Presented by Christy Cannon, CNM, WHNP-BC · The Midwife & More
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In this episode of The Ventura County VBAC Guide Podcast, we explore what midwives actually do to support a safer, more informed, and more empowered vaginal birth after cesarean. The conversation explains why VBAC is not simply a yes-or-no decision, why individualized care matters, and how midwives help families move from fear and confusion into clarity and confidence. It also breaks down the difference between VBAC and TOLAC, the importance of reviewing your prior operative report, the role of continuous support, and how hospital-based midwifery can combine natural birth wisdom with modern medical safety.
When people talk about VBAC, they often want one clear answer. Am I a candidate, yes or no? Is it safe, yes or no? Will it work, yes or no? But vaginal birth after cesarean is not that simple, because birth is not a fixed mechanical event that can be predicted like an X-ray or scheduled like a routine procedure.
A VBAC, which means vaginal birth after cesarean, begins with a TOLAC, or trial of labor after cesarean. That means a mother goes into labor with the goal of having a vaginal birth after a previous C-section. If that trial of labor results in a vaginal birth, the outcome is called a VBAC. For many low-risk families, VBAC can be a very real option, but the path toward it requires thoughtful preparation, skilled support, and a care team that understands the nuance of birth after cesarean.
This is where midwifery care can make a meaningful difference. A midwife's work does not begin when contractions start or when a mother begins pushing. The foundation is built months earlier through careful history-taking, medical record review, emotional preparation, birth planning, and trust. A midwife looks at the whole picture, not just the fact that someone has had a prior cesarean.
One of the first things a VBAC-supportive midwife will often want to review is the operative report from the previous cesarean. Many people assume that the scar they see on their skin tells the whole story, but the outside incision does not necessarily reveal what happened inside the uterus. A low horizontal skin incision, sometimes called a bikini cut, only shows how the surgeon entered the abdomen. It does not confirm what type of uterine incision was made.
This matters because the type of uterine scar plays an important role in VBAC planning. A low transverse uterine incision is generally considered the most favorable scar type for TOLAC because it is located in the lower part of the uterus, where the tissue stretches more passively during labor. A classical incision, which is vertical and located higher on the uterus, carries a very different risk profile because it involves the more muscular contracting portion of the uterus. Without the operative report, a provider may not have the information needed to properly understand the medical reality of a person's VBAC options.
A midwife does not treat every previous C-section as the same story. She wants to know why the cesarean happened, how the labor unfolded, what interventions were used, what the baby's position was, and what was documented in the surgical notes. That kind of detective work allows the care plan to become specific instead of generic. It also gives the family a clearer understanding of what may or may not be likely to repeat in the next birth.
A major part of VBAC preparation is understanding the reason for the first cesarean. Some reasons are non-recurring, meaning they are unlikely to happen again in the same way. A breech baby, a sudden fetal heart rate concern, or a one-time labor complication may not say much about what the body can do in a future pregnancy. These situations need to be understood, but they should not automatically define the next birth.
Other reasons may require a more strategic plan. If the previous cesarean was related to a chronic health condition, a recurring medical concern, or a complex labor pattern, the care team may need to approach the next birth differently. That does not always mean VBAC is off the table, but it does mean the plan should be individualized. A midwife uses longer prenatal visits to sort through these details, ask better questions, and help the family separate old fear from current reality.
This is also where emotional healing begins. Many women carry unanswered questions from their first birth, especially if the cesarean felt rushed, scary, or poorly explained. When a midwife takes time to review the story, the mother can begin to understand what happened instead of only remembering how it felt. That understanding can become a powerful part of preparing for a different birth experience.
Many families encounter VBAC calculators during pregnancy. These tools use population-level data to estimate the likelihood of a successful VBAC based on certain factors. While they can sometimes provide context, they should not be treated as a crystal ball. A calculator cannot know a mother's full story, her care environment, her support team, her previous birth experience, or how her labor may unfold.
The history of VBAC calculators also shows why individualized care matters so much. Older versions of some calculators included race and ethnicity, which lowered predicted success rates for Black and Hispanic patients. That raised serious concerns because race is not a biological measure of uterine strength or labor ability. Using those kinds of inputs could discourage families from even being offered a fair conversation about TOLAC.
A midwifery model places more emphasis on shared decision-making than on a single algorithmic number. That means looking at the actual person in the room, reviewing her records, listening to her concerns, and discussing the benefits, risks, alternatives, and timing of different choices. Numbers can inform a conversation, but they should not replace the conversation. A mother deserves to be treated as a whole person, not as a percentage.
One of the most helpful tools in shared decision-making is the BRAIN framework. BRAIN stands for Benefits, Risks, Alternatives, Intuition, and Nothing. When an intervention is suggested, this framework creates a pause so the family can understand what is being offered and why. That pause can be especially important during labor, when decisions may feel urgent and emotions may be high.
For example, if breaking the water is suggested to move labor along, the first question is about the benefit. Could it help contractions become stronger or labor progress more efficiently? Then comes the risk, such as infection, cord prolapse, or a change in contraction intensity. After that, the family can ask about alternatives, such as position changes, walking, rest, hydration, or waiting.
The "I" in BRAIN stands for intuition, and that part matters more than many people realize. Birth is deeply physical, but it is also emotional, psychological, and instinctive. The "N" stands for doing nothing, or waiting to see what happens. Sometimes the safest and wisest choice is not immediate action, but another hour of observation when mother and baby are both doing well.
Labor is not only mechanical. It is hormonal, emotional, neurological, and deeply connected to the nervous system. When a mother feels unsafe, unheard, rushed, or terrified, her body may respond with stress hormones that work against labor. This is not weakness, and it is not something she is imagining. It is a real physiological response.
Fear can increase adrenaline, and adrenaline can interfere with oxytocin, the hormone that helps fuel uterine contractions. If the body senses danger, it may redirect energy toward protection instead of birth. That is why unresolved trauma from a previous cesarean can become such a powerful part of VBAC preparation. A frightened body may have to work harder, not because it is incapable, but because it is trying to protect itself.
Midwives often help families process the previous birth before the next labor begins. That may include reviewing what happened, identifying triggers, discussing fears, and creating a plan that makes the mother feel safer. This kind of preparation is not just emotional support. It can be part of protecting the hormonal flow of labor.
A midwife and a doula are not the same, but together they can provide a powerful support system. A midwife is a clinical provider who monitors the medical well-being of the mother and baby, assesses labor progress, reads fetal monitoring, performs clinical exams, catches the baby, and manages complications within her scope. A doula does not provide medical care. Instead, a doula offers continuous emotional, physical, and comfort support throughout labor.
For a mother planning a TOLAC, this combination can be especially valuable. The midwife is watching the clinical picture, while the doula is helping the mother stay grounded through contractions, fear, fatigue, and transition. A doula may use counterpressure, breathing support, position changes, reassurance, and touch to help reduce stress and improve coping. That kind of steady presence can help protect the labor environment.
Continuous support also helps a mother feel less alone. A VBAC labor can bring up old memories, especially when sensations become intense or the hospital setting feels familiar in a difficult way. Having a team that understands both the medical and emotional sides of VBAC can change the entire tone of the birth room. The mother is not just being monitored, she is being held, heard, and supported.
Some families planning a VBAC avoid discussing a repeat cesarean because they worry it means they are giving up. But having a backup plan is not the same as expecting failure. Birth is unpredictable, and sometimes a repeat C-section becomes the safest choice for the mother, the baby, or both. Planning for that possibility can actually help preserve autonomy if the birth takes an unexpected turn.
A thoughtful backup plan might include who stays with the mother, who holds the baby first, whether immediate skin-to-skin is possible, whether the drape can be lowered, or how the family wants communication to happen in the operating room. These details matter because they help the family remain active participants even if the route of birth changes. A cesarean does not have to mean the mother loses her voice. It can still be a birth where she is informed, respected, and included.
This is an important part of VBAC preparation because it removes some of the panic from the unknown. If the plan changes during labor, the family is not starting from zero. They already know what matters to them, and the care team already understands their preferences. That kind of preparation can make a necessary surgical birth feel less chaotic and more supported.
Once labor begins, midwifery care often looks different because of its patience with the natural rhythm of birth. Labor does not always move in a straight line. There can be pauses, stalls, bursts of progress, and periods where the body seems to rest before moving forward again. A midwife is trained to understand the difference between a true concern and a normal labor pattern that needs time.
Instead of immediately escalating to interventions, a midwife may look at positioning, hydration, rest, emotional state, bladder fullness, baby's station, and pelvic mechanics. Sometimes what gets labeled as failure to progress is actually a baby needing a better angle through the pelvis. The pelvis is not a fixed bowl. It is a dynamic structure, and movement can help create space at the inlet, mid-pelvis, or outlet.
That is why midwives may use tools like peanut balls, lunges, side-lying positions, hands-and-knees, walking, gravity, and counterpressure. These are not random comfort measures. They can be strategic ways to help the baby rotate, descend, and find a better pathway. In a VBAC labor, this kind of patient, hands-on support may help reduce unnecessary interventions while still keeping safety at the center.
For some families, the idea of waiting past 40 weeks can feel frightening after a previous cesarean. The natural question is whether the risk automatically rises with every passing day. In the episode, the point is made that the bigger concern for many TOLAC situations is not simply time on the calendar, but aggressive induction or stimulation before the body is ready. That is why individualized monitoring matters.
If the mother and baby are doing well, fluid levels are reassuring, and the overall clinical picture is stable, a midwife may be comfortable allowing more time for spontaneous labor. This is not a passive approach. It involves ongoing assessment, fetal monitoring when appropriate, and a careful understanding of when waiting is reasonable and when action is needed. The goal is not to avoid medicine, but to avoid unnecessary pressure on the body when the body may simply need more time.
Midwives may also use natural ways to encourage oxytocin when labor slows. This could include privacy, dim lighting, emotional reassurance, touch, movement, nipple stimulation, or other methods that support the body's own hormonal rhythm. These approaches are not about rejecting medical tools. They are about using the least disruptive option that fits the moment, while keeping the mother and baby safe.
One of the biggest misconceptions about midwifery is that it is anti-medicine. In a hospital-based VBAC, that could not be further from the truth. Evidence-based midwifery combines deep respect for physiologic birth with active clinical vigilance. A midwife can support patience, movement, and natural labor while also watching closely for signs that medical action is needed.
During a TOLAC, safety requires careful attention. The care team watches the fetal heart rate, contraction patterns, maternal pain, bleeding, vital signs, and any changes that could suggest a problem. One concern in VBAC care is uterine rupture, which is rare but serious, and providers must know the warning signs. A midwife supporting a hospital TOLAC understands when patience is appropriate and when the plan must change.
This is the bridge that many families are looking for. They want a birth experience that feels personal, calm, and respectful, but they also want immediate access to medical support if needed. Hospital-based midwifery can offer that balance. It allows birth to unfold with as much physiologic support as possible while keeping modern obstetric safety close by.
A successful birth is not only defined by whether the baby is born vaginally or by cesarean. For many mothers, success also includes whether they felt heard, informed, safe, respected, and included in the decisions being made. This is especially true after a previous birth that may have felt frightening or out of control. A VBAC can be deeply healing, but so can any birth where a mother's voice is honored.
The goal of midwifery care is not VBAC at all costs. The goal is an empowered, informed, safe birth where the family understands the options and participates in the plan. Sometimes that may lead to a vaginal birth after cesarean. Sometimes it may lead to a repeat cesarean that is chosen or needed with clarity and support. Either way, the mother deserves dignity, patience, and individualized care.
If you are planning a birth after cesarean, the most important first step is to gather your records and speak with a qualified provider who can review your personal medical and surgical history. Your operative report, the reason for your first cesarean, your current pregnancy, and your care environment all matter. General education can help you ask better questions, but your own plan should be made with someone who knows your full story. You deserve a birth team that sees you as more than a scar, more than a statistic, and more than a risk category.
Educational Disclaimer. This article and podcast episode are for general educational purposes only. They are not medical advice and do not create a provider-patient relationship. VBAC candidacy and TOLAC planning should always be discussed with a qualified maternity care provider who can review your personal medical history, previous operative report, pregnancy details, and current risk factors. Always consult your own care team before making decisions about labor, birth, or medical treatment.
Christy Cannon, CNM, WHNP-BC is the first Certified Nurse Midwife to offer holistic birth services at Los Robles Hospital, Thousand Oaks, blending personal, one-on-one midwifery care with the safety net of a hospital and an on-call OB. If you are hoping for a VBAC, the first step is a conversation.
Serving Thousand Oaks, Westlake Village, Newbury Park, Agoura Hills, Oak Park, Simi Valley, Woodland Hills, Calabasas, Moorpark, Malibu, Hidden Hills and the surrounding Ventura County and West LA communities.