In the US, 32 % of babies are born via cesarean section. I’ll let that sink in for a moment. That’s almost 1/3 of deliveries. We’re talking about a MAJOR surgery here. While it is possible to have a positive experience with the proper preparation and support, it can be extremely traumatic and difficult to have an even longer road to healing in the postpartum period.
Individuals whom have previously given birth via C-section have a difficult decision to make: schedule another C-Section or labor and have a “vaginal birth after cesarean” (VBAC). Here are questions I hear all of the time as a birth doula.
Should I have a scheduled repeat C-Section or try for a Vaginal Birth After Cesarean (VBAC)?
First of all, we’ve come a long way from “once a cesarean, always a cesarean”. Due to concern for uterine rupture, or a separation of the uterine muscle at the previous surgical scar, the recommendation was to deliver by C-Section every time to avoid labor. Secondly, we now know that for a “good candidate”, the risk of a complications of a repeat C-Section is about the same as the risk of complications from a VBAC. This means that either option could work for you and your family.
To make this choice, you need a provider who is willing to take the time to discuss each option in full, including what a complication might look like in either scenario to help you understand fully the decision ahead and pick the right option for you. Research OB/GYN offices in your area who are supportive of VBAC and have had a high success rate in this area.
What risk is associated with VBAC vs. Repeat C-Section?
The risk of a VBAC is that the previous incision site will open up while the uterus is contracting during labor. This is more commonly known as uterine rupture and occurs during just under 1% of TOLACs when all conditions for safety are met (0.2-1.5%). This risk may increase in the event of 2 previous cesareans (0.9-3.7%). Uterine rupture can lead to excessive blood loss and it can occur quickly. While maternal death from uterine rupture is rare, is does account for 5% of all pregnancy-related deaths each year.
Risks of a repeat Cesarean section include surgical injuries to the bowel and bladder, longer hospital stay, infection in the uterus, bladder, or skin incision, blood clots in the legs or pelvis, increased pain after delivery, possible respiratory issues in the baby, and an exponentially increasing risk with each additional surgery.
For these reasons, the American College of Obstetricians and Gynecologists has stated that VBAC is potentially safer than repeat cesarean. With the likelihood of complications being rare and similar in each case, you are simply choosing the nature of the risk you are willing to take. One must consider future reproductive capacity in the decision making, as each additional C-section becomes riskier.
What does TOLAC mean?
TOLAC, or Trial of Labor after Cesarean, entails watching closely as labor progresses to ensure that the laboring person and baby are tolerating labor well and to look out for any signs that the uterus and uterine scar may be under too much stress to tolerate the strong, frequent contractions necessary for a vaginal delivery. You may hear your labor referred to as ‘TOLAC’ before delivery and ‘VBAC’ in the postpartum.
Am I a good candidate for TOLAC/VBAC?
Candidacy for VBAC is first determined based on safety. You are safe to try a labor if:
- Your first C/Section incision was made “low transverse”, or a single incision left to right along the bottom of your uterus.
- You have had one previous cesarean. Some providers may consider after 2 previous cesareans (VBA2C), but the risk of uterine rupture is higher. History of other surgeries or procedures on your uterus may also be a contraindication, as is a history of a uterine rupture.
- You have a single baby in vertex, or head down, position
- Your placenta has not implanted on top of your scar.
Having had a previous vaginal delivery makes you a very good candidate for VBAC.
Next, you can discuss with your provider considerations for whether you are likely to have a successful VBAC. We can help evaluate this by considering the likelihood that the condition that resulted in your C-Section the first time around would occur again. Some examples of scenarios unlikely to occur again: breech or other malposition of the baby, a failed induction of labor (ex: I only ever got to 4 cm during my induction even though they tried all the medications), cord prolapse, or baby’s heart beat was concerning during labor. An indication more likely to occur again would be a failure of baby to descend through the pelvis after becoming completely dilated and pushing for many hours. This example does NOT mean that it is impossible to have a successful VBAC, just that we cannot eliminate the possibility that there was a structural reason that baby was not able to enter the pelvis.
Every labor is different. The state of the vaginal canal (bones, soft tissue), the babies position and size, the strength, frequency and quality of your contractions, where you are in your mind and spirit, and the support of and attitude the people attending your labor all work together to create YOUR birth scenario. If you have met the basic safety criteria for a trial of labor, none of the other factors are predetermined.
What are my chances of successful VBAC?
The overall rate of VBAC success is 74%. This means approximately 3 out of 4 trials of labor will end in vaginal delivery and 1 will result in a repeat C-Section.
What will my labor look like at the hospital?
Probably pretty similar to a typical labor in the hospital. You can be admitted when in active labor and use most of the tools available. The scope of available options for labor depends on your birthing location and their practice protocols. Most if not all hospital environments require continuous fetal monitoring- the monitors that measure baby heart rate and your contractions, and create the “strip” for your nurses and providers to monitor. This is to look out for signs of rupture at your scar site so that they can act quickly to prevent harm to you or your baby. Uterine rupture presents with a sudden drop in fetal heart rate as well as increased uterine tone. Continuous monitoring allows rupture to be diagnosed quickly and to be treated immediately.
Some hospitals, like NHRMC, have monitors that are wireless for walking around or waterproof for getting into showers or tubs to make this monitoring requirement less restrictive to your labor. Ask your provider if this is available at their hospital! You may choose to utilize all of the pain management options available or none at all.
What if I need to be induced?
It is possible to induce your labor if there is a risk to your health or the baby’s health to remain pregnant. You can safely use the drug Pitocin to encourage contractions, but cervical ripening (i.e. Cytotec, Cervidil, etc.) medications are contraindicated for those with a uterine scar.
How do I pick a provider?
Try to find a provider that supports VBAC success! Ask lots of questions about their thoughts about and comfort with TOLAC clients.
- What are your credentials? Where do you deliver?
- What are your or your delivery site’s policies regarding VBAC? Do I have to have my baby by a certain time? What are my monitoring options in labor? What pain management options will be available to me at your site?
- Do all the providers at your practice or delivery site support VBAC? Is there a scenario where I would not be able to try?
- Will someone from your practice definitely be present during my labor or do you share call with other practices?
- Will you support a labor after 2 previous C-Sections? (if applicable)
Remember, it is not informed decision making if you haven’t explored all the risks and benefits of all choices and alternatives in a non-judgmental environment with lots of time and space to ask questions. Having a successful VBAC in Wilmington, NC is 100% obtainable. But your shot is that much higher with the right support team (doula included…shameless plug!) by your side.
For more information about Cesarean support, visit the International Cesarean Awareness Network at www.ican-online.org.
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