In the United States, about one-third of all births are cesarean sections. Some are planned, often because of a medical concern, and others are unplanned, because of issues during labor.
Doctors used to think that having a baby by C-section meant any additional children you have should also be delivered by C-section.
That’s no longer the case. If you would like a vaginal delivery, you should talk to your provider about the possibility of a trial of labor after cesarean (TOLAC) in an attempt to have a vaginal birth after cesarean (VBAC). Nationally, TOLAC has a 60 to 80 percent success rate of ending in a vaginal birth; the rest of the time, a repeat C-section is needed.
“There’s no one right way to have a baby,” says UNC Health certified nurse-midwife Jenny Cox. “But it’s important that pregnant people feel they can come to us with their desires about how they want their pregnancy and birth to go. Honest conversations during prenatal care go a long way in supporting decision-making in labor.”
Cox explains some of the considerations that go into these decisions.
Benefits and Risks of TOLAC and VBAC
Vaginal delivery has some benefits compared to C-section. Because you’re not having surgery, you typically have a shorter hospital stay, a quicker recovery after the birth and lower risk of complications associated with surgery including infection, heavy bleeding and injury to other organs.
“Some people want to avoid the longer recovery, particularly when they already have another child at home or know they must return to work,” Cox says.
Even if you recovered quickly after your C-section, Cox says it’s OK to pursue a VBAC if that’s how you want to deliver.
“Most pregnant people have the assumption that their first baby will be born vaginally, and when that doesn’t happen, they can experience this as a loss,” Cox says. “It can be especially difficult when it was unplanned and if you didn’t feel like you were part of the decision-making. Feelings about pregnancy and birth are deeply personal and any conversation and decision-making around this process must be patient-centered.”
The number of children you wish to have may also be a factor in delivery decision-making. The risk of placental abnormalities in future pregnancies increases with each C-section. In some cases, these abnormalities can result in the need for a hysterectomy and loss of future fertility.
The decision to attempt labor after a C-section also comes with risks, the most serious being uterine rupture. This tear in the uterine wall can be life-threatening for both the woman and the baby. That’s why understanding the likelihood of your trial of labor ending in vaginal birth is important.
Understanding the Likelihood of a Vaginal Birth After C-Section
At the beginning of your prenatal care, your provider will review your medical history to determine if laboring is safe for you, and if so, they can use a calculator to predict your likelihood of a vaginal birth. The calculator considers your age, BMI, your obstetric history (the reason for your previous C-section and if you’ve ever had a vaginal delivery), and if you have treated chronic hypertension.
“The reason for the first C-section might indicate those who will be more likely to have a subsequent vaginal birth,” Cox says. “If the baby was breech or if the baby had an abnormal heartbeat in labor, those are things that probably won’t repeat. If there was an issue with dilation or pushing phase, that might indicate a higher chance of ultimately requiring another cesarean birth.”
Even those issues don’t automatically disqualify you from attempting a VBAC. No matter what the calculator says, it’s important to talk through your specific situation with your provider.
“The calculator is not perfect, and it is not intended to either dictate a repeat cesarean or require a TOLAC,” Cox says. “Its purpose is to guide a conversation between you and your provider about what is best for you and your own personal risk tolerance for labor.”
The calculation is modified when you are admitted for delivery to include data on how long the pregnancy lasted and information from a cervical exam.
When considering a repeat C-section or attempting a vaginal birth, it is important to know that all births carry some risk. The risks of a scheduled repeat C-section and a VBAC are similar, but the risks of an unscheduled cesarean during labor are somewhat higher.
Preparing for a Trial of Labor
Your prenatal care will proceed the same way no matter what type of delivery you choose, but you and your provider should spend time talking about precautions that will be taken should you choose a trial of labor. The two standard recommendations during TOLAC are having IV access and continuous fetal monitoring. If a uterine rupture occurs, having IV access is important to begin lifesaving measures. Continuous fetal monitoring is crucial, as a drop in fetal heart rate can be an initial sign of uterine rupture.
Labor is unpredictable, but you should talk to your provider about what they’ll be evaluating during the trial of labor, how long you can labor, and how the decision will be made to proceed to a C-section if necessary.
“We will pay attention to vital signs, fetal heart rate, progress of labor, and presence of abnormal vaginal bleeding or pain in labor. All of these can be indicators of uterine rupture and must be evaluated carefully,” Cox says.
Finding a Supportive Team for VBAC
If you want to pursue a vaginal birth, ask your provider about their success rates with VBAC and how many patients attempt a trial of labor after C-section. Some providers may have a lower risk tolerance than others and may recommend a repeat C-section. Smaller practices or practices in rural areas may not have the resources to support trials of labor.
If you don’t feel satisfied with your provider’s recommendation or the way the conversation about the VBAC was handled, consider a second opinion. It might be the same result, but you may feel more heard.
“A lot of people feel they didn’t get to be part of the decision with their first C-section; they felt like the provider made it and moved on without them,” Cox says. “That lack of communication can make you wary of advice you’re given in a subsequent pregnancy. You should find someone who will have the conversation with you about what you want your birth to look like and what might happen. We can talk through benefits and risks and your safe options.”
Having trust in a provider during prenatal care can translate into feeling supported during labor as well. If you feel safe and secure with your team during delivery, you’re more likely to be satisfied with the effort, whether a trial of labor is successful or not.
“One person’s C-section can be negative because they weren’t part of the decision-making, while someone with the same story might feel the experience was positive because of how they were treated in the process,” Cox says. “You get the same baby either way, but I want you to feel satisfied with your care all along the way—even if things did not go as you had planned and hoped. Our job as providers is to do everything we can so that you and your baby are healthy and have the best possible experience.”
If you have questions about what’s possible for you during labor and delivery, talk to your provider, or find one near you.