fine in order to try for a vba. So let's end with a discussion about the recommendations for a low intervention tolac. So say you want to have a low intervention birth as few interventions as possible. So one of the things that people often want to do in a low intervention birth is not have IV fluids, and that is totally fine. You don't have to be connected to IV fluids during a tolac, but I do recommend that you have a saline lock. A saline lock is when an IV catheter is placed in a vein, but then it's just capped off. That way it's there in case of emergency. This is particularly important if you know that you are a hard stick to have that saline lock there, it can just be covered up and used if needed.

(31:35): It doesn't necessarily have to be connected to anything. The other thing that's different for a low intervention tolac is unlike a circumstance where a low intervention birth in general, I do recommend that you do continuous fetal monitoring, and that is because abnormalities, as I mentioned earlier, abnormalities in the baby's heart rate is one of the first signs of uterine rupture. So we really want to keep an eye on the heart rate at all times. So continuous fetal monitoring is appropriate in the circumstance in order to have better safety during the experience, and we don't want you to eat a ton in active labor when you are attempting a V vac. If you have another cesarean, it's best for your stomach to be empty. So we want to stick to minimal eating, so nothing that's going to be super duper heavy when you're in the active part of labor.

(32:35): If you feel like you need to eat, and a lot of people don't have the desire to eat in active labor, but you want to do things that get through your system quickly, like applesauce or smooth peanut butter, highly refined things like white crackers. You can do honey to get a little sugar for energy, but this is not the time to eat like a full course meal when you are attempting a vbac. Now, some doctors may encourage epidural so that in the event you have a C-section or a C-section needs to be done quickly, then you don't have to be put to sleep for the surgery. That is not something that I feel like has to routinely be done. If you don't get an epidural, then you are accepting the possibility that you may need to be put to sleep for an emergent surgery. So that's something that you can discuss with your doctor.

(33:18): I don't think you have to have an epidural in order to do a vbac. And then to wrap things up, I want to give you those questions to ask if you want to have a vbac, these questions that you need to ask early, early, early in the process. The first one is do you and the hospital support VBAC or tolac? That's really, really important. You want to ask this early. If they say yes, then you also want to ask what happens if I develop a condition where labor induction is recommended? Because there may be some doctors who support VBAC and the hospital supports it, but then they don't support it if labor needs to be induced. So you want to know that option as well because remember, it is fine to be induced with the tolac, so you want to get that clarity upfront as well.

(34:10): And then the final thing is then what do I do or what happens if I go past my due date? You will see some doctors who will say, oh, well, you can try for a VBAC once you get up to 39 weeks. And then if you haven't gone into labor by 39 weeks, then we recommend a C-section. And that's not based on any sort of evidence. You want someone who will give you some time to go into labor on your own. Definitely, definitely, definitely want someone who will give you some time. In general, you don't want a provider who is just tolerant of you having a VBA who's like, well, if all of the circumstances and stars align and everything is perfect, you really want somebody who is supportive of you having a VBAC and will do the things that are necessary to support it.

(34:55): So waiting for labor to happen naturally supporting you if you need a labor induction, those are things that you want, not just someone who's like, well, okay, I mean, I guess if it happens, that's fine. You want someone who is actively enthusiastic about supporting you having a vbac, and just please remember. The last thing is that there are no guarantees in birth. There are no guarantees in birth. No one is guaranteed a vaginal birth. The best you can do is try and if you have another cesarean, you are not a failure. You grew an entire human being in your body. There is absolutely nothing that is a failure about that. So just to recap, VBAC versus tolac. Tolac is trial of labor after cesarean. VBAC is vaginal birth after cesarean. It becomes a VBAC after a successful tolac. Most women are candidates for tolac. If you've had one or two prior low transverse cesarean births, you are a candidate for to tolac.

(35:54): However, if you had a previous uterine rupture, if you've had extensive fibroids removed or uterine surgery, if you've had a type of incision that is not compatible with VBAC or condition, that is not compatible with vaginal birth, you are not a candidate for vbac. There are benefits and risk to vbac, so you need to discuss those with your doctor. If your first scenario was for a reason that is not likely to recur, there is a higher chance for a successful vbac. However, we don't know whether or not you're going to be successful until we try. There are those scenarios that make doctors uncomfortable with vbac, and you can still be induced. You can still try. If you have a big baby, you can still try if you go past your due date. Those are the evidence-based recommendations for those. And then it's possible to have a low intervention Tolac or vbac.

(36:44): The biggest thing that's different is that you shouldn't be eating a lot, and also you really should do continuous fetal monitoring to be safe. And don't forget those questions to ask. The most important thing is understand early what your options are. Do your hospital, does the doctor support vbac? Do they support labor induction? But if you go past your due date, get that information upfront. Now, if you want a place to connect with other moms and you can ask about their experiences with VBAC and tolac, come join the all about pregnancy and birth Inner Circle community as a free group on Facebook. Just head to Dr Nicole, sorry, head to facebook.com/drNicoleRankins or search on Facebook for All About Pregnancy and Birth or search on Facebook for Inner Circle, and it should come up, join the group. You can connect with other folks about their experiences with vba so that you have it doing a solid share of this podcast with a friend. I would appreciate you sharing the podcast to help me reach and serve as many pregnant folks as possible. Also, if you like this podcast, leave me a five star review on Apple Podcast. I appreciate it. It helps the show to grow, and I love to hear what you think about the show. Also, follow me on Instagram at @DrNicoleRankins. You can get lots of great pregnancy and birth information there too. So that's it for this episode. Do come on back next week and remember that you deserve a beautiful pregnancy and birth.