The decision to attempt a Vaginal Birth After Cesarean (VBAC) involves a Trial of Labor After Cesarean (TOLAC), which is the process of laboring with the intention of achieving a vaginal delivery. This option can offer benefits such as a shorter recovery, fewer risks of infection and hemorrhage compared to a repeat cesarean, and a reduced likelihood of future placental problems. Preparing for a successful VBAC involves a comprehensive approach focusing on medical eligibility, physical readiness, and securing a supportive care team.
Determining Medical Eligibility
The first step in preparing for a VBAC is confirming medical eligibility, as not all individuals who have had a prior cesarean delivery are candidates for a TOLAC. The most significant factor is the type of uterine incision from the previous cesarean. A low transverse uterine incision, which is the most common type, carries the lowest risk of uterine rupture during a TOLAC, estimated at less than 1%.
Individuals with one or two previous low transverse cesarean deliveries should be offered a TOLAC. Conversely, those with a previous classical (vertical) or T-shaped uterine incision, or a history of prior uterine rupture, are not candidates due to a substantially increased risk of complications. The reason for the initial cesarean is also a predictive factor; a previous cesarean for a non-recurring issue, such as a breech presentation, is associated with a higher VBAC success rate than one for labor dystocia. A short interval between pregnancies, generally less than 18 months, decreases the probability of success and increases the risk of uterine rupture.
Optimizing Physical Health Before Labor
Once medical eligibility is confirmed, focusing on physical preparation in the months leading up to labor can significantly increase the chances of a successful VBAC. Maintaining a healthy lifestyle and managing weight gain within recommended guidelines helps optimize overall health, as a high body mass index (BMI) is associated with a lower VBAC success rate. Regular, pregnancy-appropriate exercise, such as walking, swimming, and prenatal yoga, builds the necessary stamina and strength for labor.
Specific exercises can promote optimal fetal positioning, which is a major factor in labor progress. Techniques like deep squats, cat/cow stretches, and diaphragmatic breathing help open the pelvis, improve flexibility, and encourage the baby to move into the best position for birth. Consulting a Webster-certified chiropractor or a pelvic floor physical therapist can also help ensure proper pelvic alignment and muscle function. Adequate time between pregnancies, ideally 18 to 24 months, allows the uterine scar to heal.
Selecting the Right Support Team
Choosing a healthcare provider and birth facility supportive of a TOLAC is the most influential step in preparing for a VBAC. Ask potential providers, such as obstetricians or midwives, about their personal VBAC success rates and their overall cesarean rate. Providers should be able to discuss their experience with VBACs and their comfort level with allowing labor to progress without unnecessary intervention.
The facility must be equipped to handle potential emergencies, having immediate access to an operating room, anesthesia, and personnel capable of performing an emergency cesarean delivery. Specific questions should address the hospital’s VBAC policies, such as whether they impose a time limit on labor or if they have restrictions on mobility or pain management options. A provider who encourages an unmedicated birth or supports the use of a labor doula often indicates a philosophy that aligns with successful spontaneous labor.
Labor Protocols and Monitoring
When labor begins, the experience for a TOLAC involves specific protocols. Upon admission to the hospital, an intravenous (IV) line is started to provide immediate access for fluids or necessary medications. This is a safety measure to facilitate a rapid response should an emergency arise, such as a uterine rupture.
Continuous electronic fetal monitoring (CEFM) is recommended throughout labor for a TOLAC to closely track the baby’s heart rate. Changes in the fetal heart rate tracing can be the first indication of a potential uterine complication, necessitating swift action. Epidural analgesia remains a compatible pain management option, as it does not prevent a VBAC and provides a rapid pathway for anesthesia if an emergency cesarean is required. The goal is to allow labor to progress spontaneously while maintaining vigilance to ensure the safety of both parent and baby.