FIGO Issues Updated VBAC Guidelines

by | Oct 3, 2025 | VBAC or Repeat Cesarean?

Graphic: "Good Clinical Practice"


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Maternal and neonatal outcomes of VBAC after one [cesarean] are comparable with planned repeat [cesarean], according to available current literature, and VBAC has the advantage of obviating the short- and long-term risks of repeat [cesarean]. In the presence of favorable factors, success rates of VBAC range from 60% to 80%, with a previous vaginal birth (particularly a VBAC) being the single best predictor of success. — International Federation of Gynaecology and Obstetrics (2025)

Hot off the press is the International Federation of Gynaecology and Obstetrics’ (FIGO’s) updated guidelines for VBAC. In this article, I’ve summarized the research analyses supporting FIGO’s recommendations and excerpted the relevant ones. I’ve also added introductions to the subsections and my comments to provide perspective on FIGO’s findings and recommendations. At the end is my usual “takeaway” section, where you’ll find advice on implementing your choice. As you can see, though, this is a long piece. So if you’re interested in a VBAC and just looking for reassurance from an authoritative body that VBAC is a reasonable option—even the better option under most circumstances—feel free to stop with the opening quote and use the internal links to jump to my excerpts of FIGO’s recommendations or just go straight to “Your Takeaway.”

Research Summary

Before we get to the research findings, keep this caveat in mind: The studies cited in FIGO’s guidelines were conducted in hospitals with obstetricians attending the births, and that has consequences for their results. We know that most adverse outcomes in VBAC labors occur in labors that ended in a cesarean or during which the scar gave way (Butwick 2025; Landon 2004). We also know that typical obstetric management results in higher repeat cesarean and scar rupture rates than are achieved with midwifery care. Taken together, this means that the VBAC and scar rupture rates reported in the guideline’s source studies are not the best that can be achieved. In evidence of this:

  • FIGO’s guidelines cite two studies reporting VBAC rates of 65 percent and 63 percent with no prior vaginal births or VBACs. In contrast, two studies of births attended by midwives in homes and freestanding birth centers both report VBAC rates of 81 percent in this same population (Cheyney 2014; Lieberman 2004).
  • FIGO’s guidelines state that on average, the uterine scar will give way in 8 per 1,000 VBAC labors. However, typical medical management may include inducing or strengthening VBAC labors with IV oxytocin, which the guidelines acknowledge increase the likelihood of the scar giving way.

Management can also be the root cause of repeat cesareans that FIGO’s guidelines attribute to characteristics of the woman or birthing person. For example:

  • FIGO’s guidelines note that VBAC rates are lower when the prior cesarean was done for progress delay compared with nonreassuring fetal heart rate or breech presentation. However, a study reported that when the prior cesarean was for progress delay, less time was given in the VBAC labor compared with these other indications (Shipp 2000). How many labors after a prior cesarean for progress delay might have ended in vaginal births had doctors allowed more time?
  • FIGO’s guidelines also note that some studies find that predicted big baby increases the odds of the scar giving way. But doctors are more likely to induce labor when they think the baby is going to be big in the belief that earlier delivery will reduce likelihood of cesarean (FYI: it doesn’t), and induction increases the odds of scar rupture.

VBAC Rates

Country-specific VBAC rates range from 60-80 percent, and the US rate is 75 percent. VBAC attempt rates, on the other hand, are very low. As the guidelines report, in the United States, VBAC occurred in 22 percent of births after one cesarean, 7 percent after two, and 5 percent after three. If 75 percent of all VBAC labors in the United States end in vaginal birth, then these rates mean that most deliveries after prior cesarean are planned repeat cesareans.

The guidelines state that obstetricians should take into account factors that would increase vaginal birth probability above 80 percent or decrease it below 60 percent when counseling patients. [Me: As you saw earlier, the care provider’s practice style matters as much, if not more, than the characteristics of the woman or birthing person. In evidence of this, see my Resource Library article: “VBAC Calculators Lowball Probability of VBAC.”]

The guidelines recommend “medicolegal frameworks” to protect staff from litigation as “apprehension over litigation remains a significant reason why obstetricians hesitate to offer patients VBAC.” [Me: This is a tacit admission that many obstetricians don’t practice according to medical ethical principles. Medical ethics enjoin obstetricians to act for the benefit of their patients. Failing to offer VBAC because of fear of being sued violates that principle.]

Risk of Scar Rupture

The guidelines quote scar rupture rates ranging from 3-7 per 1,000 VBAC labors and note that rates were 14 per 1,000 according to a study of VBAC after two prior cesareans. [Me: As we saw above, and as the guidelines also acknowledge and discuss, management as well as inherent factors affect scar rupture rates.]

Outcomes of Planned VBAC Compared with Planned Repeat Cesarean

Keep in mind as you go through this section that:

Also, I’m going to confine this section to outcomes that have potential ongoing consequences and omit ones that once they are treated or heal are over and done.

Maternal Outcomes

  • Maternal mortality: rare but increased rate with planned repeat cesarean. One large analysis pooling data from multiple studies reported a rate of 13 per 100,000 planned repeat cesareans compared with 4 per 100,000 planned VBACs.
  • Hysterectomy: rare and statistically similar occurrence rates between the two, meaning that the difference is likely to be due to chance. The most common reason for hysterectomy was scar rupture in VBAC labors and placenta accreta in planned repeat cesareans. [Me: Placenta accreta is largely a complication of having had prior cesarean deliveries, and the odds of it occurring increase with the number of prior cesareans.]
  • Pelvic floor weakness: no studies comparing long-term pelvic floor function between planned repeat cesareans and planned VBAC labors. The guidelines note that some of the risk of pelvic floor weakness (urinary stress incontinence, pelvic floor prolapse) is due to pregnancy, not birth route, and that likelihood of experiencing symptomatic pelvic floor weakness varies according to the timing of the original cesarean. For these reasons, the guidelines state: “Planned repeat [cesarean] for the prevention of pelvic floor disorders should not be considered protective against stress incontinence and prolapse.”

Outcomes for the Baby

  • Deaths around the time of birth: rare but increased rate with planned VBAC. One large analysis pooling data from multiple studies reported a rate of 5 per 10,000 planned repeat cesareans compared with 11 per 10,000 planned VBACs, and another reporting the variation in rates among studies reported ranges of 0-1 per 1,000 for planned repeat cesareans and 0-3 per 1,000 planned VBACs.
  • Hypoxic-ischemic encephalopathy: rare but increased occurrence rate of abnormal neurologic signs in VBAC labors. One study reported 0 occurrences among 15,801 planned repeat cesareans versus 12 in 17,898 (7 per 10,000 VBAC labors) planned VBACs. However, six of those 12 cases occurred in labors that were either induced or augmented with IV oxytocin, and seven involved scar rupture. [Me: See what I mean? Management counts. Important to note as well is that half of all newborns with abnormal neurologic signs will make a complete recovery (Pin 2009), which makes permanent impairment exceedingly rare (3 per 10,000 VBAC labors not induced or augmented or in which scar rupture occurred).]

Factors Affecting the Probability of VBAC

Factors affecting the probability of VBAC fell into two categories: factors that increased or decreased the probability of VBAC and factors that increased or decreased the probability of the scar giving way, which, of course, would end the labor with a cesarean.

Factors Affecting Vaginal Birth

  • Previous vaginal birth or VBAC: greatly increased VBAC rate compared with no previous vaginal birth or VBAC. Rates with prior vaginal birth or with one or more prior VBACs ranged from 83-94 percent compared with 63-65 percent with neither. [Me: As I noted above, the VBAC rate with no prior vaginal births or VBACs in the studies of home and birth center births was 81 percent (Cheyney 2014; Lieberman 2004).]
  • Other factors: decreased probability of VBAC with previous cesarean for progress delay, predicted big baby, or high maternal BMI. [Me: I’m not providing statistics here because as discussed above, we don’t know to what degree a reduced VBAC rate is inherent to the factor and to what extent it is due to management. In fact, in another example of how management influences outcomes, the guidelines report on a study finding that, when laboring with a big baby, having labor start on its own increased the odds of VBAC.]

Factors Affecting Scar Rupture

  • Number of previous cesareans: increased probability of scar rupture with planned VBAC after two prior cesareans versus after one, but similar severe adverse outcome rates compared with a planned third repeat cesarean. VBAC rates after two cesareans were 70-71 percent. Previous vaginal birth or VBAC increased the VBAC rate in the current pregnancy, and induction or augmentation of labor reduced it. [Me: High VBAC rates and similar adverse outcome rates compared with a third planned cesarean make planned VBAC the better option.]
  • Type of uterine incision: unclear whether having a previous low vertical uterine incision increases probability of scar rupture compared with the standard low transverse incision. The guidelines theorize that the probability may depend on how far the incision extends upward into the main body of the uterus.
  • Interval between births: increased probability of scar rupture with less than an 18 month interval between births compared with 18 months or more. The guidelines don’t give the numbers, only that rates are increased.
  • Thickness of the lower part of the uterus: thickness of the lower uterine segment isn’t a useful means of predicting probability of scar rupture. [Me: The guidelines come to this conclusion based on lack of a standardized technique for taking measurements and an agreed upon cutoff. What they don’t mention is that all the studies of uterine thickness have used finding small windows in the scar at the time of repeat cesarean as their outcome measure. How many of these would have progressed to scar rupture in a VBAC labor is unknown, but it probably would have been very few.]

Other Considerations

Twin Pregnancy

The VBAC rate is high: 72 percent, and scar rupture rates and other adverse outcomes occur at rates similar to those in singleton pregnancies.

External Cephalic Version 

Using a hands-to-belly technique for turning breech babies head down does not cause problems with the uterine scar.

Induction and Labor Augmentation

Inducing labor and strengthening contractions with IV oxytocin increase probability of scar rupture and decrease vaginal births. Misoprostol should not be used for ripening a cervix unfavorable for labor because of its association with scar rupture.

Requirements for VBAC

The guideline’s requirements for VBAC cut both ways. On one hand they enjoin obstetricians to promote vaginal birth. On the other, they set limitations on when VBAC is allowed, which, since the only alternative to labor is cesarean surgery, denies the right of every person—pregnant women and birthing people not excepted—to decline medical intervention.

Assessment and Counseling

“The patient should be thoroughly counseled on the risks and benefits of VBAC versus planned repeat [cesarean].” [Me: It is common for care providers to emphasize the risks of VBAC and say little about the risks of repeat cesarean (Declercq 2013).]

“Several prediction models for VBAC success exist but many lack external validation and are at high risk of bias, hindering generalizability and applicability.” [Me: In plain English, VBAC calculators don’t work and shouldn’t be used in recommending for or against planning VBAC. (See my article on this topic.)]

Infrastructure and Setting

“VBAC should be performed in facilities that have resources for 24-h emergency [cesareans], blood bank, and [newborn intensive care nursery] backup owing to the associated maternal and neonatal risks.” [Me: The argument for limiting VBAC labors to hospitals capable of handling emergencies 24/7 is bogus. Emergencies occur in non VBAC labors. If a hospital isn’t safe for a VBAC labor, it isn’t safe for labor, period.]

“Supportive one-to-one nursing/midwifery care and continuous electronic fetal monitoring is the standard, given that fetal heart rate abnormality is the most common sign of [scar] rupture.” [Me: Seeing as most hospitals monitor labors from a central station, few hospitals would provide “supportive one-to-one nursing care.”]

Epidurals do not mask the pain of scar rupture and should not be withheld on that basis.

Labor Management

“Women attempting VBAC have similar labor patterns as women who have not had a prior [cesarean].” [Me: This statement is problematic as it will give obstetricians unrealistic expectations of how quickly labor should progress in VBAC labors with no prior vaginal birth or VBAC. One of the two studies they cite found that VBAC labors with no prior vaginal birth progressed on average at the pace of first labors, which progress much more slowly than is typical for subsequent labors. In the other, two-thirds of the participants had previously birthed vaginally and would, for that reason, have a labor pattern similar to that in labors with only prior vaginal births.]

Routine exploration of the uterine scar after VBAC is not recommended. Neither is surgical repair if uterine exploration is performed and a symptomless window is found.

FIGO’S Recommendations

As you’ll see, FIGO’s guidelines have much to say that is supportive of planning VBAC. On the other hand, use of the word “may” implicitly gives clinicians and hospitals the final say over VBAC. Since the only alternative to labor is repeat cesarean surgery, that’s a problem because it denies the right of every person—pregnant women and birthing people not excepted—to decline medical intervention.

Predicted Big Baby

“Fetal macrosomia alone is not an absolute contraindication to VBAC.”

Number of Prior Cesareans

“Women with a single previous [cesarean] may be offered VBAC in the absence of any contraindication to vaginal birth.”

“If a woman with two prior [cesareans] and a vaginal birth strongly desires a VBAC, . . . this option may be available in some high-resource facilities.”

Type of Uterine Incision

“VBAC is safe and associated with low absolute risks of [scar] rupture in women with a previous low transverse or low vertical uterine incision.”

“VBAC is contraindicated in women with previous classical [cesarean] (a vertical incision on the upper (contractile) uterine segment), inverted T or J incisions, and previous incisions that extend into the upper uterine segment.” [Me: These types of incisions are rarely used.]

Interbirth Interval

“An interbirth interval of at least 18 months is recommended for VBAC for optimal maternal and neonatal outcomes.”

Prediction of Scar Rupture and Vaginal Birth

“Routine use of antenatal lower uterine segment thickness measurements for the prediction of [scar] rupture . . . is not recommended.”

“Routine use of prediction models to predict VBAC success is not recommended.”

Multiple Pregnancy

“Twin pregnancy is not an absolute contraindication to VBAC.”

Breech Presentation

“External cephalic version can be safely attempted in women with a singleton breech presenting fetus and a prior low-transverse uterine incision.”

Induction and Augmentation of Labor

“Induction of labor is not contraindicated in women with one previous low uterine incision.”

“Induction of labor is associated with a lower VBAC success, as well as increased risk of [scar] rupture.” [Me: So, induction and strengthening contractions with IV oxytocin decreases the chances of vaginal birth and increases the chances of scar rupture, but it’s fine to do it anyway? Not to mention, as you saw above, that studies of VBAC in homes and birth centers achieved substantially higher rates of VBAC in labors with no prior vaginal birth or VBAC without their use compared with rates in hospital studies.]

“Mechanical methods such as amniotomy [breaking the bag of waters] and transcervical Foley catheter [inserting a balloon catheter into the cervix] are recommended for cervical ripening and induction of labor.” [Me: These methods aren’t associated with an increase in scar rupture.]

“Misoprostol should not be used for cervical ripening and induction of labor in women with a previous [cesarean] because it is associated with a high risk of [scar] rupture.”

Facility Requirements and Care During Labor

“VBAC should only be performed in facilities with resources for 24-h emergency [cesarean], blood bank, and [newborn intensive care nursery].” [Me: To repeat what I wrote above, the argument for limiting VBAC labors to hospitals capable of handling emergencies 24/7 is bogus. Emergencies occur in non VBAC labors. If a hospital isn’t safe for a VBAC labor, it isn’t safe for labor, period.]

“Supportive one-to-one midwifery/nursing care in labor and continuous electronic fetal monitoring are recommended, as fetal heart rate abnormality is the most common sign of [scar] rupture.” [Me: Most hospitals monitor labors from a central station, which means they don’t provide “supportive one-to-one nursing care.”]

“Epidural analgesia is not contraindicated during VBAC.”

“The same standards and recommendations for evaluating labor progress in women without a previous [cesarean] apply to women undergoing VBAC.” [Me: To repeat what I wrote above, this statement will give obstetricians unrealistic expectations of how quickly a labor should progress in VBAC labors with no prior vaginal birth or VBAC. One of the two studies they cite found that VBAC labors with no prior vaginal birth progressed on average at the pace of first labors, which progress much more slowly than is typical in subsequent labors. In the other, two-thirds of the participants had previously birthed vaginally and would, for that reason, have a labor pattern similar to that in labors with only prior vaginal births.]

“Routine uterine exploration after VBAC is not recommended.”

“Surgical repair of asymptomatic uterine scar [windows] suspected by uterine exploration after VBAC is not recommended.”

Your Takeaway

So, what have we learned from FIGO’s VBAC guidelines? Well, one thing we learned is that it’s hard to come by a practitioner willing to attend VBACs. As we saw in the section on VBAC rates, in the United States “once a cesarean” unfortunately still usually means “always a cesarean,” an observation further supported by a 2025 study finding that labor after cesarean was available in fewer than 16 percent of US counties (Ranchoff 2025). Another is that, when developed by obstetricians, even supportive VBAC guidelines fall short of optimal care. I can’t help with the first problem, but I can provide some questions to help you determine whether the practices and policies of the care provider you’re considering best promote an uneventful labor that ends in vaginal birth.

  • Will you or someone in your practice be attending my birth? Some hospitals use “laborists,” obstetricians employed by the hospital who manage labors and births there. There’s no point continuing with the rest of these questions if your doctors or midwives won’t be responsible for your care in labor.
  • What percentage of your patients with a prior cesarean plan a VBAC? This number tells you whether this care provider truly encourages VBAC. This should be most of them since few circumstances contraindicate VBAC.
  • What percentage of those who plan a VBAC with no prior vaginal birth or VBAC have a vaginal birth? As we saw above, rates of 80 percent are achievable, but I’d call anything above 70 percent acceptable.
  • Do you use a VBAC prediction calculator to advise me about candidacy for VBAC? VBAC prediction scoring systems are in wide use, and in many cases, they are being used to discourage or deny VBAC. Obviously, there are factors that would decrease the probability of vaginal birth, but the likelihood of VBAC depends far more on the beliefs and policies of the clinician than it does on factors relating to you or your previous cesarean. Certainly, too, denying VBAC based on a low prediction score should send you out the door.  
  • Under what circumstances would you recommend a repeat cesarean? These should be serious medical conditions or labor complications, not circumstantial reasons such as having a prior cesarean for slow progress, a baby estimated to be bigger than average, going past your due date, or failing to meet preset time limits for making progress in labor.
  • What are your criteria and policies for VBAC labors? The only difference from care in a non-VBAC labor for which a case can be made is continuous fetal monitoring.
  • Do all the others in your practice feel as you do about VBAC? If not, how can I ensure that I will be attended by someone who does? Most doctors and midwives are in group practices and rotate who is on call for births. It is entirely possible that some practice members don’t permit VBAC or hedge it about with so many non-evidence-based restrictions that it amounts to the same thing.

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References

Butwick A, Baer RJ, Farooqi N, et al. Severe Perioperative Surgical Morbidity With Cesarean Delivery. Obstet Gynecol 2025.

Cheyney M, Bovbjerg M, Everson C, et al. Outcomes of care for 16,924 planned home births in the United States: the Midwives Alliance of North America statistics project, 2004 to 2009. J Midwifery Womens Health 2014;59(1):17-27.

Declercq E, Sakala C, Corry MP, et al. Listening to Mothers III. Pregnancy and Birth. New York: Childbirth Connection; 2013.

Landon MB, Hauth JC, Leveno KJ, et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med 2004;351(25):2581-9.

Lieberman E, Ernst EK, Rooks JP, et al. Results of the national study of vaginal birth after cesarean in birth centers. Obstet Gynecol 2004;104(5 Pt 1):933-42.

Pin TW, Eldridge B, Galea MP. A review of developmental outcomes of term infants with post-asphyxia neonatal encephalopathy. Eur J Paediatr Neurol 2009;13(3):224-34.

Ranchoff BL, Geissler KH, Goff SL, et al. Trends in Labor After Cesarean Delivery Access in the US. JAMA Netw Open 2025;8(8):e2526224.

Shipp TD, Zelop CM, Repke JT, et al. Labor after previous cesarean: influence of prior indication and parity. Obstet Gynecol 2000;95(6 Pt 1):913-6.