BirthGuide Chicago’s Road Map to a Trial of Labor After C-Section

You had a c-section with your previous pregnancy and now you’re pregnant again. Will you try for a vaginal birth after cesarean (VBAC) this time around, or will you plan a repeat c-section? This article points you to some third-party resources that will help you consider which way to go, and then walks you through the process of finding the best VBAC providers.

We cover:

  • VBAC or repeat Cesarean — resources to help you decide
  • Choosing a VBAC-friendly hospital and practitioner
  • Best Chicago-area hospitals for VBAC
  • Options for midwife-attended VBAC
  • VBAC in a midwife-led birth center
  • A hospital alternative if you live in the West suburbs
  • Options if you’ve had two prior C-sections (VBA+2C)
  • A complete list of Chicago-area hospitals where VBAC rates are above average.

[Note that several Chicago-area home birth providers may offer the option of a home birth after cesarean, but only if your most recent birth was a successful VBAC. This article focuses on options for women who have not had a vaginal birth since their last cesarean, so we don’t address the option of VBAC at home.]

The old adage “once a cesarean, always a cesarean” has been debunked.

VBAC

The American College of Obstetricians and Gynecologists (ACOG) currently takes the position that VBAC “is a safe and appropriate choice for most women who have had a prior cesarean delivery, including some women who have had two previous cesareans.

The American College of Nurse Midwives (ACNM) likewise encourages a trial of labor after c-section (TOLAC):  “Women who are candidates for labor after cesarean should be encouraged to consider VBAC.

So VBAC is an option every woman should at least look into.

Before you plan a repeat cesarean, do a little digging to figure out whether VBAC might be a good option for you.

 

Here are some resources to help you weigh trial of labor vs. planned cesarean:

Choosing a provider for trial of labor after cesarean (“TOLAC”)

If you decide to try for a vaginal birth this time around, your first priority should be to find a supportive provider. You’re not just looking for someone who says “yes”, you’re looking for someone who enthusiastically supports a trial of labor after c-section.

This is the key piece of advice offered by Erica Fleischer, who is a Co-Leader of the Chicago Chapter of the International Cesarean Awareness Network, Inc. (ICAN) — a nonprofit organization whose mission is “to improve maternal-child health by reducing preventable cesareans through education, supporting cesarean recovery, and advocating for vaginal birth after cesarean (VBAC).”

As Fleischer explains, “You’ll hear from a lot of providers that, ‘Sure, you can have a VBAC.’ But then if you don’t go into labor spontaneously before 39 or 40 weeks, they want to do a repeat c-section. Or if you develop a medical condition that means you need to deliver right away, they refuse to induce you, so they’re basically requiring you to have a c-section. We always tell people that the most important thing is to have a provider is truly supportive.” That means providers who actively promote VBAC.

Dr. Richard K. Silver is the Chairman of Obstetrics and Gynecology and Chief Academic Officer at NorthShore University HealthSystem. He practices at NorthShore’s Evanston Hospital, which is where Erica Fleischer had her VBAC and which has one of the very best VBAC rates in the Chicago area.  Dr. Silver attributes the hospital’s excellent outcomes in part to the fact that it’s a Level III hospital, which means that the doctors and midwives there see some of the rare but serious complications that can arise when a woman has multiple cesareans.

As Dr. Silver explains it, “Repeat cesarean is more risky for the mother. For instance, we inherit patients from other hospital systems when their placenta grows through the uterine wall and threatens their life. We handle up to 20 cases a year. These are really challenging cases, involving transfusions, multiple surgeries, urological issues. This is one of the risks of repeat cesareans and one of the long term consequences of not offering vaginal trial of labor appropriately.”

VBACSo what does it mean to offer trial of labor appropriately? Dr. Silver’s answer is that it starts with good counseling. “You have to be non-coercive, but you also have to overcome the understandable barrier. Someone’s had a less than ideal experience with their prior labor and it ended with c-section. If it were me, I’d raise my hand and say, ‘This time, let’s skip the labor and just repeat the cesarean.’ You can absolutely understand why they’d make that choice. So you have to address that with factual data, with good information, including the effect that a second cesarean section may have on the pregnancies after this one. Women need the data.”

Look for a provider who explains the risks and advantages of both VBAC and scheduled repeat c-section, whichever way you’re leaning at the outset.

 

Saint Anthony Hospital is another top performing hospital for VBAC in the Chicago area. Saint Anthony has a unique model: all pregnant and laboring women are cared for in the first instance by Saint Anthony’s midwives, backed up by a team of obstetricians. That means that the culture at Saint Anthony strongly reflects the midwifery model of care — a culture of patience, confidence in the natural process of birth, respect for the broad range of normal, and an emphasis on communication and shared decision-making.

According to Dr. Michele Bucciero, Saint Anthony Hospital’s Clinical Director in Obstetrics and Gynecology, that culture is key to the hospital’s excellent VBAC outcomes.  “You have to explain to patients why you’re not necessarily intervening right away and why you’re letting them do things on their own. And I think you have to be patient. You can’t be anxious, running to the back for surgery if they don’t make progress every two hours. You have to give them the time.”

Michelle Korzek, CNM, is the Directory of Midwifery Services at Saint Anthony Hospital. She attributes the hospital’s culture of patience in part to the unique perspective that midwives bring. “As midwives, we’re not going to look at someone who’s had a previous c-section as being ‘abnormal’ per se. We always look at birth as a normal life process. That gives us confidence to leave the process alone more of the time.”

It’s clear that the midwives and OBs at Saint Anthony are totally aligned on this. As Dr. Brucciero says, “It’s how midwives train and how they look at birth, which is so drastically different than how obstetricians train and look at birth. If I were interested in a trial of labor after cesarean, I would definitely want a midwife taking care of me.”

Look for a provider who will be patient and who trusts the process of birth. Consider a midwife.

 

The question of training is clearly important. Dr. Silver has been in practice for more than 30 years and he has seen drastic changes in approaches to VBAC over that time. “When I was in training, we offered pretty much everybody a trial of labor and the success rate was around 80%. For women with non-recurring indications [meaning that the reason for their previous c-section is not likely to recur this time around], 8 or 9 out of ten would delivery vaginally. And even those with the lowest odds of success, maybe someone who got stuck at seven centimeters or who pushed for four hours and still couldn’t deliver her baby, even those women have a 50/50 shot at delivering vaginally.”

Dr. Silver believes that providers can have skewed perceptions of the risks and benefits of a trial of labor. “Sometimes providers forget that if they allow trial of labor often enough, they’re going to be avoiding a lot of surgeries.”

VBAC

Of course, it’s not providers but mothers who actually undertake the trial of labor. That raises another important component of good counseling, according to Dr. Bucciero. “Women need to go into it with realistic expectations. For most, it’s not going be a rapid birth. Most likely it’s going to take a while, you’re going to be uncomfortable. It might be a little anxiety provoking, and at the end of the day you may need another section. I think that’s just something people have to understand. So you need to be patient and realistic. And what that requires is confidence. It’s the provider’s job to give you that confidence.”

Dr. Silver agrees that confidence is critical. “When choosing a provider, I would ask, ‘what is the culture of your labor and delivery unit? Are your nurses and other folks supportive of this or do they get anxious when they have a patient with a scarred uterus?’” The anxiety of people around you can undermine your confidence and derail your labor.

Look for providers who are confident in your ability to birth vaginally after c-section. If they believe you can do it, so will you.

 

Because it’s so important to find a supportive provider, don’t limit yourself to nearby hospitals. An hour or even an hour and a half drive might be inconvenient for prenatal visits and unpleasant when you’re in labor, but ultimately could be worth it.

As Dr. Silver points out, “People get anxious about being far from the hospital, but I think that’s a little overrated, especially with a VBAC. A lot of moms had a protracted first labor so they’re not likely to have a rapid labor this time around.” Dr. Silver has cared for vaginal trial of labor patients who live as much as an hour and a half away. That means you can look beyond the hospitals closest to you to find providers you really trust. In the list of top options for VBAC below, you’re likely to find a hospital well within a safe distance almost no matter where you live in the Chicago area.

You don’t have to limit your search to nearby hospitals.

 

Other factors to consider when choosing your provider

The most important thing is to find a provider who is supportive. But there are other considerations as well.

One is monitoring technology. Mothers trying for a vaginal birth after cesarean are required to have continuous electronic fetal monitoring, where a belt around their belly transmits fetal heart tones to a receiver. In some hospitals, the monitor significantly limits the mother’s ability to move around. But some hospitals offer the option of monitoring by telemetry, which transmits the fetal heart tones wirelessly. That allows the laboring woman to walk around instead of being tethered to the monitor. As Erica Fleischer puts it, “All Chicago area hospitals will require you to be monitored the whole time for a TOLAC [trial of labor after cesarean], but that doesn’t have to mean you’re stuck on your bed.” Being able to move around and try different positions can help you labor effectively, and an effective labor is less likely to end with a cesarean.

Look for a hospital that offers telemetry monitoring.

 

Another question to ask is whether there is an anesthesia team in the hospital at all times. This is important so that if a cesarean birth becomes necessary, it can be performed without delay.

Look for a hospital that has an anesthesiologist on site 24/7.

VBACAnd Fleischer has a few more recommendations for women who want a VBAC. “First, hire a doula. The evidence shows that they reduce the rate of c-sections, and that kind of support is particularly valuable for VBAC. Second, if your c-section was for failure to progress or failure to descend, consider body work like physical therapy, chiropractic or the Spinning Babies technique. There are plenty of women who address physical issues that made their first labor difficult and then have no issue with their next birth. And third, work through any emotional trauma you may carry from your first labor. ICAN offers support for that, including through a closed Facebook group.”

Not every mother who qualifies for and chooses a trial of labor will have a vaginal birth, although success rates tend to be very high, often around 80 – 90% or more. But for many woman, the decision to try for a VBAC has benefits even if another cesarean becomes necessary. Dr. Bucciero puts it like this: “ I think at the end of the day, even if people aren’t successful, I feel like they’re okay getting another c-section, knowing they put in their best effort. There is some kind of mental shift and bonding that happens just by going through the labor process, that a lot of people that walk in and get a c-section don’t necessarily experience. I feel like people that go through labor and really give it their all often end up more satisfied with their choice, even if they don’t end up having a natural delivery.”

Summing it up

VBACAlthough the evidence supports trial of labor for most women who’ve had cesarean births, not all providers are wholeheartedly comfortable with VBAC. If you’re considering a vaginal birth this time around, don’t stop at a discussion with your current provider.

Instead, plan to get opinions from several doctors and/or midwives who support and have attended lots of successful VBACs. You’ll get a more balanced feel for the risks and benefits of a trial of labor by hearing multiple points of view, and you’re also more likely to find someone you truly connect with. A trusting relationship is especially important for a trial of labor after c-section since you need to feel confident that you and your provider have the same goals.

The best way to find VBAC-supportive providers is to start with hospitals and midwife-led birth centers that have high VBAC rates. (See our list below).  Remember that not all hospitals and not all individual practitioners have the same criteria for trial of labor after cesarean. Just because you don’t qualify in one setting does not mean that you don’t qualify anywhere.

You don’t need to limit yourself to the hospitals closest to you. Many providers will agree to care for you even if you are traveling a distance to get to them. Given the importance of finding a supportive provider, cast a wide net if you need to.

When you’re interviewing providers at your setting of choice, here are some questions to ask:

  • Will you allow me to go past my due date if that’s my informed decision?
  • Are you willing to induce or augment my labor if that becomes medically necessary?
  • Will I have fewer options in labor because I’ve had a previous c-section?
  • What are the advantages and disadvantages of a trial of labor in my case?
  • What are the advantages and disadvantages of planning a repeat cesarean in my case?
  • How confident are you that I can successfully have a VBAC?
  • Do you offer telemetric monitoring?
  • Do you have anesthesia teams on-site 24/7?

Best options for trial of labor after cesarean in the Chicago area

If you’re planning a VBAC, below are some options to consider, including:

  • Best hospitals for VBAC
  • Options for a midwife-attended VBAC
  • VBAC in a midwife-led birth center
  • Additional options if you live in the far West suburbs
  • Options if you’ve had two prior C-sections (VBA2+C)
  • A complete list of the hospitals whose VBAC rates are above average for the Chicago area.

⇒ TIP: You can use the BirthGuide search tools to find good VBAC providers. Go to the provider search page on BirthGuideChicago.com and use the “High VBAC Rate” filter in the left-hand column to find the hospitals with the highest VBAC rates:

Or use the drop down in the “Sort by” box to sort search results by VBAC rate, highest to lowest:

Best Hospitals for VBAC

Here is a list of the hospitals with the best VBAC statistics:

North
  • NorthShore University Evanston Hospital: Almost 200 babies are born by VBAC at NorthShore University Evanston Hospital and the hospital’s VBAC rate (34.5%) is the second highest in the Chicago area. Both midwives and doctors support trial of labor after Cesarean. With a VBAC rate that is among the very highest for Chicago-area hospitals, and with the highest volume of VBACs among hospitals in this category, Evanston Hospital is the top choice for VBAC in the Chicago area.
  • AMITA Health Presence Saint Francis Hospital: Another option on the North Shore is AMITA Health Presence Saint Francis Hospital, where the VBAC rate is 29.5%. Saint Francis has a smaller volume of births overall, so the number of VBACs is lower – 30 per year. This means that the nursing staff see only 2 or 3 VBACs per month. But the high rate clearly demonstrates a commitment to VBAC.
Central
  • AMITA Health Saints Mary & Elizabeth Medical Center: At Saints Mary & Elizabeth Medical Center, 77 mothers had successful VBACs in the most recent reporting year, representing 30% of all mothers having their babies at the hospital after a prior Cesarean birth. Saints Mary & Elizabeth does have a midwife practice but the hospital reported to BirthGuide that only doctors attend VBACs there.
  • University of Illinois Hospital: More than 100 mothers had successful VBACs at University of Illinois Hospital in the most recent reporting year, and the hospital’s 27.9% VBAC rate — like the other hospitals on this list —  is “among the highest” in the Chicago area. At U of I, midwives can support a trial of labor after cesarean, so that’s an option you may want to consider.
  • Mercy Hospital: Mercy Hospital’s VBAC rate of 30.3% is the third highest among those Chicago-area hospitals that perform more than 50 VBACs per year. With a volume of 83 VBACs per year, its overall statistics are very similar to those at Saints Mary & Elizabeth. The hospital’s listing page reflects that midwives at Mercy can care for you if you elect trial of labor after Cesarean birth.
South
  • University of Chicago Medicine: The Family Birth Place at the University of Chicago in Hyde Park is a relative newcomer and has quickly become a leader in the Chicago area for evidence-based, woman-centered, low intervention birth. Their doctors and midwives attended just over 100 successful VBACs in the most recent reporting year, with a VBAC rate of 28.9%.
  • Advocate Trinity Hospital: On the far South Side is Advocate Trinity Hospital. With a smaller volume of births overall, Advocate Trinity performs fewer VBACs (34 in 2017) than some of the other hospitals on this list. But its excellent VBAC rate of 30.1% demonstrates a real commitment to VBAC. Its stats are very similar to those of Saint Francis Hospital to the north in Evanston.
  • Two other South Side options you might consider are Holy Cross Hospital and Jackson Park Hospital. Both have very high VBAC rates — 39.3% at Holy Cross (the highest in Chicago) and 33.3% at Jackson Park — but their overall volumes are quite low and so they do only a few VBACs each year (11 per year at Holy Cross, just 5 per year at Jackson Park).
West/Southwest
  • Saint Anthony Hospital: The best option for VBAC on Chicago’s Southwest Side is Saint Anthony’s, where 53 mothers had successful VBACs in the reporting year, for an overall VBAC rate of 32.1%. Saint Anthony’s has a unique model of care: all women are in the care of midwives in the first instance, supported as needed by back-up obstetricians. This is equally true for women choosing a trial of labor after c-section.

Options for a midwife-attended VBAC

Of the hospitals with the best VBAC rates, the following offer in-hospital midwifery care for women planning a trial of labor after cesarean:

The following additional hospitals have midwives who can care for you if you choose a trial of labor after cesarean. The overall VBAC rates at these hospitals are lower than those in the top tier, but still above-average compared to other Chicago-area hospitals. And keep in mind that the reported VBAC rates at these hospitals are combined for both doctors and midwives. The rates for the midwives separately are not reported and could be higher.

Option for VBAC in a midwife-led birth center

There are two midwife-led birth centers in the Chicago area: The Birth Center at PCC and the Alternative Birthing Center (or “ABC”) at West Suburban Hospital.  The Birth Center at PCC is a freestanding birth center and Illinois regulations do not allow it to take VBAC patients. But the ABC at West Suburban Hospital is an in-hospital birth center and is equipped to handle VBACs. (Note that West Suburban also has a standard labor and delivery service where midwives also practice.) As a midwife-led birth center, the West Sub ABC follows the midwifery model of care, avoiding intervention whenever possible and offering hands-on support from providers who are experts in natural childbirth. Telemetry monitoring is available and the midwives are skilled at using positioning to help your labor along. Their VBAC rate is medium high and their VBAC success rate is 81%. If you are planning a VBAC and are attracted to the midwife-led birth center model, this is an option to consider.

Alternatives if you live in further west or northwest

Of the top-rated hospitals, Saint Anthony Hospital is the furthest west, near the intersection of Pulaski and 26th Street. If that is further away than you want to travel, you could consider the following alternatives, all of which have higher than average VBAC rates:

Options if you’ve had two prior c-sections (VBA2+C)

The American College of Obstetricians and Gynecologists takes the position that VBAC can be a safe and appropriate choice for some women who have had two prior cesarean births. Not all providers offer the option of VBAC to women who have had more than one c-section, but several do — including a number of the hospitals with the highest VBAC rates.  If you’ve had two cesarean deliveries before this pregnancy, you may still have the option of a vaginal birth this time around, depending on the reasons for your past c-sections and other factors. The following hospitals are good places to start if this is something you’d like to pursue. Again, different providers will have different criteria for a trial of labor after two c-sections: just because one provider says no doesn’t necessarily mean they all will.

Complete list of hospitals whose VBAC rates are above average for the Chicago area

Hospital/ Birth Center City Number of VBACs in 2017 VBAC rate (2017) Compared to other Chicago-area hospitals, this rate is . . .
Holy Cross Hospital Chicago (South) 11* 39.29% among the highest
NorthShore Univ HS Evanston Hospital Evanston 194 34.46% among the highest
Jackson Park Hospital & Medical Center Chicago  (South) 5* 33.33% among the highest
Saint Anthony Hospital Chicago (West) 53 32.12% among the highest
Mercy Hospital & Medical Center Chicago (Central) 83 30.29% among the highest
Advocate Trinity Hospital Chicago (South) 34 30.09% among the highest
AMITA Health Saints Mary and Elizabeth Medical Center Chicago (Central) 77 29.96% among the highest
AMITA Health Saint Francis Hospital Evanston 31 29.52% among the highest
University of Chicago Medicine Chicago (South) 101 28.86% among the highest
University of Illinois Hospital & Health System Chicago (Central) 110 27.85% among the highest
West Suburban Medical Center Oak Park 53 26.37% medium high
St Bernard Hospital & Health Care Center Chicago (South) 19* 21.59% medium high
Advocate Illinois Masonic Medical Center Chicago (North) 63 21.50% medium high
Rush University Medical Center Chicago (Central) 79 21.29% medium high
Northwestern Memorial Hospital Chicago (Central) 293 20.78% medium high
Mount Sinai Hospital Chicago (West) 92 20.67% medium high
Little Company of Mary Hospital Evergreen Park 30 19.61% medium high
AMITA Health Adventist Medical Center Glen Oaks Glendale Heights 14* 19.18% medium high
Macneal Hospital Berwyn 46 18.33% medium high

 *The hospitals with an asterisk perform fewer than 20 VBACs a year.

 

About the VBAC rates reported on BirthGuide

Providers are listed on BirthGuide as having a risk-adjusted VBAC rate that is “among the highest” if their VBAC rate is one standard deviation or more above the average rate for all hospitals listed on BirthGuide. (BirthGuide lists all maternity hospitals in Cook, Dupage and Lake counties that were included in the Illinois Department of Public Health’s “Illinois Health Report Card” as of 2/14/2019.) On the mobile version of the site, these providers’ VBAC rates are listed as “high”.

The VBAC rates used in this calculation come from the Illinois Department of Public Health (IDPH), which reports the VBAC rates for all Illinois hospitals. The IDPH VBAC rates reflect the number of women who have had at least one prior c-section in the past and who then have a vaginal birth at that hospital in the reporting year, divided by the number of all women who gave birth at that hospital in that year who have had at least one prior c-section. So the VBAC rate takes into account both the women who try for a VBAC and the women with a history of c-section who schedule a repeat cesarean with this pregnancy. The VBAC rates reported by IDPH are risk-adjusted.

Some providers also self-report their VBAC success rate. The VBAC success rate is the percentage of all women who choose a trial of labor who ultimately have a vaginal birth. That rate will be much higher than the overall VBAC rate because it considers only the population of women who qualify for and elect to try for VBAC, without taking into account women who are scheduled for a repeat c-section.

The highest overall VBAC rates will reflect both that a high percentage of women are offered a trial of labor and that skilled support helps a high percentage of those to succeed.

 

The photos in this article document a successful VBAC and are used with the permission of Amanda E Photography in Peoria Illinois.