Labouring after a Caesarean Section

Making an informed choice regarding a vaginal trial of labour or a repeat caesarean section involves considering
both the risks and benefits of each choice.
 

Benefits of a VTOL (Vaginal Trial of Labour)

The benefits of having a vaginal birth after a prior caesarean include:
● Decreased recovery time
● Decreased physical discomfort postpartum
● Decreased risk of hysterectomy, infection, blood clots and blood transfusion
● Reduced respiratory complications for the newborn



Risks Associated with a VTOL
 
The risks of a trial of labour after caesarean section (TOLAC or VTOL) include:
 
● Uterine rupture -- This occurs when the scar on the uterus from the previous section opens. This is an obstetrical
emergency and causes severe complications for both the baby and the parent. If a c-section is not performed
immediately following a rupture, there is a risk of both a fetal and maternal death. The risk of a uterine rupture for
clients with one previous transverse lower segment incision is 0.5% or 5 clients out of 1000 (1in 200). The risk increases
if the baby is due within 18-24 months from their previous c-section or if the labour is induced or augmented with oxytocin.
 
VTOL is not recommended when:
 
● There are previous incisions other than a transverse lower segment incision, such as a previous uterine surgery
● Previous uterine rupture
● Placenta previa
● Less than 18 months has passed since the previous c-section
 
An obstetrical consultation is recommended for clients who have had a previous caesarean when the type of
incision is unknown.



What are the Chances of Having a Vaginal Birth After Having a Prior Caesarean?

Based on research, the success rate for VTOL is 65-77 %. The success rate is higher for individuals who had their
previous c-section for a reason that is nonrecurring, such as malpresentation, for example a breech. The success
rate is also higher if the individual has had a previous vaginal delivery, has a favorable cervix, goes into labour
spontaneously, or has a maternal age less than 40 years. The success rate may be decreased for individuals who
had their previous c-section because of labour dystocia, or failure to progress. Other factors that decrease the success
rate include the need for an induction or augmentation of labour, a birth weight of greater than 4000 grams (8lb 13 oz),
increased BMI (>30) or hypertension.
 


What are the Benefits and Risks of Having a Repeat Caesarean Section?
 
Some individuals decide that they do not want to have a VTOL and would prefer to have a repeat c-section.
 
The main benefit of having a repeat c-section is a decreased risk of uterine rupture. Individuals who choose an
elective repeat c-section also have a decreased rate of maternal complications (such as infection) as compared
to those who labour and then need a c-section for medical reasons.
 
With caesarean section there is an increased risk of hysterectomy, longer postpartum recovery, and need for
blood transfusions.



Lakeridge Health Oshawa protocols and SOGC
(Society of Obstetricians and Gynaecologists of Canada)
Recommendations for Individuals Planning a Trial of Labour After
Caesarean Section Include:
 
Continuous Electronic Fetal Monitoring
Because the first sign of a concern (uterine rupture) is fetal heart rate decelerations, the use of continuous
fetal monitoring allows for early detection and prompt timing of delivery.
 
Intravenous (IV) Fluids
If an emergency arises, having an IV in place allows for quick access to anaesthetic for an emergency
caesarean section.
 
Clear Fluids Only
To reduce your risk of aspirating undigested food if a caesarean section is needed, you should have only sips
of clear fluids during labour.
 
Consider Epidural Pain Relief
Having an epidural during your labour also allows for quick access, should the need for an emergency
caesarean section arise.



Choice of Birthplace
 
The midwives at Community Care Midwives, in accordance with SOGC recommendations, strongly recommend a
hospital birth for all clients planning a VTOL. For clients who are making an informed decision to have a VTOL at
home, it is important that they understand that uterine rupture is an emergency that requires an immediate
caesarean section. In an emergency, transport time to the hospital from home would delay access to emergency
obstetrical services and will significantly increase the chances of severe fetal and/or client complications and/or death.
CCM is unable to provide continuous fetal monitoring at home, potentially further delaying the diagnosis of a uterine
​rupture and appropriate care.
 
https://www.pregnancyinfo.ca/birth/delivery/vaginal-birth-after-caesarean/