One persistent myth about Cesarean delivery is that after you have one, you can never deliver vaginally again. Although there are some risks to keep in mind, this is simply not true. In general, women who plan to have children again after a C-section have two options for their next birth: another C-section, or a vaginal birth after Cesarean delivery, also known as VBAC.
Most women who deliver a VBAC give birth to healthy babies, and suffer no complications.
What is a TOLAC? TOLAC stands for a trial of labor after Cesarean delivery. It refers to the mother’s attempt to deliver vaginally following a previous C-section. A TOLAC is a plan to deliver vaginally; at least until something occurs that changes the plan. About 40% of women who attempt a TOLAC will undergo another C-section to complete the delivery.
A Cesarean delivery is a major surgical procedure. Many women prefer to deliver vaginally for a variety of reasons, including:
- Less invasive than surgery.
- Shorter hospital stays and quicker recoveries.
- Less pain during recovery.
- Decreased risk of infection, scarring, and tissue damage.
- Ability to stay awake and actively participate in the birth of your baby.
- Decreased risk of complications associated with multiple C-sections (i.e. injury to the bladder or bowel, placenta abnormalities, and hysterectomy).
The greatest risk of a TOLAC is the possibility of a scar rupturing from your prior C-section. The surgical scar runs either vertically or horizontally across your uterus, and if it ruptures, this could pose life-threatening consequences to you and your baby.
The rupture of this scar is rare; however, some women are more at risk for rupture than others. The shape and location of the scar affects your particular risk.
- Low risk: Transverse – The scar runs left-to-right across the uterus. If you’ve only had one or two transverse C-sections, you may be able to attempt a TOLAC with relatively low risk.
- High risk: Vertical – The scar runs from the top of the uterus to near the bottom. It is recommended that you do not attempt a TOLAC.
When deciding whether or not to try a TOLAC, you should ask yourself a few questions.
- Do you want to have more children after this birth? The greater number of C-sections you have, the riskier it becomes to attempt a TOLAC.
- Has your uterus ever ruptured? This significantly increases your chances of a second rupture.
- Is your birthing facility prepared to handle an emergency that may arise from a failed TOLAC?
- Are there any other factors that may complicate your vaginal delivery (placental abnormalities, abnormally-shaped uterus, macrosomia, malpresentation, etc)?
Discuss your concerns with your Ob/Gyn.
What medications may be used during VBAC?
Artificially inducing labor. As your approach delivery, your cervix will begin to dilate to allow the baby through. In some cases, your Ob/Gyn may administer oxytocin to dilate the cervix earlier, or strengthen contractions – this is called inducing labor. Inducing labor is not recommended for all women attempting TOLAC, if it could increase the risk of uterine rupture.
Pain management. As with any vaginal delivery, women undergoing VBAC should be able to manage the pain with narcotic drugs, a local anesthesia, and/or an epidural, which will numb the body from the waist-down. There is no evidence to suggest that anesthesia will increase the risk of uterine rupture during TOLAC.
Changes to your Delivery Plan
Encountering complications during your TOLAC can make it unsafe to give birth vaginally. This may occur if something is wrong with you or the baby, or if you need to have your labor induced. Your maternity care provider will do everything they can to respect your wishes for a vaginal birth, but sometimes a C-section will be unavoidable.
On the other hand, some women choose to have a second C-section, but then decide to change their plan if they go into early labor and the baby appears healthy.
Whatever you decide, be sure to talk with your doctor about the possible changes that could occur during labor, so that you can carefully weigh the risks and benefits in advance. Include your birthing partner into your plans so that you can have his or her full support throughout your delivery.