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To TOLAC or not to TOLAC...that is the question!!!

birth cesarean section Apr 01, 2020

TOLAC stands for Trial of Labour after Cesarean Section and if it is successful it ends in a VBAC Vaginal Birth after Cesarean Section.  Check out our free Birth Plan Download here! 

Why are we talking about this you might ask?  Because it is a question that many women struggle with and their thoughts are influenced by many different things.  We think it is so important for women, and their partners, to understand all of the potential issues and then make a decision based on good sound information that is right for their family!!! 

Now as usual, it is important to discuss this with your care provider, as there will be some people who do not fall into this discussion, and other issues may factor into the decision that we do not touch on...but this should cover the Broad strokes!!!

 

Why Try for a VBAC?

Everyone has different reasons for wanting to try for a successful VBAC here are a few!

  • Planning on having multiple pregnancies
  • Wanting to try to have a vaginal delivery
  • To avoid having another surgery

Let's talk about each of these a bit more. 

Planning on Having Multiple Pregnancies:

If you are planning on having multiple (3 or more) children, then the more cesarean sections you have the riskier each becomes due to scar tissue from the previous, and the increased risk of placental problems (placenta previa or others) due to the multiple scars on the uterus.  So most providers, who know their patients are hoping to have large families, will recommend a TOLAC to decrease these specific risks.  

 

Wanting to try to have a vaginal delivery:

Some women have a desire to try for a vaginal delivery, others do not.  This is very individual and there is not necessarily rhyme or reason to either of these desires, or there are very good reasons!  So we as care providers have to do our best to support women in their choices, as long as they are well informed of the risks and benefits of their choices, and to help support their wishes in a safe environment.  We are all different, and so are our thoughts and feelings around modes of delivery! 

Learn more about preparing your perineum for a vaginal delivery with our free guide! 

 

Wanting to avoid another surgery:

Although cesarean sections are generally considered very safe, they do have risks associated with them and usually a more significant recovery time than vaginal deliveries.  Each surgery we have has increased risks due to scar tissue, and each comes with it’s own risks of increased bleeding, infection and damage to bowels and bladder during the procedure.  Major surgery also increases a woman’s risk for Deep Vein Thrombosis or blood clots in the legs.  

Recovery time for cesarean sections are about 6 weeks until you can get back to normal activities, where as it takes 2-3 weeks to recover from a “normal” vaginal delivery (ie no big tear or episiotomy needed).  If you have a toddler at home, this can be a significant difference, as you can not lift anything heavier than your baby for six weeks!.   

Now, lets keep in mind, that a successful VBAC can include a delivery including forceps, vacuum +/- an episiotomy.  It is important to consider these things when deciding on whether you would like to move forward with a TOLAC. These things can influence the recovery from delivery. 

 

A “Good” TOLAC Candidate:

A “good” candidate can have up to a 75% chance of having a successful VBAC.  The most important reason in being a “good” candidate is the reason you had a cesarean section in the first place.  Some reasons that women had a C/S that would make them a good candidate area:

  • Placenta Previa
  • Breech position and planned C/S
  • Fetal Heart Rate abnormalities with an otherwise normally progressing labour
  • Baby in a “bad” position (such as occiput posterior)
  • Having had a very large baby, and this pregnancy baby is significantly smaller
  • If you go into labour on your own

Reasons that may decrease the likelihood of having a successful VBAC:

  • Failure to progress normally in previous Labour despite reasonably sized baby in a good position
  • Previous surgery on uterus (fibroid removal for example)
  • If you go past your due date
  • If you have had two or more cesarean sections
  • If you are significantly overweight
  • If you have a large baby (estimated weight >4000 gr)

 

Risks associated with TOLAC

It is important to be aware of risks associated with anything that we choose to do, and mode of delivery is no different.  The most common risks are:

  • Uterine Rupture
  • Requiring emergency cesarean section
  • Infection or Bleeding
  • Complications with baby

Lets go through each of these in more detail

 

Uterine Rupture:

This is the term for the scar on the uterus coming apart during labour.  It happens in about 1/200 women who try for a VBAC. It is important to know about as it can lead to bad outcomes in mom and baby.  The risk of baby dying due to a uterine rupture is about 1/2000 planned VBACs or 1/10 uterine ruptures. This is the reason why it is not recommended that women who are attempting a VBAC labour and/or deliver at home.  If the uterine rupture is recognized, then most of the time we are able to perform emergency surgery to save mom and babe, but if we can’t act quickly (within 10-20 minutes) we put mom and babe at significant risk. 

 

Requiring Emergency Cesarean Section:

This is a known risk, and the reason we mention it is that recovering from an emergency repeat cesarean section is more challenging than that of a elective (by choice) repeat cesarean section. So depending on your chance of having a successful VBAC, you may not deem it worth it! 

 

Infection/Bleeding

The risk of these are actually lower in women who planned for a VBAC, than those who planned for a repeat cesarean section - regardless of if they actually had a successful vaginal delivery or not!  

 

Complications with Baby

This is the question most women ask first...which is the safest option for my baby? Well the risks are quite low for both options, but probably slightly lower of having significant issues as a result of birth in the planned cesarean section, and slightly lower in terms of breathing issues that may require a longer stay for VBAC.  

 

Recap

TOLAC is a safe option for many women, if they choose to do it!  Your plans can look different and change over time, so never feel like if you have decided one thing you can’t change your mind! TOLAC is not the right choice for some women and is for others!  Some women will even plan for a C/S and then if they go into labour before their C/S date will try for a TOLAC! The most important thing is to discuss all of these options with your care provider and come up with a safe plan that you are comfortable with (not your friends, parents etc).  

 

So there you have it!! We hope this information helps to empower your decision along with a good discussion with your care provider!

 

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