VBAC and TOLAC in Pregnancy

Benefits and Risks of Vaginal Birth After a C-Section

A mother holding her newborn baby in the hospital.
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Women who give birth via cesarean surgery often have mixed feelings: joy at having a healthy, happy baby, appreciation that there is a surgical way to handle what may have been a difficult or even impossible vaginal birth, and, often, disappointment: Some moms feel they missed out on a unique experience and have hopes that if they become pregnant again, they'll be able to have a TOLAC, which stands for trial of labor after cesarean. If that's successful, then they will have gone on to have a VBAC or vaginal birth after cesarean.

It's not a given that a woman who's had a C-section will be able to give birth naturally the next time around, and in fact, there are a number of potential obstacles to that happening. On the other hand, for those who are able to have VBACs, not only do they get to experience firsthand what it's like to go through labor (if they didn't before their C-section) and delivery, but they also enjoy the benefits of not having to undergo the risks of having major surgery and the considerable recovery period afterwards.

The American College of Obstetricians and Gynecologists (ACOG) says that TOLAC leading to VBAC is a safe option for most women. Read on to learn about the benefits and risks of attempting, and succeeding, to giving birth to a baby vaginally after delivering by C-section previously.

Benefits of TOLAC and VBAC

Although the exact origin of surgical childbirth isn't known (the theory that Julius Caesar was born this way and that's how the surgery got its name hasn't been substantiated), there's no question babies have been born by C-section for centuries. What is known about the procedure is the earliest surgeries were done on women who were dying or had already died while in labor.

In modern times, however, a C-section is more likely to save a woman's life (or her baby's) or to at least bring about the healthiest outcome for mother and child. Nevertheless, it's major surgery and has risks beyond those of vaginal childbirth (see below). Avoiding these risks is one of the major plusses of attempting to give birth vaginally after having had a C-section. Here are others:

  • Shorter hospital stay. Based on recommendations by the American Academy of Pediatrics (AAP), ultimately the length of time a mother and baby stay in the hospital depends on their individual circumstances. However, most go home after 48 hours after a vaginal birth, but stay for several days after a C-section.
  • Shorter recovery time. There's a huge difference between healing from a vaginal delivery and healing from major abdominal surgery. This is true even if a woman had to be stitched up after having tears or an episiotomy (in which a small cut is made in the vagina to make it easier for a baby's head to fit through).
  • Lower risk of complications. Although relatively uncommon, after a surgical delivery a woman there may be problems such as postpartum fever, an infection of the uterus (endometritis) or of the area where the incision was made, blood clots in the leg or lungs (a condition called thromboembolism that could be life-threatening), and the need for a blood transfusion due to blood loss, which is greater with a cesarean section than with a vaginal birth.
  • Decreased risk of health problems associated with repeat cesareans. These include bowel or bladder injury, hysterectomy, and problems with the placenta in future pregnancies.
  • Less risk for the baby. In particular, infants born via C-section sometimes develop a breathing problem called transient tachypnea that lasts for the first few days after birth, according to the Mayo Clinic. And in very rare cases, a baby's skin might be nicked during a surgical birth.

The Risk of Rupture

Although rare according to ACOG, there is one potential risk associated with TOLAC and VBAC that is extremely serious: that the scar on the uterus from having had a cesarean will rupture. If this happens, there will no longer be pressure from the uterus to help push the baby out and an emergency C-section will be necessary.

To prevent this from happening, it's important to know what kind of incision was made in the uterus during the C-section. There are three possibilities:

  • Low transverse ("bikini"), in which the incision was made from side-to-side across the lower, thinner part of the uterus. It's the most common type of incision and carries the least chance of future rupture.
  • Low vertical. An up-and-down cut made in the lower, thinner part of the uterus that has a higher risk of rupture than a low transverse incision.
  • High vertical, or “classical.” This up-and-down incision in the upper part of the uterus sometimes is done for very preterm cesarean deliveries. It has the highest risk of rupture.

If you've had a cesarean section, the type of external scar you have on your skin doesn't necessarily indicate what type of incision you have on your uterus. Even if the obstetrician who performed your c-section created a low transverse incision in your skin (which is preferred because the scar it produces is discreet), he or she may have made a vertical cut in your uterus. The medical records from your surgery should include this information. It will be important for you and your caregiver in future pregnancies to know in case you want to try for a vaginal birth.

Who Should Try For a VBAC?

For many women, the chances of achieving a vaginal birth after having had a C-section are good, according to ACOG and the National Institutes of Health, provided they meet certain criteria. As long as your doctor agrees, you are likely a good candidate for TOLAC and VBAC if:

  • You have undergone one or two prior C-sections both with a low transverse uterine incision—even if you have a twin pregnancy or you need to be induced.
  • You have no other conditions that would normally require a cesarean, such as placenta previa.
  • The reason you had a prior C-section was the baby was breech.
  • Your previous cesarean took place early in labor, before your cervix was fully dilated.
  • You have discussed the risks and benefits of attempting a vaginal birth with your doctor and understand them.
  • You and your caregiver have an agreed upon plan for what to do in case of uterine rupture or another problem that would mean you need an emergency cesarean delivery. This is especially important if you will be working with a midwife.
  • You are having your baby in a hospital or other facility where if necessary an emergency C-section can be performed seamlessly (there are appropriate nursing and anesthesia staff, an operating room, and an obstetrician or another surgeon on hand).

In general 60 percent to 80 percent of expectant moms who meet the criteria and attempt a TOLAC will have a successful vaginal delivery. This is especially true of women who've already had a VBAC, who go into labor spontaneously, and who experience a normal progression of labor.

A Word From Verywell

If you go through a trial of labor after a cesarean that doesn't ultimately lead to a vaginal birth and you wind up having another cesarean, it's OK to feel disappointed. It's perfectly normal and doesn't negate the joy and relief you also will feel at having delivered a healthy, happy baby. Allow yourself to grieve not having the experience you had hoped for and tune out the well-meaning comments about how you should just be happy you and the baby are all right. Focus on the fact that you did your best and it's not your fault if a vaginal birth wasn't in the cards this time around. The better able you are to celebrate your efforts, the more quickly you'll be able to move on and enjoy getting to know your newest little bundle of joy.

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