One of Oula’s core principles is that there is no “right way” to give birth – let’s unpack what this means! There is more than one way a baby might be born and it is important to be aware of these different options to make an informed decision that aligns with your birthing preferences and medical needs. In this blog post, we will discuss the three primary types of birth: vaginal birth, cesarean birth, and vaginal birth after cesarean (VBAC), also referred to as trial of labor after Cesarean (TOLAC).
What is a vaginal delivery?
A vaginal birth is the most common route of delivery, with around 68% of births in the United States and 80% of births globally being vaginal deliveries. After a period of time in which the uterus contracts around the baby, guiding it lower into the uterus and simultaneously applying pressure on the cervix, the cervix will dilate and thin out to allow the baby to enter into the vaginal canal. When the baby descends into an optimal position in the pelvis, the pregnant person will use the strength of their contractions to guide the muscles of their uterus and pelvic floor to push the baby out. As the baby is born they will be “caught” by a birth attendant (such as a midwife or a doctor) but otherwise will not be physically aided in being delivered.
In some cases, a provider may suggest an operative vaginal delivery (OVD) if there were a concern that spontaneous vaginal delivery may not be successful or if there were a concern of fetal distress that would be resolved by expedited delivery. OVD involves the use of one of two instruments to assist the baby’s delivery: forceps and vacuum extraction. Forceps are smooth metal instruments that resemble large spoons and are used to grasp the baby’s head and guide it through the birth canal. Vacuum extraction involves the use of a suction cup that is placed on the baby’s head to help pull the baby out during contractions.
The use of OVD is not without risks and is performed infrequently. 3.1% of deliveries in the United States are OVDs; 0.5% used forceps and 2.8% used a vacuum. Risks associated with OVD include injury to the baby such as bruising or swelling of the scalp, facial nerve injury, and skull fracture. It may also increase the incidence of lacerations of the pregnant person. However, when OVD is performed by a skilled practitioner in appropriate cases, the benefits of OVD can outweigh the risks including reducing the risk of fetal distress, preventing prolonged labor, and avoiding the need for cesarean delivery.
What is a C-Section?
A cesarean birth, commonly referred to as a C-section or a C-birth, is a surgical procedure in which the baby is delivered through an incision made in the pregnant person’s abdomen and uterus. This type of birth is usually recommended if vaginal delivery poses a risk to the pregnant person’s or baby’s health, twins or a multiple gestation birth, breech presentation, previous uterine scarring, or abnormal placental location (such as complete placenta previa, when the placenta covers the internal cervical opening). During a C-birth, the pregnant person is given regional anesthesia (epidural or spinal) to numb the lower half of the body or general anesthesia to induce unconsciousness. After making an incision, the doctor will deliver the baby and close the incision with stitches (suture) or staples. Midwives cannot perform C-births, however some are trained to assist a doctor in the procedure or may be present in the room to help explain to the pregnant person the steps of the procedure.
Depending on the specifics of a pregnant person’s medical history and prenatal course there are many clinical reasons why a C-birth may be suggested as the most optimal method of delivery. If a provider is suggesting a C-birth it is often after full consideration of the clinical picture where the benefits of a controlled delivery far outweigh the risks. Let’s review what some of the risks associated with a C-birth might be! Babies born via C-birth have an increased likelihood of developing transient tachypnea; a benign, self-limiting condition in which the baby’s breathing may be too fast for several days after birth. One study identified that 2.42% of babies born via C-birth developed transient tachypnea compared with 0.64% of babies born vaginally. Risks to the birthing person can include heavy bleeding (hemorrhage), infection to the uterine lining, bladder, and/or bowel, and increased risk of blood clot formation in the legs (deep vein thrombosis or DVT). Having one C-birth also increases the risk of subsequent pregnancies needing surgical delivery including abnormal placental attachment in the uterus or the risk of uterine rupture (tearing along the incision line from the previous surgery).
Let’s talk briefly about what a “gentle Cesarean” means. A gentle C-birth is the same procedure as a regular Cesarean section but with an intentional focus on creating a positive birth experience and creating spaces for the pregnant person to actively participate in the birth. In a gentle Cesarean, the surgical drape is lowered at the time of the delivery allowing the pregnant person to witness the birth of their baby. Skin-to-skin is encouraged; in a traditional C-birth, the baby is taken away for cleaning and monitoring immediately after delivery. In a gentle C-birth, the baby is placed directly on the birthing person’s chest, allowing for immediate skin-to-skin contact before being evaluated by the pediatrics team. Some hospitals allow pregnant people to bring music to play during the delivery. Finally, medical staff may delay clamping of the umbilical cord by approximately 30 seconds allowing more time for the baby to receive blood from the placenta. It should be noted a gentle C-birth might not always be clinically possible depending on the status of the baby and the birthing person. Even if it is clinically possible, not all hospitals have policies that allow for these requests. If time allows it is recommended to discuss your birthing goals via gentle Cesarean with the doctor who will perform the C-birth before entering the operating room.
What is a VBAC?
Vaginal birth after cesarean (VBAC) is a type of birth that allows pregnant people who have had a previous cesarean delivery to attempt a vaginal birth in their subsequent pregnancies. Two terms are utilized in this space, often interchangeably: VBAC and TOLAC. TOLAC, trial of labor after cesarean, encompasses the prenatal care and labor aspect while VBAC, vaginal birth after cesarean, describes the success story of a vaginal birth! In the past, pregnant people who previously delivered via C-birth were told that they could only deliver via Cesarean. Current evidence supports that for pregnant people who have had one prior C-birth with a low transverse incision (Pfannenstiel incision) and have an otherwise healthy pregnancy without significant risk factors, TOLAC is considered to be a reasonably safe option. It is imperative to discuss the specific risks and benefits of your pregnancy with your healthcare provider to make an informed decision.
One rare but serious risk associated with TOLAC is uterine rupture. This is when the incision scar from a previous C-birth breaks open. While uterine rupture can happen at any point in pregnancy, it almost always takes place while the pregnant person is in labor due to the strength of uterine contractions. Uterine rupture occurs in 0.4 – 0.7% of TOLACs amongst pregnant people with one prior low-transverse incision.
Typically, TOLAC is not recommended for pregnant people who have had more than one prior uterine procedure or who have a classical (vertical) incision due to the increased risk of uterine rupture. While Oula currently does not offer TOLAC to pregnant people who have had two prior C-births, there are other practices and providers who may offer this.
Of all of the different choices you have to make throughout your prenatal course, choosing the mode by which you will deliver your baby may be one of the more salient ones. You may be at the point of questioning whether there even is choice in the matter. Pregnant people may enter this journey with plans of vaginal delivery and find that the clinical situation leaves little to no wiggle room for choice. And yet having the information and data around all possibilities prior to this very important day may allow you to feel ready to embrace any and all modalities of delivery. Remember; there is no “right way” to give birth! But all pregnant people have the right to walk away from their deliveries feeling empowered and informed. Talking with your provider early on about all delivery methods and what options are right for you and your pregnancy is a good first step.