Cesarean sections happen for elective and emergent reasons, but a vaginal birth after cesarean might still be an option for the right candidate in subsequent pregnancies.
You’ve previously delivered two healthy children vaginally. You’re now pregnant with twins. You and your doctor have agreed to a vaginal delivery because Baby A is head down.
You labor in the operating room to be on the safe side. Baby A is delivered vaginally with no complications. However, an emergency arises, and Baby B has to be delivered via cesarean section.
You know you aren’t done having children, but will you have to have a cesarean section with the next one?
A trial of labor after cesarean (TOLAC) is an opportunity for women who have had one previous lower transverse abdominal cesarean to attempt a vaginal delivery rather than a planned repeat cesarean delivery. If the baby is delivered vaginally, it is considered a successful vaginal delivery after cesarean (VBAC).
Terms to know:
- TOLAC: trial of labor after cesarean
- VBAC: vaginal birth after cesarean
How to tell if you’re a good candidate for a TOLAC and possible VBAC
The answer is not as simple as just having a previous cesarean section.
1. How long has it been since your last pregnancy?
The uterus needs time to heal after delivery, mainly if a cesarean section is performed.
The more time between pregnancies (called the interpregnancy interval) makes you a better candidate for attempting to labor. Your provider might suggest otherwise if you’ve gone six months or less between pregnancies.
2. Why did you have a cesarean section in the first place?
Sometimes, things happen in labor that are outside of our control. Still, the likelihood of them happening again is most important when determining if you’re a good candidate for a TOLAC and VBAC.
Certain things, like placental abruption, placenta previa, and breech presentation, are unlikely to reoccur.
However, if your cervix never dilated or you had a prolonged active phase of labor, you need to speak with your provider to discuss possible risks of this occurring again.
Are you a good VBAC candidate? Three things to ask your provider
- What type of incision was made?
- What are the risks?
- What resources are available?
1. What type of incision was made?
When you look in the mirror after your delivery, you will most likely see a small incision that was made near your bikini line, but what’s most important is what lies beneath.
The type of incision made through your uterus is the most significant factor for a TOLAC.
A history of one lower transverse uterine incision makes you a great candidate for a trial of labor. That’s because this incision is made in the lower uterine segment, which does not take an active part in contractions during labor.
If you received a classical or T-incision, you would not be considered an excellent candidate to labor safely. Your provider might even suggest scheduling a repeat cesarean section close to 39 weeks to prevent labor from even starting.
2. What are the risks?
The type of incision matters because there is an increased risk of uterine rupture.
Uterine rupture is the separation of the uterine muscle. When the rupture goes through all layers of the uterus (a complete rupture), it is considered a life-threatening emergency. Uterine rupture is also associated with an increased hysterectomy rate and intrapartum fetal death.
As scary as those things sound, there is also risk involved with choosing a repeat cesarean section. It is surgery, after all.
There is an increased hemorrhage rate, blood transfusion, and intensive care unit admission. More cesarean sections also increase the risk of the placenta adhering to the uterus too deeply. This is called the placenta accreta spectrum and occurs most often when there is a scar on the uterus.
3. What resources are available?
Safety is the top priority for you and your baby when you consider a TOLAC.
Talk with your provider about what resources will be available to you where you choose to deliver.
- Is the on-call provider required to be on-site? What about anesthesia?
- If not, are they within 30 minutes of the hospital?
- Will you be allowed to deliver in a labor room? Or will you need to labor in the operating room?
- Is an epidural required?
Find out everything you can about what you should expect for your trial of labor. Not only is each provider different in their comfort level and experience with TOLACs, but each hospital system will also have differing policies.
The most important question to ask yourself before considering a TOLAC and VBAC
What do you value the most?
For some women, a planned cesarean section makes the most sense. That’s totally okay.
For others, the desire to experience labor or a vaginal delivery drives their decision-making. That’s totally okay, too!
A lot of mental work goes into planning a TOLAC.
You must sit with your midwife or obstetrician and talk honestly about your risk factors, desires, and fears.
- Have you ever had surgery on the top of your uterus?
- Are you okay with continuous fetal monitoring?
- What were the circumstances surrounding your cesarean section?
Making an informed decision about your labor and delivery is ultimately the most important thing. So, maybe you had an unplanned cesarean section. That doesn’t mean you’ll never be able to labor again.
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Mother to two sweet girls, women's health nurse practitioner, and certified nurse midwife that realized after the delivery of her first daughter that so much was lacking in regard to postpartum care and support so she created the community that she wished she had. Fiat Midwifery provides evidence-based and accessible content, support, and memberships all aimed at empowering women from pregnancy, postpartum, parenthood, and beyond.