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Vaginal Birth and Cesarean Section

The goal of delivery is to have a healthy mother and baby. Roughly 70% of all women in the US deliver vaginally. Vaginal delivery includes four stages of labor from initial cervical dilation until one hour after delivery of the placenta. When problems arise during delivery it may sometimes be necessary to look toward other forms of delivery or some means of assisting a vaginal delivery already in progress.

Cesarean section or c-section is the surgical procedure used to deliver a baby through incisions in the walls of the abdomen and uterus. There are several indications for c-section including failure to progress, failed induction of labor, abnormal uterine contractions, eclampsia, diabetes, heart disease, previous uterine rupture, previous classic (vertical incision) cesarean section, fibroids, fetal distress, breech presentation, or placental abruption.

  • Cesarean Section
    There are two main types of c-section:

    Low transverse cesarean

    The low-transverse procedure is performed the majority of time because it does not involve an incision in the uterine muscle wall, but rather in the fibrous lower segment of the uterus. This reduces the risks of bleeding, infection and bowel adhesions; it also may allow the mother to deliver a second pregnancy vaginally.

    Classic cesarean

    This involves making an incision vertically (up and down) through the muscle wall of the uterus. Some strong indications for the use of classic c-section include a premature fetus, certain fetal presentations, uterine fibroids, or cervical cancer. Although this technique can make it easier to deliver the baby, the risk of future complications is higher, and would prohibit vaginal delivery in subsequent pregnancies.

    Risks associated with cesarean delivery

    There is an increased risk of maternal complications with c-section over vaginal delivery, generally due to the risks of anesthesia and surgery, such as bleeding, infection, pneumonia, and injury to other organs such as the bladder or bowel.

    Your obstetrician will advise you on the need for a cesarean section taking into consideration the risks and benefits for you and your baby. Your clinician is best prepared to answer your specific questions about the need for cesarean section.

  • Labor stimulants

    Labor stimulants are medications and/or methodologies used to start or progress labor. While medications are one way to induce labor, natural ways to stimulate labor include bowel preparation (castor oil or enema), breast stimulation and sexual activity that include female orgasm. These measures may work favorably to “ripen” or soften a cervix or to help induce labor. All of them may have a role in releasing prostaglandin and oxytocin which stimulate contractions. While there is some evidence that these measures may be effective, you should always discuss the appropriate use of these measures with your clinician.

    There are different types of medication used to help ripen or soften the cervix, to get labor started called induction, or to help supplement or augment contractions. The following describes medical approaches to stimulate or enhance labor.

    Induction of labor

    Induction means that labor is artificially begun by the use of medication. This may be undertaken when the risk of continued pregnancy is greater to the mother or fetus than the risk of delivery. Such cases would include pre-eclampsia, heart disease, diabetes, Rh-incompatibility, fetal abnormality, premature rupture of membranes, or post-term pregnancy. Some conditions that preclude induction of labor include previous uterine surgery that cuts through the uterine wall, acute fetal distress, a premature fetus with immature lungs, and an abnormal fetal presentation such as a breech.

    If your cervix has not begun to soften and thin, your clinician may try to “ripen” it with medication before induction of labor. Inductions tend to work more favorably (less time in labor and less chance of a cesarean section) with a soft, thin cervix. Medications administered as vaginal suppositories, act by releasing concentrated doses of prostaglandin directly into or around the cervix. Prostaglandins may initiate spontaneous labor so use of prostaglandins requires careful monitoring of you and your baby. You will have fetal monitoring and vital signs taken frequently to assure that both of you are tolerating this medication. Prostaglandins can cause strong uterine contractions, which may not be tolerated by the baby.

    Oxytocin is the hormone that controls uterine contractions and assists with milk production. Giving oxytocin (Pitocin) through an IV induces labor by stimulating uterine contractions. With oxytocin, you and your baby will be closely monitored to be sure that you both are tolerating the medication. Amniotomy, or rupture of membranes, may also be used to help induce labor. Occasionally complications can occur such as prolonged uterine contraction causing fetal distress, severe water retention, and uterine muscle exhaustion, which may lead to increased postpartum bleeding. Your obstetrician or midwife will be best prepared to help you make decisions regarding the need for induction of labor.

  • Rupture of membranes

    This is what is meant by the expression "my water broke." The amniotic sac opens and releases the amniotic fluid, either in a trickle or a gush. This can sometimes be the first sign of labor though in most cases, contractions and cervical dilation may start before the membranes rupture.

    Many women are not always sure if they’ve actually broken their water; here are some differences to help sort this out:

    • Urine is yellow and amniotic fluid is clear to straw colored; in a few cases amniotic fluid may be greenish brown
    • Amniotic fluid does not smell like urine

    Empty your bladder, put on a clean sanitary pad and lay down for about thirty minutes. If you have broken your water, when you stand up your pad will be moderately soaked from the amniotic fluid that has pooled in the vagina.

    If the membranes rupture before the onset of labor it is called premature rupture of membranes (PROM). If you think that your membranes have ruptured, notify your clinician immediately; most likely you will be directed to come to the office or your birthing center.

  • Vaginal Birth after Cesarean Section (VBAC)

    It is possible to deliver vaginally after having had a c-section with a previous pregnancy. Your provider will discuss whether or not you are a good candidate for a trial of labor after a cesarean delivery, or VBAC candidate. Success rates for VBAC range from 60-80%. If problems arise during this trial of labor, the baby may need to be delivered by c-section. The biggest risk for any vaginal delivery whether or not you’ve undergone a previous cesarean section, is uterine rupture. This occurs less than 1% of the time but is a medical emergency for both the mother and baby.

    Favorable Factors increasing the success of VBAC are:

    • Previous vaginal delivery
    • Going into labor naturally as opposed to having labor induced
    • Reason for previous c-section is not likely to recur, such as breech presentation or fetal distress

    Unfavorable factors decreasing the success of VBAC are:

    • Being overweight
    • Pregnancy beyond 40 weeks
    • High birth weight of the baby
    • Pregnancy induced hypertension
    • Short time span between pregnancies

    Remember the benefits of vaginal birth versus surgical birth when making this decision, – these include:

    • Faster recovery time
    • Shorter hospital stay
    • Prevention of potential complications of surgery including blood loss, infection, anesthesia risks, injury to bowel and urinary tract, blood clots in the leg, and death (maternal death rate is 18.4 per 100,000 for cesarean section which is twice the rate for vaginal birth)
    • Easier time with breastfeeding without an abdominal incision
    • Emotional benefits of successful vaginal birth.

    If you are interested in VBAC, begin this discussion with your clinician early in your pregnancy.

  • Breech presentation

    Breech presentation is one of the atypical positions a baby may present with at term. “Mal-presentations” are fetal positions at delivery other than headfirst in the birth canal. These include -- transverse lie, where the baby is lying horizontally; footling, where a foot is the presenting part; and breech where the buttocks or feet are presenting first.. Before 28 weeks up to 25% of fetuses are in breech position, but by 34 weeks most have rotated into the vertex (headfirst) position.

    Common causes for breech include prematurity, multiple gestation (twins or triplets), low birth weight, fetal abnormalities, and uterine abnormalities. Breech presentations can be diagnosed by examining the uterus (feeling for fetal parts by pushing on the uterus) as well as by ultrasound. If a breech is found after 37 weeks but before labor begins, the baby can sometimes be turned around while in the uterus, a procedure called external cephalic version. The advantage of this procedure may mean that the baby can be delivered vaginally in vertex position.

    Version is successful up to 75% of the time. Medication is given first to relax the uterus before your clinician and his/her assistant attempt to turn the baby around by pushing the abdomen in specific ways. Fetal monitoring and ultrasound often are used to monitor the fetus. Version does carry a slight risk of umbilical cord compression and placental abruption or separation, both of which would require immediate c-section. Therefore version is done close to the delivery room or birthing center as a precautionary measure.

    Under certain conditions it is possible to deliver a breech vaginally. This requires a number of factors to be highly favorable; factors include fetal size, position, age and stability, as well as adequately sized maternal pelvis and experience of the obstetrician. If any of these factors is questionable, the breech generally will be delivered by cesarean section. The reason is that the baby's head is the largest part of its body. If the rest of the body is delivered first and the opening is too small, the head may become stuck. This will necessitate emergency cesarean section and poses potential complications to the newborn.

  • Forceps delivery

    Forceps are spoon-like instruments connected at a handle that are commonly used to assist delivery if there is a slow down during the pushing stage. Forceps are used to gently pull the baby's head down through the birth canal and the rest of the baby is delivered normally. Indications for use include lack of adequate rotation of the fetal head or abnormal uterine contractions. Some disorders in the mother, like high blood pressure, heart and lung diseases, may make the use of forceps necessary to prevent the mother from straining too hard during pushing.

    An episiotomy usually is performed prior to using forceps to allow extra room for both the instruments and the baby’s head to pass easily. Forceps can be used only if the baby is headfirst and there is adequate room in the maternal pelvis. Complications can sometimes arise from the use of forceps that include trauma to the birth canal and bruising to the baby which goes away after a few days. Ask your health care provider if you have questions about the use of forceps.

  • Vacuum extraction

    Vacuum extraction is another method used to assist during the pushing stage of labor. This device basically is a suction cup that is attached to the baby's head to help gently pull the baby out of the birth canal using controlled low-level suction pressure. Some advantages of vacuum extraction over the use of forceps include the need for a smaller episiotomy, and the ability to select which part of the head presents first, allowing for the smallest diameter possible.

    It is not used in premature deliveries because of the risk in harming the baby's immature scalp or head from the suction. Sometimes there can be trauma to the vaginal wall or swelling of the fetal scalp, which goes away in about one week. If you have further questions about vacuum extraction, ask your clinician.

  • Episiotomy

    An episiotomy is an incision made in the perineum (area of skin between the vaginal opening and the rectum) during delivery to enlarge the opening for the baby. About 50% of all women who delivery vaginally will have an episiotomy.

    Whether or not you need an episiotomy will depend on the amount of tissue in your perineum, size of the baby, as well as you and your clinician’s preferences.

    Research on the use of surgical episiotomy versus natural tearing shows pros and cons for both methods. The decision to opt for a surgical episiotomy over a natural tear must take into consideration your desires for a low intervention birth, maternal and fetal factors that may necessitate a quick birth and your clinician’s experience in repair of a natural tear.

    An episiotomy is performed by first administering a local anesthetic to reduce pain from the episiotomy. It is surgically repaired after the birth of the baby and before the delivery of the placenta. There is a risk of wound infection, which can be greatly reduced by keeping this area clean. If infection does occur, it can be easily treated with antibiotics.

    There are a two natural ways, perineal massage and warm soaks that may help reduce the need for episiotomy. Perineal massage may be done after 36 weeks by gently stretching the vaginal opening with your thumbs while using a lubricant. Perineal massage combined with warm soaks during labor helps perineal tissue stretch and relax, avoiding or reducing tearing at delivery. Ask your obstetrician or midwife about using perineal massage and warms soaks, and episiotomy during labor.

  • Stages of labor

    There are four stages of labor during vaginal birth. Not all will be readily apparent to you during labor but your clinician might use these descriptions to explain what is happening.

    The first stage

    The first stage starts with the onset of labor and ends with the fully dilated cervix. It is divided into two phases, latent and active. The latent phase consists of early cervical dilation (widening of the cervical opening) and effacement (shortening of cervical length) that takes place at a slow rate until the cervix is 3-4 centimeters wide. During the active phase, cervical dilation continues at a faster rate until the cervix is fully dilated (10 cm). Duration of the first stage of labor is highly variable. Generally, first time mothers can expect it to last 6-18 hours, while those with prior deliveries should expect 2-10 hours in the first stage.

    As long as you and the baby are physically stable during the first stage, you will be allowed to walk around, shower, use tubs if available, sit, rock, and have sips of clear fluids, ice and popsicles. You may have either an IV or an IV access plug (heplock) for IV medications. This is a precaution/safety net in case of a medical emergency, but also is helpful in giving pain medications and extra fluids. Your pulse, blood pressure, temperature, respiratory rate and the baby’s heart sounds will be monitored periodically to make sure things are going well. Examination of the cervix will be periodic according to how labor progresses.

    The second stage

    This stage begins when the cervix is fully dilated and you feel the urge to push. Each contraction moves the baby’s head, and body as it bends and flexes to get through the birth canal. Sometimes the baby even needs to rotate from back to front to achieve a headfirst, face down position. For first time mothers, this stage can last from 30 minutes to three hours, while for those with previous deliveries it may take only 5-30 minutes.

    During this stage you will be pushing with each contraction. The baby’s heart rate will be monitored to make sure there is no distress during contractions. Crowning means that the baby’s head has begun to emerge from the birth canal. When necessary, an episiotomy (surgical incision to widen the vaginal opening) may be performed to allow extra space for the head to pass through the perineum (area between the rectum and vagina). After the head is delivered the baby’s nose and mouth will be suctioned to remove any fluid and mucus. The mucus protected the baby while it was surrounded in amniotic fluid. A check is done to make sure that the baby’s neck is clear of the umbilical cord.

    Shortly thereafter the rest of the baby will be delivered and the cord will be cut ending the second stage of labor.

    The third stage

    The third stage involves delivery of the placenta. After the baby emerges, you will be examined for any tears that need to be repaired; local anesthetic will be used to numb the area. Within 5-10 minutes the placenta starts to separate and will be delivered by gentle pulling of the umbilical cord and pressing down on the uterus. You will feel contractions as the uterus clamps down to stop the bleeding.

    The fourth stage

    This stage lasts for one hour following delivery of the placenta. As the uterus contracts to begin returning to its normal size, there will be bleeding. During this stage you will be closely monitored to assure your recovery from delivery. Your pulse and blood pressure, uterine size and tone, and bleeding will be checked closely for 6-10 hours after delivery.

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