Want a VBAC? Read On! A TOLAC (Trial of Labor after Cesarean) May Be Within Reach!


Having a VBAC (Vaginal Birth After Cesarean) delivery, is within reach for more women thanks to The American Congress of Obstetricians and Gynecologists’ newest guidelines supporting a TOLAC for the right women. To have a TOLAC, your previous doctor would need to have given you a single low transverse incision, on your uterus, and you would not have medical contraindications for a vaginal birth.

When a woman desires a TOLAC, she wants what all women want - a healthy baby. However, she also wants a new kind of birth experience - vaginal.

For some women, because they did not expect to have a cesarean, they may question in hindsight whether they needed one. Barring a medical emergency, fetal positioning is often a subject pondered. Questions that need to be addressed include, 1. was the prior cesarean for a non recurring medical reason, i.e. a breech presentation, or 2. was it for a recurrent pattern, i.e. the pelvis may have been narrow to accommodate both prior babies weighing in at respectively 6 and 7 pounds.

While women understand that a cesarean may be scheduled for a medical indication, those who started labor spontaneously and ended up with a cesarean delivery for other reasons, may question its necessity. Feelings of anger and betrayal may ensue, and some women require counseling to enter the next pregnancy with confidence. The route of delivery matters for many women because some insist they never needed one. The search is then on for a provider who offers a TOLAC.

Here are some TOLAC and VBAC tips:

  1. Get Your Delivery Operative Report: Bring it with you. Your provider needs to learn what kind of prior uterine incision was made in order to determine if you can TOLAC or need a repeat cesarean. If a report of the prior cesarean is unavailable, it is not an automatic contraindication to TOLAC. Your provider will review other clinical and medical factors, and risks versus benefits to determine if you are a safe candidate for TOLAC. Women who have gone into spontaneous labor, and had a prior vaginal birth are more successful.

2. What is the risk of uterine rupture? After one low transverse cesarean it is

0.5-0.9%. However, neither repeat Cesarean delivery nor TOLAC is without risk.

Vaginal Birth after Cesarean is associated with fewer complications, but a failed trial

of labor after cesarean is associated with more complications than elective repeat

cesarean. Your chance of rupture increases if your c section occurred less than 18

months prior to conception of this pregnancy, or if you had a single layer uterine

closure.

3. Is Oxytocin Used with TOLAC? There are strict medical guidelines for using

oxytocin infusion during labor. Discuss with your provider.

4. Fetal Monitoring. Expect continuous fetal and uterine monitoring as heart rate

challenges need surveillance. A hospital attending will be on call.

5. Midwives. Midwives co manage TOLAC with an obstetrician.

6. Twins. You have good chance to TOLAC barring other issues that may arise, such as

the position of the babies.

7. Two prior Cesareans? The really big news is if both were low transverse deliveries,

a TOLAC is an option with provider consent.

8. Prior Emergency Cesarean? Medical and clinical factors such as your BMI, gestational age, and baby’s birth weight, are reviewed in terms of how these factors may have contributed to your emergency cesarean. The likelihood of TOLAC success or an appropriate repeat cesarean are discussed.

9. Birth Counseling. I would strongly recommend counseling with an experienced

provider. Discuss reasons why you think you had a cesarean, and the medical report,

and emotions.

10. Become Informed, Find out your providers’ philosophies, review your individual

health for TOLAC, and your hospital’s TOLAC policies. Weigh risks versus benefits

and what feels right. Providers should carefully evaluate a woman’s individual factors

for a TOLAC.

As Jason Kanos, MD, Vice Chairman for L&D Quality and Patient Safety at Mt. Sinai West, and my collaborating obstetrician who co manages my TOLAC clients here in New York City, shares, "TOLAC deliveries can be a safe option for many women who want a vaginal birth. Options and risks should be discussed with your obstetrician and midwife. I encourage most women who are candidates for a vaginal birth to attempt a trial of labor.”

I hope you found this useful.

Have you heard any inspiring VBAC stories?

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© 2020 by Risa Klein

Risa Klein, CNM

Manhattan Midwife

Tel: (917) 806-4992

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