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Vaginal Birth After Cesarean Section

(VBAC; Trial of Labor after Cesarean [TOLAC])

Definition

Vaginal birth after cesarean section (VBAC) is giving birth vaginally after having a baby in an earlier pregnancy by Cesarean section (C-section).
Attempted Vaginal Birth After Cesarean Section (VBAC)
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Reasons for Procedure

The goal of this procedure is to give birth vaginally, rather than through an elective C-section. Many women who have had a C-section in the past can deliver future babies vaginally with a low risk of complications.

Possible Complications

If you are planning to have a VBAC, your doctor will review a list of possible complications, which may include:
  • Unsuccessful VBAC—Some women attempting VBAC require a repeat C-section. Most often, this is due to fetal distress during labor and failure to progress during labor. This may be caused by ineffective labor contractions.
  • Uterine rupture—This rare but life-threatening condition occurs when the uterus tears along the prior C-section scar. This is due to poor healing of the prior uterine incision. An emergency C-section is performed in this situation.
  • Bleeding
  • Uterine infection
  • Tear of tissue around the vagina
  • Complications requiring forceps or vacuum extraction
  • Injury to the baby
Some factors that may increase the risk of complications include:
  • Type of previous uterine incision—This may influence your risk of the uterine scar tearing during VBAC.
  • Reason for prior C-section—The chances of having a successful VBAC are lower for women who had a prior C-section for a reason that could recur with their next labor and delivery. Reasons include a difficult labor and the cervix not opening fully.
  • Number of prior C-sections—A higher number of prior C-section deliveries decreases the likelihood for a successful VBAC, because the uterine wall has been weakened.
  • Large baby or a baby in the wrong position inside the womb
  • Induced labor—Some labor-inducing drugs can increase the risk for uterine rupture. Because of this, your doctor may advise against a VBAC if you require these drugs.
  • Mother’s health—Conditions like diabetes , heart disease , and high blood pressure increase the risk of complications.

What to Expect

Prior to Procedure

During pregnancy, you should:
  • Be sure to go to all prenatal care visits with your doctor.
  • Eat nutritiously and drink plenty of fluids.
  • Get as much sleep as possible.
  • Read about giving birth and take a childbirth class.
  • Choose a support person to be with you during labor and delivery.
  • Write a "birth plan" that explains what you want and helps you to think about possible complications.
  • Talk to your doctor about:
    • Ways to contact her after hours and when you should call
    • Steps you should take when in labor
    • Whether you want pain relief during labor
    • Perineal massage—The perineum is the area between the anus and the vagina. Massaging this area may help to reduce your chance of trauma to the area.
    • How you will travel to the hospital
    • Arrangements for home and work
  • Be aware of the signs of labor, which include:
    • Contractions
    • "Water breaks" (amniotic fluid that surrounds the baby leaks out through the vagina)
    • Back pain
    • Slight vaginal bleeding
True Versus False Labor
Before "true" labor begins, you may have periods of "false" labor. These are irregular contractions of your uterus, called Braxton Hicks contractions. They are normal, but can be painful. Timing the contractions is a good way to tell the difference between true and false labor. Note how long it is from the start of one contraction to the start of the next one. Keep a record for an hour. If the contractions are getting closer together, longer, and stronger, then it may be true labor. If you think you are in labor, call your doctor.
Birth
During this process, you will prepare to deliver your baby. At the beginning of labor, the uterus will begin to contract, moving the baby down the vagina (birth canal). The cervix, the opening of the uterus into the vagina, will slowly enlarge to a diameter of about 10 centimeters. This will allow the baby to pass through and be delivered through the opening of the vagina.

Anesthesia

Labor can cause severe pain. While planning the delivery, talk to your doctor about your options for pain relief. In the beginning stages of labor, relaxation techniques (like meditation and rhythmic breathing) may be helpful. Keep in mind that every woman's labor is different and everyone experiences pain differently.
There are many medical options for pain control. All treatments to relieve pain during labor have risks and benefits. Make sure you discuss these with your doctor.
  • Pain medicines by IV or intramuscular injection:
    • Given when contractions become stronger and more painful
    • Can cross into the baby's bloodstream
  • Epidural block:
    • Injected near spinal cord
    • Given in small amounts by an anesthesiologist (a doctor who specializes in anesthesia)
    • Drug does not cross into baby's bloodstream
    • Decreases pain and feeling in your lower body
    • Provides good pain relief and allows you to continue with delivery
    • Can cause headaches after delivery and drop in blood pressure, as well as changes in baby's heartbeat
  • Spinal block:
    • Injected into spinal fluid
    • Used for pain relief during delivery, especially if forceps or vacuum extraction is needed
    • Often used for C-section
    • Numbs lower half of the body and reduces your ability to push
    • Provides good pain relief and works quickly
    • Can cause headaches and drop in blood pressure, as well as changes in baby's heartbeat
  • Local anesthesia:
    • Injected into vagina or surrounding area
    • Used if an episiotomy (cutting near the vagina) is needed
    • Also used when vaginal tears are stitched
    • Does not relieve pain of contractions during labor
  • General anesthesia:
    • Causes you to be asleep during delivery
    • Rarely used for routine vaginal deliveries
    • Often used for C-sections or emergencies

Description of Procedure

Once the cervix is fully dilated (opened) and the baby seems to be heading down the birth canal, the nurses will help prepare you for delivery. Your legs may be draped with cloths. Some doctors will clean the area around the vagina with an antiseptic solution.
You may put your legs into holders, especially if you have an epidural. The nurses and your support people may hold your legs in a comfortable position. This will help you to push. Your doctor may encourage you to find a position that is right for you. Each time you have a contraction, you will be instructed to push. This involves bearing down like you are trying to have a bowel movement.
"Crowning" is when the baby's head is seen at the opening to the vagina. When this happens, you may be asked to slow your pushing. Depending on your delivery plan, the doctor may massage your perineum to gently stretch it. An episiotomy is not routinely done, but in some cases, it is necessary.
Once your baby's head is out, you will be asked to stop pushing. The doctor will check to make sure that the umbilical cord is not around the baby's neck. Then, you will be able to push the rest of the baby out. If the baby appears healthy and is breathing well, he may be placed on your stomach. The umbilical cord will be clamped and cut. Within the next 20 minutes, the placenta will be delivered.
Sometimes the baby's head does not move as expected through the birth canal. If this happens, your doctor may use forceps or vacuum extraction to move the baby. These will only be used if the baby is most of the way through the birth canal.
Vaginal Birth
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Immediately After Procedure

You may have the following:
  • Stitches if the perineum is cut or torn
  • Abdominal massage to help the uterus clamp down and decrease bleeding
  • Cleansing of the vaginal area, perineum, and rectum
  • Ice pack to soothe and decrease swelling of the perineum
  • A shot of oxytocin (Pitocin) to help decrease bleeding
  • Pain medicines

How Long Will It Take?

This is extremely variable. The average time for you to deliver your first baby vaginally is 12 hours.

How Much Will It Hurt?

Labor causes severe pain. Talk to your doctor about your options for managing the pain.

Average Hospital Stay

The usual length of stay for a vaginal delivery is 1-3 days. Your doctor may choose to keep you longer, however, if complications arise.

Post-procedure Care

Having a baby will change you physically and emotionally.
Physical Effects
Physically, you might have the following:
  • Sore breasts—Your breasts may be painfully engorged when your milk comes in. Also, your nipples may be sore.
  • Constipation —You may not be able to move your bowels until the third or fourth day after delivery.
  • Stitches may make it painful to sit or walk.
  • Hemorrhoids —Hemorrhoids are common. They may make it painful for you to move your bowels.
  • Hot and cold flashes—This is due to your body trying to adjust to the change in hormones and blood flow levels.
  • Urinary or fecal incontinence—During delivery, your muscles were stretched. This may make it hard for you to control your urine and bowel movements.
  • "After pains"—The shrinking of your uterus can cause contractions. These can worsen when your baby nurses or when you take medicine to reduce bleeding. It is normal to have this after delivery.
  • Vaginal discharge—This is heavier than your period and often contains clots. The discharge gradually fades to white or yellow and stops within two months.
  • Weight—Your postpartum weight will probably be about 10 pounds below your full-term weight. Water weight drops off within the first week as your body regains its salt balance.
Emotional Effects
Emotionally, you may be feeling:
  • "Baby blues"—About 80% of new moms have irritability, sadness, crying, or anxiety . This begins within days or weeks of giving birth. These feelings can result from hormonal changes, exhaustion, unexpected birth experiences, adjustments to changing roles, and a sense of lack of control over your new life.
  • Postpartum depression (PPD)—This condition is more serious and happens in 10%-20% of new moms. It may cause mood swings, anxiety, guilt, and persistent sadness. Your baby may be several months old before PPD strikes. It is more common in women with a personal or family history of depression.
  • Postpartum psychosis—Postpartum psychosis is a rare, but severe condition. Symptoms include difficulty thinking and thoughts of harming the baby. If you feel this way, call your doctor right away.
  • Sexual relations—You may not feel physically or emotionally ready to begin sexual relations right away.
Ways to Take Care of Yourself
  • When your baby sleeps, take a nap.
  • Set aside time each day to relax with a book or listen to music.
  • Shower daily.
  • Get plenty of exercise and fresh air.
  • Schedule regular time for you and your partner to be alone and talk.
  • Make time each day to enjoy your baby. Encourage your partner to do so, too.
  • Breastfeeding is encouraged unless your doctor tells you otherwise.
  • Clean less and have easier meals. Take a break from having visitors if you feel stressed.
  • Ask for help when you need it.
  • Talk with other new moms and create your own support group .
  • Delay having sexual intercourse and putting any objects in the vagina until you have had your six-week check-up.
  • Be sure to follow your doctor's instructions .

Call Your Doctor

After you leave the hospital, contact your doctor if any of the following occurs:
  • An unexplained fever of 100.4°F (38°C) or above in the first two weeks
  • Soaking more than one sanitary napkin an hour, or if the bleeding level increases
  • Wounds that become red, swollen, or drain pus
  • New pain, swelling, or tenderness in your legs
  • Hot-to-the-touch, significantly reddened, or sore breasts
  • Any cracking or bleeding from the nipple or areola (the dark-colored area of the breast)
  • Foul-smelling vaginal discharge
  • Painful urination or a sudden urge to urinate; inability to control urination
  • Increasing pain in the vaginal area
  • Cough or chest pain, nausea, or vomiting.
  • Depression, hallucinations, suicidal thoughts, or any thoughts of harming your baby
In case of an emergency, call for medical help right away.

RESOURCES

American Academy of Family Physicians http://familydoctor.org/

Women's Health.gov http://www.womenshealth.gov/

CANADIAN RESOURCES

Health Canada http://www.hc-sc.gc.ca/index%5Fe.html/

Women's Health Matters http://www.womenshealthmatters.ca/

References

The American College of Obstetricians and Gynecologists. Vaginal birth after previous cesarean section. Practice Bulletin . July 2004.

Landon MB. Maternal and perinatal outcomes associated with a trial of labor after prior Cesarean delivery. N Engl J Med . 2004;351:2581-2589.

Trial of labor after cesarean (TOLAC), formerly trial of labor versus elective repeat cesarean section for the women with a previous cesarean section. The American Academy of Family Physicians website. Available at http://www.aafp.org/PreBuilt/clinicalrec%5Ftolac.pdf . Accessed August 31, 2005.

Vaginal birth after C-section. MayoClinic.com website. Available at: http://www.mayoclinic.com/invoke.cfm?objectid=AEB2CFEE-5ECD-41DF-80F6314B6CF6B266 . Accessed August 19, 2005.

Vaginal Birth After Previous Cesarean Delivery. The American Congress of Obstetricians and Gynecologists, Practice Bulletin No. 115 . August 2010.

Revision Information

This content is reviewed regularly and is updated when new and relevant evidence is made available. This information is neither intended nor implied to be a substitute for professional medical advice. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with questions regarding a medical condition.

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