Topic Overview

What is a vaginal birth after cesarean (VBAC)?

If
you have had a
cesarean delivery (also called a C-section) before,
you may be able to deliver your next baby vaginally. This is called vaginal
birth after cesarean, or VBAC.

Most women, whether they deliver
vaginally or by C-section, don’t have serious problems from childbirth.

If you and your doctor agree to try a VBAC, you
will have what is called a “trial of labor after cesarean,” or TOLAC. This means that you plan to go
into labor with the goal to deliver vaginally. But as in any labor, it is hard
to know if a VBAC will work. You still may need a C-section. As many as 4 out
of 10 women who have a trial of labor need to have a C-section.footnote 1

Is a trial of labor safe?

Having a vaginal birth after having a C-section can be a safe choice for most women. Whether it is right for you depends on several things, including why you had a C-section before and how many C-sections you’ve had. You and your doctor can talk about your risk for having problems during a trial of labor.

A woman who chooses VBAC is closely monitored. As with any labor,
if the mother or baby shows signs of distress, an emergency cesarean section is
done.

What are the benefits of a TOLAC?

The benefits of a
VBAC compared to a C-section include:

  • Avoiding another scar on your uterus. This is
    important if you are planning on a future pregnancy. The more scars you have on
    your uterus, the greater the chance of problems with a later
    pregnancy.
  • Less pain after delivery.
  • Fewer days in the
    hospital and a shorter recovery at home.
  • A lower risk of infection.
  • A more active role for you and your birthing partner in the birth
    of your child.

What are the risks of TOLAC?

The most serious risk
of a trial of labor is that a C-section scar could come open during labor. This is very
rare. But when it does happen, it can be very serious for both the mother and
the baby. The risk that a scar will tear open is very low during VBAC when you
have just one low cesarean scar and your labor is not started with medicine.
This risk is why VBAC is often only offered by hospitals that can do a rapid
emergency C-section.

If you have a trial of labor and need to
have a C-section, your risk of infection is slightly higher than if you just
had a C-section.

Frequently Asked Questions

Learning about VBAC:

Getting treatment:

Ongoing concerns:

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Is VBAC Right for You?

Having a vaginal
birth after having a C-section can be a safe choice for most women. But it can have risks for both the mother and the baby. Whether VBAC is right for you depends on what
risk factors (things that increase your risk) you have that could make it unsafe. You and your doctor can decide whether VBAC is right for you.

As with a first-time childbirth, even if you are a good
candidate for a successful VBAC, there is no guarantee that you will give birth
vaginally and without complications.

What Affects VBAC Success

Pregnancy, labor, and
delivery are different for every woman and difficult to predict. Even if your
first pregnancy required a cesarean, the next one may not. The likelihood of a
successful
vaginal birth after cesarean (VBAC) is influenced by
many things. Usually a combination of things affects how well or poorly a
trial of labor goes.

Your chances of a successful VBAC are best when:footnote 1

  • Your previous cesarean was not done for stalled
    labor.
  • You do not have the same condition
    that led to a previous cesarean (such as a
    breech, or feet-down, fetus).
  • You have had
    a vaginal delivery or a successful VBAC before.
  • Your labor starts on its own and your
    cervix dilates well.
  • You are younger than
    35.footnote 2

Your chances of a successful VBAC are lower when:footnote 2

  • Your previous cesarean was because of difficult
    labor, which is called dystocia. This is especially true if you were fully
    dilated when you had a cesarean section for dystocia.
  • You are
    obese.
  • You are older than 35. footnote 2
  • Your fetus is very large [estimated as bigger
    than 9 lb (4082 g)].
  • You are beyond 40 weeks of pregnancy.
  • Your last pregnancy was less than 18 months ago.

VBAC can be considered for pregnancies with twins.

Risks of VBAC and Cesarean Deliveries

Whether you
deliver vaginally or by cesarean section, you are unlikely to have serious
complications. Overall, a routine vaginal delivery is less risky than a routine
cesarean, which is a major surgery. But a pregnant woman who has a cesarean scar
on the uterus has a slight risk of the scar breaking open during labor. This
is called uterine rupture.

Although rare, uterine rupture can be
life-threatening for both mother and baby. So women with risk factors for
uterine rupture should not attempt a
vaginal birth after cesarean (VBAC).

Risks of VBAC

The risks of VBAC include:

  • Problems during labor that result in a cesarean delivery. This occurs with about 20 to 40 out of 100 women who try VBAC. But
    it doesn’t happen with 60 to 80 out of 100 women who try VBAC.footnote 1

  • Rupture of the scar on the uterus
    , which is rare
    but can be deadly to the mother and baby. A
    vertical incision used in a past C-section, use of certain medicines to start (induce) labor, and many scars on the uterus from past C-sections or other surgeries are some of
    the things that can increase the chance of a rupture.
  • The chance of infection. Women who have a trial of labor and
    end up having a C-section have a higher risk of infection. This means that the
    risk of infection is lower after vaginal births and after planned cesareans.footnote 3

Risks of any cesarean

The risks of cesarean
delivery include:

  • Infections.
  • Pain.
  • Blood loss that
    requires a
    blood transfusion.
  • Genital or urinary
    problems.
  • Blood clots.
  • Risks from
    anesthesia.
  • A longer recovery time.
  • Injury to the baby during the delivery. The injury usually isn’t
    serious.
  • Breathing problems (respiratory distress syndrome) for the baby after birth if the due date has been
    miscalculated and a cesarean is done before the baby’s lungs are fully
    developed.

Future risks. If you
are planning to get pregnant again, it’s important to think about scarring.
After you have two C-section scars, each added scar in the uterus raises the
risk of
placenta problems in a later pregnancy. These problems
include
placenta previa and
placenta accreta, which raise the risk of problems for
the baby and your risk of needing a
hysterectomy to stop bleeding.

For more information about cesarean risks, see
the topic
Cesarean Section.

Exams and Tests

Besides the usual prenatal tests,
your doctor will take measures to assess whether vaginal delivery is likely to
be a safe birthing option for you. (For more information on standard prenatal
tests, see the topic Pregnancy.) These extra measures can help you and your
doctor make a well-informed decision about your delivery.

Assessments done sometime during the pregnancy to help find out whether
a trial of labor is a safe option
may include:

What to Expect

Information, preparation, and
teamwork are needed for a successful
vaginal birth after cesarean (VBAC).

Childbirth and VBAC education

To prepare for
labor, consider taking a childbirth education class at your local hospital or
clinic. You and your birthing partner can learn:

  • What to expect during labor and
    delivery.
  • How to manage the birth using controlled breathing and
    emotional and physical support.
  • What medical pain-control options
    may be available for a vaginal delivery.

Labor

Other than requiring closer monitoring,
trial of labor after cesarean, or TOLAC labor, is the same as normal labor. During early labor, a woman can
remain as active and mobile as she wants. There are no specific restrictions
for TOLAC until active labor begins. During the
active period of labor, continuous fetal heart
monitoring is done to watch for early signs of fetal distress or uterine
rupture. (For more information, see Exams and Tests.)

If you are attempting trial of labor and you have not
had a previous vaginal birth or your previous cesarean was done early on in
labor, your labor will be like a first-time labor.

For more information about labor and delivery, see the
topic
Labor and Delivery.

Medicines for starting or strengthening a trial of labor

As the end of pregnancy nears, the cervix normally becomes soft and begins to open (dilate) and thin (efface), preparing for labor and delivery. When labor does not naturally start on its own, labor may be started artificially (induced).

Some doctors avoid the use of any medicine to start (induce) a trial
of labor
, because they are concerned about uterine rupture. Other doctors are comfortable with the careful use of
oxytocin (Pitocin) to start labor when the cervix is
soft and opening (dilating).

If your labor slows or stops progressing, your doctor may use oxytocin to
strengthen (augment) contractions.

Pain medicine

As with most vaginal births, most
women who choose VBAC can safely use pain medicine during labor.

Pain medicine usually is started when the
cervix has opened (dilated)
3 cm (1.2 in.) to
4 cm (1.6 in.). Types of pain
medicines used include:

  • Local anesthesia, which numbs the small
    area where the medicine is injected.
  • Epidural anesthesia, which partially or fully numbs the entire lower part of the
    body. Studies have shown that epidural anesthesia does not
    increase uterine rupture rates during
    vaginal birth after cesarean (VBAC) trials of
    labor.footnote 3
  • Opioids (narcotics), which partially relieve pain and help you
    relax.

Recovery

Vaginal birth after cesarean (VBAC) recovery is similar to recovery after any vaginal birth.
After a vaginal delivery, the mother and baby can usually go home within 24 to
48 hours. By comparison, recovery from a cesarean section requires 2 to 4 days
in the hospital and a period of limited activity as the incision heals.

The overall risk of infection is low for both vaginal and cesarean
deliveries. But it is lower after a vaginal birth. Before you leave the
hospital, you will receive a list of signs of infection to watch for in the
first few weeks after delivery.

For more information, see:

What to Think About

Any woman in labor-not just one
attempting a
vaginal birth after cesarean (VBAC)-might have
complications during childbirth that require a
cesarean section delivery.

If there is no
medical reason for a cesarean, vaginal delivery is generally a safe option for
both mother and baby. It is common, though, to fear going through labor after
having had a cesarean delivery. This is especially true for women who have
tried a vaginal birth but, after a long and difficult labor, ended up
delivering by cesarean.

The ultimate decision to try a vaginal birth is made by you
and your doctor. If you want to try a VBAC but your doctor is not in favor of
your choice and does not have a clear reason, consider getting a second
opinion.

If you are considering VBAC, talk
with your doctor about:

  • The risks of vaginal and cesarean deliveries in
    your case. Here are some points to keep in mind:

    • Serious complications with either vaginal
      or cesarean births are uncommon.
    • A cesarean section is a surgical
      procedure and requires the use of anesthesia. Any surgery carries a risk of
      infection, excessive blood loss, and problems caused by the
      anesthesia.
    • Women who need a cesarean after a trial of labor
      have a higher rate of infection than those who have a cesarean without a
      trial of labor.
  • Whether your doctor will be available in the
    hospital throughout your labor and whether the hospital has facilities for an
    emergency cesarean delivery.
  • The possibility that a trial of labor
    may end in cesarean delivery.
  • How and at what point during labor
    the decision is made to do a repeat cesarean.
  • Which types of pain
    medicine or anesthesia you may use during labor and delivery or during a
    cesarean.
  • Your specific risk factors for
    uterine rupture during VBAC and the possible
    complications of a rupture, such as removal of the uterus (hysterectomy).

Other Places To Get Help

Organization

American Congress of Obstetricians and Gynecologists
(ACOG)
www.acog.org

References

Citations

  1. American College of Obstetricians and Gynecologists (2010). Vaginal birth after previous cesarean delivery. ACOG Practice Bulletin No. 115. Obstetrics and Gynecology, 116(2): 450-463.
  2. Miller DA (2010). Vaginal birth after cesarean. In Management of Common Problems in Obstetrics and Gynecology, 5th ed., pp. 52-56. Chichester: Wiley-Blackwell.
  3. Cunningham FG, et al. (2010). Prior cesarean delivery. In Williams Obstetrics, 23rd ed., pp. 565-576. New York: McGraw-Hill.

Other Works Consulted

  • Institute for Clinical Systems Improvement (2011). Health care guideline: Management of labor, 4th edition. Available online: https://www.icsi.org/_asset/br063k/Labor-Interactive0511.pdf.
  • National Institutes of Health consensus development conference statement: Vaginal birth after cesarean: New insights March 8-10, 2010. Obstetrics and Gynecology, 115(6): 1279-1295.

Credits

ByHealthwise Staff
Primary Medical Reviewer Sarah Marshall, MD – Family Medicine
Specialist Medical Reviewer Femi Olatunbosun, MB, FRCSC – Obstetrics and Gynecology

Current as ofMarch 16, 2017