There Are No Dumb Questions: Trial of Labor After Cesarean
It’s the second week of January, and this week, we’re gonna chat about advocating for your own health needs and wants this year. For those of us starting out this year with a little heartbeat inside our uterus, little legs pushing up on our lungs, and tiny hands punching our bladders, there’s a lot of things to think about. There are even more things to consider if you’ve had a C-section before.
If you’ve had a little human through C-section previously, you could either have a repeat cesarean or what we like to call a TOLAC or trial of labor after cesarean. What does this mean, though? If successful, TOLAC will allow you to have your baby vaginally.
So, what are some reasons to attempt a TOLAC? Well, C-sections are major abdominal surgeries you may want to avoid. Multiple C-sections could contribute to abnormal placentation, which means for your NEXT baby (that is if you wanna experience this at least once more), there is an increased risk of your placenta covering your cervix or growing into your uterine wall, which can mean complications. Risks of TOLAC include uterine rupture (typically 1%) and unsuccessful TOLAC (~30%) requiring C-section which could increase the risk of infection and need for blood transfusions.
On the other hand, there are benefits to repeat C-sections too, including being able to time your birth, easy opportunity for tubal ligation (if you decide this is for sure your last baby), and minimizing the risk of uterine rupture.
Some things to think about with TOLAC- Obstetricians will mostly avoid prostaglandins (such as misoprostol) for ripening your cervix to jump-start labor due to increased risk of uterine rupture, but may still use mechanical ways to help you dilate such as a transcervical foley catheter.
Here are some things to ask your obstetrician or keep in mind when considering TOLAC vs. repeat C-section:
Am I a candidate for TOLAC? If you’ve had certain types of incisions in your previous cesarean, you may not be. Also, certain previous uterine surgeries and previous uterine rupture will also make it too dangerous to attempt TOLAC. If you had a myomectomy, your surgeon for that procedure will tell you if they think you can TOLAC or not.
What if I’ve had multiple C-sections before?
What are the baby’s estimated gestational age and weight? Are these favorable for the baby through a trial of labor?
What could be used to help induce or augment labor? Is it harder to have a delivery after induction of labor after cesarean?
Is an epidural ok to have during TOLAC?
What monitoring will I and the baby have during a TOLAC?
And there are many more things to keep in mind when considering either TOLAC or repeat cesarean. Especially important to note is the fact that Black and Latinx women have higher rates of C-section than white counterparts and being Black/Latino is included as a risk in the VBAC calculator (which predicts the success of TOLAC), even though there is no biological basis for this. In summary, most women with one previous C-section and a low-transverse incision are candidates for TOLAC at most institutions and should talk about this with their doctors. 60-80% of TOLACs are successful! You could still be a candidate for TOLAC if it’s something you want to do, and if you don’t, that’s OK too. Knowing thes
e things lets you take charge of your pregnancy and do what's right for you, with help from your obstetrician of course. Stay healthy and educated ladies!
Pro Tip: Take these questions to your next doctor's visit. Be empowered with the right questions to get the care you deserve! Or just ask us, book an appointment today.