Cesarean Birth and VBAC

Source: *The Birth Partner* (5th ed.) — Penny Simkin with Katie Rohs

What a Cesarean Birth Is

A cesarean is a surgical birth. The baby is delivered through an incision in the abdomen and uterus. In the United States, approximately 30 to 33% of births are by cesarean — more than in most other developed countries.

A cesarean is major abdominal surgery. Recovery is longer and more complicated than vaginal birth. At the same time, it is common, it is generally safe, and for some situations it is the right and necessary choice. The birth partner's role is to understand when a cesarean is medically indicated, how to prepare, what the procedure involves, and how to support recovery.

Medical Reasons for Cesarean

**Clear medical indications:**

• Active herpes lesion at the onset of labor
• Placenta previa (placenta covering the cervix)
• Prolapsed umbilical cord
• Acute fetal distress that cannot be resolved with conservative measures
• Certain fetal abnormalities
• Maternal conditions making vaginal birth dangerous (severe cardiac disease, certain anatomical issues)
• Labor that has arrested after adequate trial (failed induction or prolonged arrest of active labor despite augmentation)
• Baby in a transverse (sideways) or certain breech positions
• Cephalopelvic disproportion that cannot be resolved with positioning

**Relative indications (judgment calls):**

• Prolonged second stage
• Suspected macrosomia (large baby) — note that size estimates at term are unreliable
• Prior uterine surgery
• Maternal exhaustion after a very long labor
• Multiple gestation (twins, triplets) depending on presentation

**Non-medical reasons:** Convenience, fear of labor, scheduling. Elective primary cesarean carries more risk than vaginal birth and is not recommended without medical indication.

Preparing for a Planned Cesarean

If a cesarean is scheduled in advance (e.g., for placenta previa, persistent breech, repeat cesarean):

**Before surgery:**

• Nothing to eat or drink for a period of hours before (typically 6 to 8 hours for solid food, 2 hours for clear liquids)
• IV line placed in the arm
• Abdomen shaved (area of incision)
• Urine catheter placed (usually after the spinal or epidural is working, so it is painless)
• Blood pressure cuff on the arm, pulse oximeter on the finger, heart monitor leads placed

**Pre-surgical conversation with the team:**

• Request delayed cord clamping if possible — many surgical teams can now accommodate this
• Request skin-to-skin in the OR, or as soon as the birthing person is in recovery
• Request a clear drape so the birthing person can see the birth
• Discuss who will be in the room and where the birth partner will stand
• Discuss what happens if the baby needs the NICU

The Cesarean Procedure

**Anesthesia:** Most planned and urgent-but-not-emergency cesareans use a spinal block (single injection) or epidural extension. Takes effect within minutes. The birthing person is awake and aware for the birth.

**The operating room:**

• Bright, cold, and full of equipment
• Several staff present: surgeon, assistant, scrub tech, anesthesiologist or CRNA, nurses, pediatric provider
• A drape is placed at chest level so the surgical field is not visible (unless a clear drape is requested)
• The birth partner sits at the head of the table beside the birthing person

**The incision:**

• Most commonly a transverse (horizontal) incision just above the pubic bone (Pfannenstiel incision). Heals with a low-profile scar.
• Less commonly, a vertical midline incision (used in emergencies or when the lower segment is inaccessible)
• A second incision is made in the uterus, typically low and horizontal

**The birth:**

• The surgeon gently opens the layers of tissue and uterus
• Amniotic fluid is suctioned
• The baby is lifted or guided out through the incision
• The baby is shown to the parents over the drape
• If all is well, the baby is placed on the birthing person's chest immediately (or handed to the birth partner)
• The cord is clamped and cut

**Repair:**

• The placenta is removed
• The uterus and abdominal wall are sutured in layers
• This takes 30 to 45 minutes after the birth
• The birth partner stays with the baby during this time — if skin-to-skin in the OR is not possible, the birth partner holds the baby

**What it feels like:** The birthing person is awake. There is no pain during surgery (the anesthesia blocks sensation), but there is pressure, pulling, and tugging sensations as the surgeon works. Some people find this disconcerting; most manage well with advance preparation.

**What the birth partner does:** Sit beside the birthing person's head. Hold their hand. Talk to them. Be their anchor. When the baby is born, describe what you see. Be enthusiastic and present. If the baby is placed on the birthing person's chest, support the baby's head and weight so the birthing person does not have to reach awkwardly.

Emergency Cesarean

An emergency cesarean happens when there is no time for preparation — fetal distress, prolapsed cord, placental abruption, or a situation that escalates suddenly.

**What happens:** The pace increases dramatically. Staff may move faster than seems comfortable. Questions may need to wait.

**The birth partner's role in a true emergency:**

• Follow instructions immediately and without delay
• Go where you are told to go
• Stay with the birthing person if permitted, or go to the baby if not
• Ask questions after the baby is delivered
• Provide presence and calm without impeding the team's work

If general anesthesia is required (no time for regional): The birth partner will likely not be in the OR. Go directly to the baby. Hold the baby skin-to-skin until the birthing person is awake and can meet them.

Postoperative Recovery

**Immediate:** The birthing person spends 1 to 2 hours in recovery (or labor and delivery room) while anesthesia wears off. IV fluids and monitoring continue. Nurse checks are frequent. A urinary catheter remains in place for 12 to 24 hours.

**Pain management:**

• Epidural morphine (Duramorph): provides extended pain relief for up to 24 hours. Administered before the epidural is removed.
• Oral medications: ibuprofen, acetaminophen, and occasionally oral narcotics for breakthrough pain.
• The incision will be painful. Rolling from back to side, getting out of bed, and walking are all very painful at first. Each day is meaningfully better.

**Activity:**

• Early walking (within 24 hours) speeds recovery and reduces risk of blood clots
• Rolling technique to get out of bed: lift the knees, shift hips to one side, then roll shoulders to follow. Avoids straining the incision.
• Support the incision with a pillow when coughing, sneezing, or laughing

**Incision care:**

• Clamps or staples are removed on day 2 or 3
• Keep the area clean and dry
• Watch for signs of infection: redness, swelling, discharge, fever
• Itching at the scar is normal as healing progresses

**Gas pain:** Common after abdominal surgery. Avoid gas-producing foods (beans, lentils, cabbage family vegetables, carbonated drinks). Walking helps.

**Hospital stay:** Typically 48 to 72 hours after cesarean. Longer if complications arise.

**Birth partner's role in recovery:**

• Help the birthing person roll to their side before getting up
• Walk close so they can lean on you
• Place a pillow over the incision when they hold the baby
• Ask the nurse or lactation consultant for breastfeeding positions that avoid pressure on the incision (football hold, side-lying)
• Take on nighttime baby care as much as possible during the first days

Cesarean Recovery at Home

Recovery from a cesarean takes 6 to 8 weeks. Lifting nothing heavier than the baby is the standard guidance for 6 weeks. Driving is restricted until the birthing person can make sudden movements without pain and is off narcotic medications.

The incision area may be numb for months as nerve endings regenerate. Some people experience permanent numbness or a ridge of scar tissue.

Emotional recovery matters as much as physical. Some people feel relieved after a cesarean; others feel grief, loss, or disappointment, even if they know it was the right decision. Allow space for both.

Vaginal Birth After Cesarean (VBAC)

VBAC is vaginal delivery in a person who has had a previous cesarean. For most people with one previous low-transverse cesarean (the most common type), VBAC is a legitimate option.

**The data:**

• VBAC success rate: 60 to 80% for appropriate candidates
• Risk of uterine rupture at the scar: approximately 0.5 to 1% overall; higher with certain situations (see below)
• Risk of elective repeat cesarean: higher maternal morbidity than VBAC if successful; slightly lower than VBAC complicated by rupture

**Good candidates for VBAC:**

• One previous low-transverse uterine incision
• No other uterine surgeries
• No clinical factors suggesting the reason for the previous cesarean will recur
• Adequate pelvis and normal fetal size

**Higher risk for uterine rupture:**

• Previous classical (vertical) cesarean incision
• More than one previous cesarean
• Induction with certain prostaglandins (misoprostol/Cytotec is generally contraindicated with a prior cesarean)
• Very short interval between pregnancies (less than 18 to 24 months)

**Trial of Labor After Cesarean (TOLAC):**

This is the attempt to labor with the goal of VBAC. Not every labor succeeds in vaginal birth — approximately 20 to 40% of TOLACs result in repeat cesarean. This is not a failure; it is an outcome.

**What VBAC labor feels like:**

• Often similar to any labor
• The caregiver monitors closely for any signs of scar stress: sudden change in contraction pattern, unusual pain between contractions, sudden bleeding, fetal distress
• Pitocin is used cautiously (and only for augmentation, not induction with misoprostol)
• Continuous EFM is standard

**The birth partner's role:**

• Understand that VBAC labor may carry more anxiety than a first labor — both the birthing person and the care team are watching for rupture signs
• Provide steady reassurance
• Know the plan if a cesarean becomes necessary: preparation is faster with a regional block already in place
• The emotional aspect of VBAC is significant — birth trauma from a previous cesarean may surface; see the section on previous difficult birth experiences in the challenging labor file

**Why VBAC matters:**

Each repeat cesarean carries cumulative surgical risk: more scar tissue, longer recovery, higher risk of placenta previa or placenta accreta (where the placenta grows into the scar) in future pregnancies. VBAC is not just about this birth — it matters for future pregnancies too.

VBAC: The Attendant Is the Variable

Source: *The Birth Book* — William and Martha Sears

The phrase "once a cesarean, always a cesarean" has no basis in current evidence. It entered obstetric culture as a matter of institutional convenience, not medicine, and it is no longer the standard guidance in most practice settings. The research supports attempting vaginal birth after a single low-transverse cesarean.

Sears reviewed studies from the 1980s and early 1990s showing VBAC success rates of 70 to 90 percent when the birthing person had a supportive attendant who genuinely believed in and encouraged the attempt. In those same studies, across more than 36,000 VBAC attempts, no mothers died from uterine rupture. The uterine rupture rate for a low-transverse scar is approximately 0.2 percent, well within the range of risks that are accepted for other common obstetric interventions.

The single most important variable in VBAC success is not the person's pelvis, their labor pattern, or their previous cesarean reason. It is whether their attendant believes VBAC is appropriate and supports it actively. Research shows that laboring persons whose providers were supportive of VBAC had dramatically better outcomes than those whose providers were technically willing but ambivalent or procedurally biased toward repeat cesarean.

What this means practically: if the person planning a VBAC has a provider who says things like "we'll see how labor goes" or "we can try, but the OR will be ready," that is ambivalence, and it predicts outcomes. The conversation about attendant philosophy should happen in the third trimester, not in labor. Switching providers or hospitals at 36 weeks is hard, but it is not impossible, and the stakes justify it.

**What to look for in a VBAC-supportive attendant:**

• Willing to let labor start spontaneously rather than defaulting to scheduling
• Does not set arbitrary time limits in active labor
• Discusses VBAC as the expected outcome, not the hoped-for one
• Is frank about the signs of scar stress (sudden change in contraction pattern, unusual pain between contractions, fetal distress) without treating rupture as imminent and inevitable

For the birth partner: if the person you are supporting has had a cesarean and wants to try for a vaginal birth, your role includes advocating for a genuinely supportive care team before the birth date, and holding steady during labor when the pressure toward repeat cesarean comes — as it often does, and not always for clinical reasons.