VBAC and trial of labor after cesarean

What is it?

Once someone has had a cesarean, the wall of their uterus has a scar. In a later pregnancy there are two options. A planned repeat cesarean, or a trial of labor.

A trial of labor after cesarean is an appropriate option for many people, and most who attempt it give birth vaginally. ¹

What decides candidacy

The type of the previous incision matters most. A low transverse incision sits in the part of the uterus that contracts least. It carries the lowest rupture risk. A classical or high vertical incision sits in the upper segment, which contracts hard. It carries much more risk. That is why the operative note from your previous cesarean matters so much. ¹

The number of previous cesareans, the reason for them, and whether you have had a vaginal birth before.

Whether the setting can respond. Guidance recommends a facility able to perform an emergency cesarean. Rupture calls for immediate delivery. ¹

What rupture looks like

A sudden abnormality in the fetal heart rate is the most consistent sign. Pain and bleeding are less reliable. Bleeding can be entirely internal. This is why continuous fetal monitoring is recommended. ^{1 2}

What does standard care look like?

The previous operative note is obtained where possible, to establish the incision type. ¹

Candidacy is assessed and discussed, with the risks and benefits of trial of labor and of planned repeat cesarean set out. ¹

The setting is appropriate. Guidance recommends a facility able to perform an emergency cesarean. ¹

Continuous fetal monitoring during the trial of labor. ^{1 2}

Induction and augmentation are handled with the specific guidance in mind, since certain agents raise the rupture risk. ¹

Attention to tachysystole where oxytocin is used. ²

An immediate response to a sudden fetal heart rate abnormality, including preparation for emergency delivery. ³

What can go wrong?

A trial of labor offered when the previous incision type made it inappropriate, or offered without the previous operative note. ¹

A trial of labor conducted at a facility that could not perform an emergency cesarean promptly. ¹

Induction agents used that guidance addresses as raising rupture risk. ¹

oxytocin at high doses or with tachysystole. ²

Continuous monitoring not used. ¹

A sudden fetal heart rate abnormality not acted on, which is the most consistent sign of rupture. ¹

Delay between the decision to deliver and the delivery, which in a rupture is the interval during which the baby has no oxygen supply. ³

The risks not discussed, so consent was not informed. ¹

Whether any of this amounts to a departure from the standard takes a physician expert reading the whole record. Rupture occurs during correctly managed trials of labor, and guidance says so. ¹

Which injuries can follow?

For the baby

• HIE, where rupture interrupts the oxygen supply. Rupture is one of the acute events recognized as capable of causing it. ⁴
• Neonatal seizures. ⁵
• Dyskinetic cerebral palsy, the pattern associated with a sudden complete loss of oxygen. ⁶
• Cerebral palsy more generally. ⁷
• Stillbirth.

For the mother

• Uterine rupture itself, including hysterectomy in some cases. ¹
• Postpartum hemorrhage. ⁸
• Bladder injury.

What does this look like in the records?

From the previous pregnancy

• The operative note from the previous cesarean, which states the incision type. This is the document that governs candidacy, and you are entitled to request it from the hospital where it was performed. ^{1 9}

From this pregnancy

• The documented discussion about mode of delivery, including risks and benefits. ¹
• Where the birth was planned to take place.

From the labor record

• The fetal monitoring strip, continuously. ²
• Any induction agent used, and the oxytocin infusion record with times. ¹
• Contraction frequency and any tachysystole. ²
• The time any sudden fetal heart rate change occurred.
• The decision-to-delivery interval. ³
• The operative note describing the rupture, if one occurred.
• The cord blood gas and Apgar score scores. ¹⁰

What can you do this week?

1. Request the complete labor and delivery record for you and your baby. The records request builder writes the letters for you.
2. Write down what you remember while it is fresh, using the delivery timeline builder.
3. Read how to read your labor and delivery records before the records arrive.
4. Check the deadline to file in your state with the statute of limitations lookup.