If you have already undergone a cesarean section, for your next pregnancy you can either have another cesarean delivery or give birth vaginally. A successful vaginal delivery with a previous history of cesarean delivery is known as vaginal birth after cesarean (VBAC). If you choose to deliver vaginally after previously having a C-section, this labor process is known as a trial of labor after cesarean (TOLAC).
Many factors play into whether or not a woman should have a VBAC. Even after the decision to deliver vaginally is made, unforeseen changes during pregnancy or labor may rule out this delivery option. Of course, it is necessary for you and your physician to take all factors into consideration and to choose the method of delivery that will be safest for both you and your baby. Both options of delivery, VBAC and repeat C-section, have their pros and cons.
The many benefits of having a VBAC include a lower rate of maternal deaths and quicker recovery time following delivery. By having a VBAC you will avoid the risks associated with having multiple C-sections including pelvic scarring, bladder and bowel injury, pelvic infection, greater blood loss and placenta accreta (when the placenta is very adherent to the uterus, causing hemorrhage).
The nationwide success rate of VBACs is 75%, but there are still some potential risks for both you and your child. There is about a 1% chance of uterine rupture, which is when the prior scar on the uterus opens up. Another possible risk is neonatal brain damage due to lack of oxygenation. The risk of neonatal brain damage is a little bit higher in a TOLAC than with a scheduled repeat C-section.
What factors might sway you towards having a repeat C-section instead of a VBAC? A repeat C-section may be favorable if you need an induction or have an unfavorable cervix. In these cases you could still potentially have a TOLAC, but the risk of uterine rupture can be as high as 2-3%. Also, if you are carrying either a large baby or twins, a repeat C-section is most likely the optimal delivery method for you. Another reason some women choose a repeat C-section is to have another operation done at the same time, such as tying their tubes.
Other factors may prevent you from having a TOLAC, such as having a scar on the upper part of the uterus from prior uterine surgery, like fibroid removal. Another consideration is that some women cannot have vaginal deliveries at all, such as those with placenta previa, breech presentation or those who are pregnant with a baby with large malformations that will not allow descent into the birth canal.
Many national organizations, including the American College of Obstetrics and Gynecology, recommend that most women with 1 prior C-section and, at times, 2 prior C-sections be offered a TOLAC. My personal recommendation as an OB/GYN is to bring your prior C-section operative report to your OB so he or she can determine if there were any complications during the first cesarean delivery that may rule out a TOLAC as a viable option. You and your OB can decide together, based on some of the facts mentioned above and your individual situation, whether having a VBAC is right for you.