Medical Examiner

How to Safely Attempt Vaginal Delivery After a C-Section

One reason our C-section rate is so high is because we’re reluctant to encourage vaginal delivery for subsequent births. But with the right precautions, we could change that.

A woman traces her fingers along her pregnant belly in this black and white photo.
Photo illustration by Slate. Photo by stevanovicigor/iStock/Getty Images Plus.

The following is a lightly adapted excerpt from High Risk: Stories of Pregnancy, Birth, and the Unexpected, from Norton/Liveright, by Chavi Eve Karkowsky.

At 2 a.m. on a Friday, she finally agreed to a cesarean. Sarah Pasternak had been on the labor floor for two days after her early prenatal appointment—on Wednesday, though it was hard to remember—showed high blood pressure. She had protein on her urine dip at the office, and along with that blood pressure, she immediately met criteria for preeclampsia, a serious disease that can affect late pregnancy. Preeclampsia can be mild; but historically, it is also one of the main reasons that women get sick and even die in pregnancy. The only cure for preeclampsia is delivery.

On that Wednesday morning, Sarah was already 39 weeks pregnant, so the decision to induce wasn’t something the doctors argued over. Sarah’s plan on that Wednesday morning had been a bagel with cream cheese on the way to work from the doctor’s office; she never got that bagel, and by the time the nurse ushered her into a labor room at the hospital, the plan for breakfast, like most of her plans, was swept aside.

Her husband joined her. IV lines were put in and labs were drawn; her cervix was checked and found to be 2 centimeters dilated. Sarah wanted to move around, but she was being put on magnesium to keep the preeclampsia from giving her seizures. The magnesium made her groggy and bleary eyed, and the nurse told her it would be dangerous for her to be off the fetal monitor, so she ended up staying in bed. After 12 hours and multiple attempts at making her cervix softer, oxytocin—a medicine meant to start contractions and open the cervix—was started.

Sarah’s initial plan had been to try a medication-free childbirth. But 18 hours into the process, still 2 centimeters dilated despite hours of painful contractions, she asked for an epidural. That was Thursday, in the wee hours of the morning. Sarah slept, but people kept coming in and increasing the oxytocin. Sometimes they would examine her cervix, then sigh and shake their heads. She became 4 centimeters dilated but then was still 4 centimeters hours later. At some point—maybe it was Thursday, late morning?—someone used a hook to break her bag of waters. They didn’t ask or warn her; they just did it.

By 6 p.m. Thursday, she was still 4 centimeters dilated. A new doctor came in, the Thursday evening shift, and told Sarah she should have a cesarean. Sarah’s husband sat up, rumpled, in the bed by the window and didn’t say anything. Sarah said no and started to cry.

By 1 a.m., the baby’s heart rate was going up and wasn’t coming down. Still 4 centimeters. The doctor told Sarah that she was likely on the way to an infection, given that her bag of waters was broken (“Broken by you people!” Sarah screamed, but only to herself). The doctor said, “I’m worried about the baby.” The doctor recommended a cesarean again. Sarah was tired and hungry and confused and most of all scared. Sarah stopped saying no. She signed the paper they put in front of her. That was at 2 a.m. on Friday.

At 2:30 a.m., they took her to the operating room. They tugged at her and pulled and told her that what she was feeling wasn’t pain, just pressure, but she couldn’t help but scream a little anyway because it felt like pain has always felt like. And finally, after all that, a wail. The baby.

The next few days were blurry and awful: pain at her incision, dizziness and nausea from the pain meds; even sitting up to breastfeed was a two-person project. She felt sadness, and anger, too, murkily directed at the doctor, at the hospital, at her body; anger at her baby mixed in with disappointment, which wasn’t any less strong five days post-op, when she visited the chirpy midwife who removed her staples.

Three years later, that baby is a healthy toddler. Sarah is physically recovered, mostly. She almost never cries about that night anymore. She and her husband still use the hospital’s name as a curse word; it works well as a synonym for shit.

And Sarah is pregnant again. She’s looking for prenatal care. And she’s friends with me, a high-risk obstetrician, so she calls me. She says, “I want whatever is the opposite of what we did the first time. I’m considering going into labor in a birthing center, or a home birth, or possibly just wandering into a forest and coming out when we’re done.” She’s joking, but only mostly.

I want to start by saying that cesarean deliveries are a goddamn gift. To have a tool to get a baby out safely, quickly, and without killing the woman is a recent invention; women have had to fight for this tool, and I am grateful to be able to offer it when appropriate and necessary.

I also want to say that Sarah had a terrible experience, one that remains painful to her and caused trauma to her and to her young family. That is all true, and deeply regrettable, and wrong. And yet, for clarity’s sake, I need to point something out: Medically speaking, none of the decisions made during her treatment were technically incorrect. Would I have done the same had I been her doctor? I’d like to think I’d have explained more or been warmer or had her participate in the decision-making in a way that felt less traumatic. But the medical answer is that I would’ve made most of those same labor management decisions, and in fact, I can tell you that I have, dozens of times.

Let’s look at this experience and the surgery that’s at the heart of it. The occurrence of the urgent cesarean delivery already represents a trauma for many women—a failure, a mix of regret and blame that isn’t associated with other surgeries. Few people have such complicated emotional landscapes surrounding their appendectomies. Birth is a life cycle event, and a complicated one; add an undesired surgery to that, and it becomes almost impossible to navigate.

Before the 20th century, cesarean delivery was a rarity because it was also often fatal. By the second half of the 19th century, the adoption of antiseptic techniques, the move of birth from the home to the hospital, and the advent of obstetric anesthesia meant that cesarean delivery became safer. But through the early part of the 20th century, cesarean deliveries were rare: Less than 2 percent of all deliveries in the United States in 1916 were surgical, likely because cesarean deliveries were still very dangerous. Statistics from 1933 report a cesarean-related maternal mortality rate of 4 to 16 percent when looking at some of the best U.S. hospitals.

In the early 20th century, improvement in cesarean delivery safety came with a corresponding linear increase in the number of cesarean deliveries performed. Sometime in the late 1990s, the rate began to rocket upward, increasing exponentially. Studies of that increase have noted that there was an increase both in first-time (or, as they are called in the medical literature, “primary”) cesarean deliveries and in repeat cesarean deliveries. Put another way, almost half of the increase in overall cesarean births was related to a decrease in women successfully attempting a vaginal birth after cesarean, also known as a trial of labor after cesarean.

This unsettling rise in cesarean delivery rate in the late 20th and early 21st century means that currently almost a third of all babies are now born by cesarean delivery, a statistic unthinkable 100 years ago. That unthinkable number describes our reality, despite the fact that the majority of both women and doctors want it to go down.

Right now, for a variety of reasons, cesarean deliveries in the United States are often overperformed. The secret to lowering the cesarean delivery rate is twofold: one, avoiding that first cesarean, and two, giving women who have had a cesarean a way out—the option to try a vaginal birth after cesarean. Trial of labor after cesarean, or TOLAC, is the exit ramp from a lifetime of surgical births.

From the moment women began to survive cesarean deliveries in the early 1900s, there was interest in how to manage their next delivery. In Europe, TOLAC was considered an acceptable risk, but in the United States, different thinking prevailed: TOLAC was considered unsafe. This meant that it was very rare: In a 1968 study, more than 80 percent of New York City physicians thought that they would never consider TOLAC a safe action. It’s not surprising, then, that 99 percent of patients with a previous cesarean delivery were delivered by an elective repeat cesarean delivery in American hospitals as late as 1974.

Over time, the medical community’s thinking about TOLAC has changed. As in many other arenas, there’s been a move toward increased patient autonomy and shared decision-making. There’s also the ugly truth that cesarean deliveries have risks that extend far beyond this pregnancy: A woman who has multiple cesareans may end up with anatomy so changed by scar tissue that each surgery becomes more and more dangerous and can ultimately limit her family size.

Then there’s the very real increase of placenta accreta spectrum. With the increase in the cesarean rate, we are seeing more and more of these placentas: placenta accreta and increta and percreta. In the area of the uterus where it has healed, the signals that tell a placenta to stop here, to implant only this far and no farther, are more likely to be compromised. Especially when there are multiple scars, a placenta can invade into or through the wall of a uterus, attaching firmly and refusing to let go. This is called a placenta accreta if it attaches past the lining of the uterus and into the muscle, a placenta increta if it’s well into the thickness of the uterine muscle, and a placenta percreta if it burrows through the uterus and into adjacent structures: bladder, bowel, blood vessels.

Invasive placental disease is more likely to occur in a uterus with a scar, and the risk increases with the number of scars that have been placed in that uterus. It turns out that pregnancy isn’t a benign growth; it needs to be a bilateral agreement between a woman’s body and a developing embryo. Without limits, the pregnancy will continue to grow, to take and overtake. It doesn’t take what it needs; it takes everything it can get.

If a woman has a placenta accreta, increta, or percreta, then that woman can hemorrhage—quickly and massively—during attempted removal of the placenta. In these situations, a hysterectomy usually has to be performed, often accompanied by massive blood loss and equally massive transfusion. If we know about the invasive placenta before delivery, late preterm delivery is recommended: planned, safe, timed to happen before a woman comes to us in labor or already bleeding. Even so, as recently as 2002, the maternal mortality rate was reported to be as high as 5 to 7 percent. That is, of course, the worst-case scenario. But even the best-case scenario is a woman who has undergone major surgery, suffered dramatic bleeding, received enormous amounts of transfusion, lost the ability to carry a pregnancy, and has ended up in the ICU with a premature baby.

The rising cesarean delivery rate of the past decades was thus followed closely by a rise in occurrence of placenta accreta spectrum. In 1970, the rate of placenta accreta spectrum was 1 in approximately 4,000 patients; in the years 1980–2002, it was around 1 in 2,500 patients. The most recent data place the risk at 1 in 533 patients—almost a tenfold increase over one generation.

Current guidelines from the American College of Obstetricians and Gynecologists about TOLAC include the need for a thorough discussion of the risks and benefits of TOLAC compared with the risks and benefits of repeated cesarean delivery. That discussion needs to include ramifications not just for this pregnancy but also for all the pregnancies a woman might want in the future. Those guidelines tell providers to offer women with one prior cesarean delivery a choice: proceed to repeat cesarean delivery or take the option of TOLAC.

Even though those are technically the choices, a lot of women can’t actually opt for TOLAC even if they want to. To safely offer TOLAC deliveries, those same ACOG guidelines that advocate that patients be permitted to make a well-informed choice also recommended in 1998–99 that a hospital be able to provide an emergent cesarean “immediately,” generally interpreted as within 30 minutes. That capability requires a bunch of really expensive commitments and a lot of highly trained personnel, including 24/7 anesthesia coverage either in-house or very close by, as well as obstetrics attending physicians constantly on the labor floor.

Rural hospitals serving large areas with a small population often can’t muster that kind of coverage, which means that they often make the decision not to allow TOLAC at their sites. For women in large swaths of the country, this means that the one hospital in their area won’t offer TOLAC, and there’s often no other option within a six-hour drive. They end up with a repeat cesarean because their theoretical choice, unsupported by real resources, remained imaginary.

Almost immediately after the 1998–99 ACOG guidelines on TOLAC were published, the U.S. TOLAC rates crashed. Over a few years, the rate dropped from approximately 25 percent to less than 10 percent. Most of that TOLAC loss was borne by rural America. In one study, TOLAC rates in rural Maine fell by more than half, from 30 percent in 1998 to less than 13 percent in 2001, and the most commonly cited reason was the inability of the hospital to meet ACOG recommendations for the provision of labor after cesarean. More recently, likely as a result of this dramatic change and the accompanying increase of placenta accreta cases, with all their morbidities, ACOG guidelines have utilized more nuanced language as an attempt to reduce the burden on these hospitals.

Despite those changes, the unavailability of TOLAC throughout many rural areas remains problematic. This has led to some women finding that they have to move to a big city near the time of their birth to allow for TOLAC; others labor at home or while driving long distances. Still others have chosen to leave the medical system altogether and pursue a home birth, counter to ACOG recommendations about TOLAC at home, sometimes leading to terrible complications.

Why has TOLAC been so tightly regulated? Why do hospitals get so nervous that they shut this service down entirely? Because 99 percent of the time, things go fine—or at least they go wrong in the usual ways. Most of the time, the baby is born vaginally; sometimes a repeat cesarean delivery is needed, but 99 percent of the time, nothing horrendous happens.

But approximately 1 percent of the time, something horrendous does happen. That horrendous event is called uterine rupture. It’s when the scar on the uterus, weaker than the surrounding unscarred muscle, breaks open. When the uterus ruptures, the uterus bleeds; this can be dangerous for the pregnant woman. But depending on luck, it’s even more dangerous for the baby: If the rupture is near or under where the placenta is attached to the uterine wall, the baby can bleed and will also have less functional connection to the maternal oxygen it needs every minute.

In most studies, uterine rupture happens approximately 1 percent of the time. And 1 percent of the time is not the same as never.

Jane Lucas comes into triage at 9 p.m., to get checked for contractions; her first baby had been breech, and she had undergone a cesarean delivery prior to labor, so this is a whole new experience for her. She is young and cheerful, excited for this baby to join her 3-year-old at home. She’s been counseled about TOLAC several times and knows the numbers better than I do. Jane wants a big family, so avoiding another cesarean is a real priority for her: She wants to have at least five kids. Maybe more! A basketball team? A soccer team? Maybe a football team. Around this joking conversation, we have Jane sign all our forms and review the consent for an emergent cesarean delivery if needed.

Jane is at 4 centimeters and the baby is low, with the fetal head right between her pelvic bones at 0 station. She’s not in a lot of pain, but her cervical exam is more dilated than it was earlier in the day, when she was seen in the clinic. Given that she’s attempting TOLAC, we decide it would be best to admit her. I counsel her that she doesn’t have to have an epidural but that I do like to offer it early in these situations: Aside from pain control, it has the nice side benefit of giving our team a safe way to do surgery without her having to go to sleep if the TOLAC doesn’t go well. Jane cheerfully agrees: “I’ve never been a huge fan of pain, anyway,” she says.

She gets her epidural at around 1 a.m. and settles into bed; I examine her, and she’s now 6 centimeters. Her labor is progressing beautifully, and I relax a bit. Research shows that this is the best possible scenario for a TOLAC; natural spontaneous labor offers the lowest risk for uterine rupture and the highest probability of successful vaginal birth.

But at 4 a.m., there’s something on the monitor that doesn’t look quite right. The residents call me, and I run toward the room; just a minute ago, the baby’s heart started beating at a higher rate, abnormally high. Is Jane developing a fever? Is she dehydrated? As I walk into the room, I hear the baby’s heart rate go from too high to too low, bump bump bump down the stairs, from 180 all the way down to the 60s. This is much more concerning; a baby can’t live for long with a heart rate in the 60s.

We quickly do our usual maneuvers: turn the patient to give the baby more of the maternal circulation, open up her IV line to give her more fluid. Still 60s; we’re now two minutes into this low heart rate. I quickly do a cervical exam to see what’s going on. Now 4 centimeters; wasn’t she 6 before? And that baby’s head is floating, high in the pelvis, not even really in the pelvis anymore. That’s not right. None of this is right. She’s going backward in labor. Shit.

In that moment, I realize that labor is reversing because the scar from Jane’s prior cesarean has blown open inside her belly. The baby is no longer being held down by the uterus because there’s no uterus behind it anymore. She has a uterine rupture.

I yell out, “Stat section; uterine rupture!” I say to Jane, “We have to go. I’m so sorry. I need to take you to the OR, and I need you to trust me. I think your uterus is ruptured.” She is scared, eyes wide over the oxygen mask, but she nods.

How long can a baby live like this? How long do I have to get this baby out, undamaged? It depends on things I can’t know right now: how much of the placenta remains attached to a normal uterine wall; how much blood the baby loses; how much blood the woman loses. It depends on location and luck. The answer to how much time I have is: go faster.

People rush to us, but we start to move without waiting for them. We leave her husband behind in the room; no time. As we roll, the charge nurse tells me that the OR is ready; the anesthesia resident is injecting medications down the syringe with one hand while pushing the bed with the other. We bang the doors to the OR open, and I hear “eight, nine, ten” as the tech finishes her instrument count. We roll Jane to the surgical bed in the usual chaos of people trying to help; we move her torso, then her legs. My OB-GYN chief resident is already pouring surgical prep over her belly before Jane is settled on the surgical bed. The pediatric team is running in, getting quick details while they go to their corner and start to get ready. I get gloved and gowned while my chief resident throws a drape over Jane. That anesthesia bolus on the run is in, thank God, and Jane has adequate anesthesia before I have my gloves on.

Anesthesia tells me I’m safe to go, and then I go, knife on skin within 15 minutes of the baby’s first fetal heart abnormality. Is it fast enough? Skin open, muscle open, some scar tissue, no time to stop; I see baby. No uterus as there should be; no thick muscular uterine wall, just baby floating in the belly, in a sea of blood. The baby is out, limp, blue; cord clamp placed; umbilical cord cut. Is that some movement as I hand her off? Please be some movement. I hand the baby off to the pediatricians. They take the baby off to the corner to start resuscitation. I hear them yell for more supplies; I hear them yell out some low numbers, bad numbers.

Jane is bleeding, so we drag our attention back to her quickly. She’s awake; she’s been awake the whole time. I hear the anesthesia team murmuring to her softly. I say aloud that we have bleeding: “EBL (estimated blood loss) 1 liter already, not controlled.” I lean over the patient and call out; I see Jane’s brown eyes widen. I’m telling anesthesia we need a transfusion because I can’t fix this quickly. I don’t have time to explain to Jane, but I wasn’t careful enough with my tone of voice and I’m sure she can hear the urgency. Anesthesia calls for help; they call for blood from the blood bank.

The chief resident and I pull at the uterus. Where is the top? Where is the bottom? What can we sew together? I find the ragged edges, finally, but we are having a hard time sewing much of it together; the scar ruptured in all directions, creating a stellate defect involving most of the front wall of the uterus. Will we have to do a hysterectomy? I know that’s not what Jane wants, especially with this baby’s fate still unknown. It’s not what any of us want for her. But the bleeding doesn’t stop; it’s getting to the point of being dangerous for her. At some point, anesthesia gives Jane something to relax her, because when I lean over again, she is breathing on her own, but her eyes are closed and her face is relaxed. We’ve called up for two units of blood; no, make that four.

Finally, we manage to find edges of tissue that are thick enough and piece the uterus together. The bleeding slows, and we add strength to the uterine wall we reconstituted out of frayed tissue, layer by layer.

In the middle of this, the baby is wheeled behind me so that Jane can see her. I note as the baby goes by that the baby is breathing on her own, that she didn’t need to be intubated: That’s good, that’s hopeful. I keep sewing. The pediatricians stop by to briefly update Jane and allow her a brief touch; Jane is awake enough to pass her hand into the incubator and pat the baby on the head; then the baby is rolled downstairs. I’m still sewing, and over an hour and four more units of blood later, we finish the surgery. Jane still has her uterus and has been stable the whole time; we roll her into the post-anesthesia recovery unit and go to find her family.

The next morning, before I go home, I stop by Jane’s hospital room. I find out that the baby is being moved out of the neonatal intensive care unit to the regular well-baby nursery today. It seems that we got there in time

On the phone with my friend Sarah, I don’t tell this story. To be truly statistically fair, I’d have to tell her 99 reassuring TOLAC stories for each upsetting rupture. But she needs to know what will be worrying her providers, so I ask her if she knows that she’ll be trying a TOLAC, that she has options. I make sure she knows what a uterine rupture is and what the odds are. I do say something like: “It doesn’t happen often, but it also doesn’t happen never. And when it happens, it can be very scary.”

Sarah wants to be safe, but she also wants to avoid surgery. We talk about what she really wants; she doesn’t really want a forest—too muddy. She doesn’t even want a home birth. What she wants is a vaginal delivery; she wants it for this pregnancy, but also because she wants out of this whole surgical birth pathway. She wants to avoid surgery and scar tissue and placenta accreta.

But more than that, Sarah wants to feel secure and safe; and more than that, really, she wants to feel like she knows what’s going on, that she’s in charge, that it’s her body, her labor, and her baby in a way that the first labor wasn’t.

And Sarah is lucky: She lives in a suburb on the East Coast, in easy distance of more than one large medical center. She has options.

The thing is, I tell her, she needs a lot for a successful TOLAC. The TOLAC experience she’s looking for requires a labor and delivery hospital that officially supports TOLAC, which means it has the necessary resources, such as full-time anesthesia and all the resources required to provide an urgent cesarean. The hospitals that are the best at TOLAC are usually the ones that have everything they need to get a patient out of trouble if things go horribly wrong.

It’s sort of counterintuitive, I tell Sarah, but it’s just the way I see it happen a lot of the time. Particularly for the TOLAC experience—where you are trying to avoid the most invasive outcome—a large hospital, with beeping monitors and protocols, is sometimes the least interventionist because those hospitals have everyone and everything they need to take care of you quickly if things go wrong. I tell Sarah that if she has the patience to tolerate the setting and the right high-level hospital, I think that they can serve her well. If she can accept a little bit of intervention in the setting, she can avoid a lot.

Sarah asks me if there’s any way to modify that giant hospital setting to make it more serviceable to her and her family. She realizes that she probably can’t change the hospital itself, but she can change who she brings as her team.

Sarah and I start talking about a professional labor-support person, often known as a doula. The role of doula is as ancient as childbirth itself, but the modern equivalent dates to somewhere around the 1990s. In the setting of that exponentially increasing cesarean delivery rate, women started to hire other women to be their birth companions and advocate for them within a medical system they often felt didn’t have their best interests at heart. It’s an acknowledgment that the current medical providers—the doctors and nurses at the hospital—don’t generally have the time or training for labor support. Thus, the modern role of doula was born: a woman who works professionally as a labor companion, offering emotional support, informational support, physical comfort measures, and advocacy throughout labor.

Despite decades of development within the United States, the title of doula is not very standardized: Many women have full certification; others are in training; and still others are not in pursuit of any formal training and are “lay” doulas. Similarly, there are a range of experiences I’ve had with doulas, almost all wonderful and one or two quite difficult. Most doulas take their advocacy work extremely seriously; most of the time, that’s wonderful for the patient. Rarely, that advocacy work can get in the way of the  medical care I’m trying to give. But research shows that doula care can decrease cesarean delivery and improve a wide array of maternal and newborn metrics. I’ve worked with many fabulous doulas who know that childbirth success can mean different things to different people and who can help a patient navigate the not completely low-risk situation of TOLAC.

When Sarah considers a return to the busy nurses and efficient epidurals, a land similar to that of her first birth, she is also considering utilizing a labor companion and advocate, someone who can help her labor at home while that’s safe and who will help her and her husband translate their desires to the medical team.

Sarah ends up with a plan to get her care at the large hospital 10 miles away, where she also plans to be accompanied by her extremely dedicated, savvy, and down-to-earth doula.

When I next talk to her, 36 weeks into her pregnancy, she sounds good.

“How do you feel?” I ask. “I feel … I feel like I know what’s going on this time,” she says.

A month later, Sarah texts me a picture of a very new newborn with a gorgeous bald head and delicate curled hands. The picture is accompanied by a gleeful caption, all caps: LOOK WHAT I DID.

For the moment, I don’t know how this baby was birthed, but I can feel the joy. That’s all Sarah really wanted, and it’s everything we all deserve.

Excerpted from High Risk: Stories of Pregnancy, Birth, and the Unexpected. Copyright (c) 2020 by Chavi Eve Karkowsky, M.D. Used with permission of the publisher, Liveright Publishing Corp., a division of W.W. Norton & Co. Inc. All rights reserved.