Vaginal birth after caesarean (VBAC) is supported by Dr. Vaishali Joshi, FRCOG, Senior Consultant Obstetrician & Gynaecologist at Kokilaben Dhirubhai Ambani Hospital, Andheri West, who trained through the London Deanery and holds Advanced Training Skills Modules in labour ward practice. For most women who have had one previous caesarean through a low transverse incision, attempting a normal delivery in the next pregnancy is a safe and reasonable choice — provided it happens in a hospital equipped to respond immediately if it does not go to plan.
“Once a caesarean, always a caesarean” is one of the most persistent pieces of obstetric folklore in India, and it is not correct. It dates from an era when caesareans were performed through a vertical incision in the upper, contractile part of the uterus — a scar that genuinely was unsafe in labour. Modern caesareans are almost always performed through a low transverse incision in the lower segment, which behaves very differently.
That said, VBAC is not the right choice for every woman, and the reason it requires careful discussion is not that it is dangerous in general but that its principal risk, though uncommon, is serious and can develop quickly. Both of those things need to be held at once.
Who is a good candidate for VBAC?
The factors that favour a planned VBAC are:
- One previous caesarean through a low transverse (lower segment) incision.
- A previous vaginal delivery, either before or after the caesarean. This is the single strongest predictor of success.
- A non-recurring indication for the first caesarean — breech presentation, fetal distress, or placenta praevia in that pregnancy, rather than a reason likely to repeat.
- Spontaneous onset of labour at term.
- A single baby in a head-down position, with an estimated weight in the normal range.
- An adequate interval since the caesarean — a short interpregnancy interval is associated with a higher risk of scar problems.
When is VBAC not advised?
- A previous classical (vertical) uterine incision or an inverted-T incision, which carries a materially higher rupture risk.
- Previous uterine rupture.
- Previous myomectomy where the uterine cavity was entered, depending on the extent of the repair.
- Placenta praevia or another absolute indication for caesarean in this pregnancy.
- Three or more previous caesareans, and, for many clinicians, two previous caesareans — where VBAC may still be considered but requires particularly careful individual discussion.
- Delivery in a unit without immediate access to an operating theatre, anaesthetist and blood bank. This is a hard requirement, not a preference.
How likely is VBAC to succeed?
Across large published series, most appropriately selected women who plan a VBAC achieve a vaginal delivery, and the chance is highest in those who have had a previous vaginal birth and who go into labour spontaneously. It falls where labour needs to be induced, where the first caesarean was for failure to progress, and where the estimated fetal weight is high.
Your own obstetrician can give you a more useful estimate than any general figure, because it is built from your specific history: why the first caesarean happened, whether you have ever laboured, how this pregnancy is progressing and how the baby is growing. Ask for that individual assessment rather than a population number.
A planned VBAC that ends in a caesarean is not a failure. Roughly one in four to one in three attempts will end that way, and an unplanned caesarean in labour is a normal and anticipated outcome of the plan — not evidence that the plan was wrong. Women who go in understanding that tend to have a much better experience of it than women who feel they have lost something.
What are the risks?
Uterine rupture
This is the risk that drives the entire discussion. The scar from the previous caesarean gives way during labour. With a single previous low transverse incision, published rates are consistently well under one per cent — uncommon, but serious when it happens, because it threatens both mother and baby and requires immediate delivery.
This is precisely why continuous monitoring in labour and immediate theatre availability are non-negotiable for a planned VBAC. The abnormality in the baby's heart rate pattern is usually the earliest sign, and the interval between recognising it and delivering the baby is what determines the outcome. A hospital that can do that within minutes is doing something a hospital that cannot simply is not.
Other considerations
- A somewhat higher chance of needing an instrumental delivery than in a first vaginal birth.
- A small increase in the chance of needing a blood transfusion compared with a planned repeat caesarean.
- Against this: a successful VBAC avoids major abdominal surgery, means a shorter hospital stay and faster recovery, lower risk of infection and clots, and — importantly for women planning more children — avoids accumulating uterine scars, each of which raises the risk of placenta accreta in later pregnancies.
That last point deserves emphasis, because it is frequently omitted. The risks of repeat caesarean are not confined to the operation in front of you; they compound across future pregnancies. A woman planning a large family faces a different calculation from one whose family will be complete after this baby.
What does a planned VBAC involve in practice?
- A documented plan, agreed in advance, recording the decision, the reasoning and what would change it.
- Delivery in a unit with immediate theatre access, a resident anaesthetist and blood bank facilities.
- Continuous electronic fetal monitoring once labour is established.
- Intravenous access and a blood sample sent on admission.
- Careful use of induction and augmentation. Both are possible but raise the rupture risk relative to spontaneous labour, and prostaglandins in particular are used with caution. If induction is being proposed, ask specifically how it will be done.
- Epidural analgesia is not a barrier to VBAC. It does not mask the signs of rupture, which are primarily changes in the fetal heart rate pattern.
Making the decision
There is a genuine choice here, and both options are reasonable. A planned repeat caesarean is a safe, predictable operation with a known recovery. A planned VBAC offers a shorter recovery and better prospects for future pregnancies, at the cost of a small but serious risk in labour and the possibility of ending in an unplanned caesarean anyway.
The right decision depends on your history, your plans for further children, the hospital where you will deliver, and how you yourself weigh those trade-offs. It is a conversation to begin in the second trimester rather than at 38 weeks, and it is entirely reasonable to change your mind.
Frequently asked questions
Is normal delivery possible after a caesarean section?
Yes, for most women who have had one previous caesarean through a low transverse (lower segment) incision. The old rule of “once a caesarean, always a caesarean” dates from an era of vertical uterine incisions, which behave very differently in labour. Most appropriately selected women who plan a VBAC do achieve a vaginal delivery, with the best prospects in those who have had a previous vaginal birth and who go into labour spontaneously.
What is the risk of uterine rupture during a VBAC?
With a single previous low transverse caesarean, published rates of uterine rupture are consistently well under one per cent. It is uncommon but serious when it occurs, because it threatens both mother and baby and requires immediate delivery. This is why a planned VBAC requires continuous fetal monitoring in labour and a hospital with an operating theatre, anaesthetist and blood bank available immediately — the interval between recognising the problem and delivering the baby is what determines the outcome.
How long should I wait after a caesarean before getting pregnant again?
A short interval between a caesarean and the next pregnancy is associated with a higher risk of scar-related complications, so an adequate gap is generally advised before conceiving again, particularly if you are hoping for a VBAC. The right interval for you depends on how your caesarean healed and your individual circumstances, so it is worth asking your obstetrician directly rather than working to a general rule.
Can I have an epidural during a VBAC?
Yes. An epidural is not a barrier to attempting VBAC and does not mask the signs of uterine rupture, which show primarily as changes in the baby's heart rate pattern on continuous monitoring rather than as pain alone. Effective pain relief can make a planned VBAC a considerably better experience, and there is no reason to endure labour without it in order to attempt a vaginal birth.
Can labour be induced if I am planning a VBAC?
It can be, but it is done with care. Induction and augmentation both raise the risk of uterine rupture relative to spontaneous labour, and prostaglandins in particular are used cautiously in women with a uterine scar. If induction is being proposed, ask specifically what method will be used and why, and how you will be monitored. Spontaneous onset of labour is associated with the highest chance of a successful VBAC.
Is a repeat caesarean safer than attempting VBAC?
Both are reasonable and safe choices, and which is safer depends on your circumstances. A planned repeat caesarean is predictable, with a known recovery and no risk of scar rupture in labour. A successful VBAC avoids major surgery, means faster recovery and lower risk of infection and clots — and avoids accumulating uterine scars, which matters a great deal if you plan more children, since each caesarean raises the risk of placenta accreta in later pregnancies. That last factor is often left out of the discussion and should not be.
Related reading
Written & medically reviewed by Dr. Vaishali Joshi, FRCOG CCT MD DNB DGO FCPS — Senior Consultant Obstetrician & Gynaecologist, Kokilaben Dhirubhai Ambani Hospital, Mumbai.
Last reviewed . This article is general information and is not a substitute for individual medical advice. Please discuss your own circumstances at consultation.