Vaginal Birth After Cesarean Section

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

by Cynthia M. Johnson, MA

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

Problems are rare, but all procedures have some risk. The doctor will go over some problems that could happen, such as:

  • Excess bleeding
  • Problems from anesthesia, such as wheezing or sore throat
  • Infection
  • Tear of tissue around the vagina
  • Complications requiring forceps or vacuum extraction
  • Injury to the baby
  • Unsuccessful VBAC—A repeat C-section may be needed if the fetus is in distress or labor is not progressing.
  • Uterine rupture (rare)—A repeat C-section will be needed if the uterus tears along the prior C-section scar due to poor healing of the uterine incision.

Things that may raise the risk of problems are:

  • Chronic diseases, such as diabetes or heart disease
  • A large baby or a baby in the wrong position inside the womb
  • The type of previous uterine incision may raise the risk of the uterine scar tearing during VBAC
  • A high number of prior C-sections causing the uterine wall to weaken
  • Prior uterine rupture or surgery
  • The reason for the prior C-section and whether it could happen again, such as difficult labor or the cervix not fully opening
  • Induced labor—some medicines can raise the risk of uterine rupture

What to Expect

Prior to Procedure

During pregnancy, the mother should:

  • Go to all prenatal care visits.
  • Eat a healthful diet and drink plenty of fluids.
  • Get plenty of sleep.
  • Read about giving birth and take a childbirth class.
  • Choose a support person for labor and delivery.
  • Create a birth plan that details preferences for labor, such as methods of pain relief.
  • Talk to your doctor about:
    • Ways to communicate, such as calling after hours
    • Steps to take when in labor
    • The use of pain relief methods during labor
    • Perineal massage of the area between the anus and vagina to lower the risk of trauma
    • Travel options to the hospital
    • Arrangements for home and work
  • Be aware of the signs of labor, such as:
    • Contractions
    • Water breaking—amniotic fluid that surrounds the baby leaks out through the vagina
    • Back pain
    • Light vaginal bleeding

True Versus False Labor

There may be periods of false labor before true labor begins. These are irregular contractions of the uterus, called Braxton Hicks contractions. They are normal, but can be painful. Timing the contractions is a good way to tell the true and false labor apart. 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. Call the doctor.

Birth

The uterus will start to contract at the beginning of labor. This will move the baby down the vagina (birth canal). The opening (cervix) 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. In the beginning stages of labor, relaxation methods like meditation and rhythmic breathing may be helpful. Keep in mind that every mother's labor is different and everyone feels pain differently.

There are many options for pain control. The doctor may give:

  • 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 the spinal cord
    • Given in small amounts
    • Does not cross into the baby's bloodstream
    • Lowers pain and feeling in the lower body
    • Allows delivery to continue
  • 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 the lower half of the body and lowers the ability to push
    • Provides good pain relief and works quickly
    • Can cause headaches and a drop in blood pressure after delivery as well as changes in baby's heartbeat
  • Local anesthesia:
    • Injected into the vagina or surrounding area
    • Used if an episiotomy (incision near the vagina) is needed
    • Also used when vaginal tears are stitched
    • Does not ease pain from contractions during labor
  • General anesthesia:
    • Causes the mother to be asleep during delivery
    • Rarely used for routine vaginal deliveries
    • Often used for C-sections, especially those done in emergency situations

Description of Procedure

After the cervix is fully dilated (opened) and the baby seems to be heading down the birth canal, the care team will help prepare you for delivery. Your legs may be draped with cloths. The area around the vagina will be cleaned with an antiseptic solution.

You may put your legs into holders, especially if you have an epidural. The care team may hold your legs in a position. This will help you to push. You may be asked to find a position that is right for you. You will be asked to push each time you have a contraction. 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. Some people may need an episiotomy, but it is not routine.

You will be asked to stop pushing when your baby's head is out. 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, your baby 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, the 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
  • An ice pack to soothe and decrease swelling of the perineum
  • An injection of medicine to help decrease uterine bleeding
  • Pain medicines

How Long Will It Take?

How long it takes varies from person to person. The average time to deliver a first baby vaginally is 12 hours.

Will It Hurt?

Pain and swelling are common in the first few days. Medicine and home care help.

Average Hospital Stay

Most people can go home in 1 to 3 days. If there are any problems, you may need to stay longer.

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 75% of new moms have irritability, sadness, crying, or anxiety. This begins within days or weeks of giving birth. These feelings can come 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 about 25% of new moms. It may cause mood swings, anxiety, guilt, and lasting 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 health problem. Symptoms include difficulty thinking and thoughts of harming the baby. Care is needed right away.
  • Sexual relations—You may not feel physically or emotionally ready to begin sexual relations right away.

Ways to Take Care of Yourself

Here are tips to take care of yourself:

  • Take a nap when your baby sleeps.
  • Set aside time each day to relax with a book or listen to music.
  • Shower daily.
  • Get plenty of exercise and outdoor time.
  • 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 sex and putting any objects in the vagina until you have had your 6 week check-up.

Call Your Doctor

Call the doctor if you are not getting better or you have:

  • Signs of infection, such as fever and chills
  • Pain that you cannot control with medicine
  • Vaginal bleeding that soaks more than one pad per hour
  • Wounds that become red, swollen, or drain pus
  • New pain, swelling, or tenderness in your legs
  • Breasts that are sore, hot, or red
  • Cracking or bleeding from the nipple or the dark-colored area of the breast
  • Foul smelling vaginal discharge
  • Pain, burning, urgency or frequency of urination
  • Depression, hallucinations, suicidal thoughts, or any thoughts of harming your baby

If you think you have an emergency, call for medical help right away.

RESOURCES:

Family Doctor—American Academy of Family Physicians
http://familydoctor.org
Women's Health—US Department of Health and Human Services
http://www.womenshealth.gov

CANADIAN RESOURCES:

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

References:

ACOG Practice bulletin no. 115: Vaginal birth after previous cesarean delivery. Obstet Gynecol. 2010;116(2 Pt 1):450-463. doi:10.1097/AOG.0b013e3181eeb251.
Trial of labor after Cesarean section (TOLAC). EBSCO DynaMed website. Available at: https://www.dynamed.com/management/trial-of-labor-after-cesarean-section-tolac. Accessed August 27, 2021.
Vaginal birth after Cesarean delivery. The American Congress of Obstetricians and Gynecologists website. Available at: https://www.acog.org/womens-health/faqs/vaginal-birth-after-cesarean-delivery. Accessed August 27, 2021.
Last reviewed July 2021 by EBSCO Medical Review BoardBeverly Siegal, MD, FACOG
Last Updated: 8/27/2021

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