Special Procedures

Induction of labour

When the risk of leaving the baby in the mother is greater than if the baby is born, labour can be brought on artificially. This is known as induction of labour.

Depending on the readiness of the cervix, different methods can be used:

  • If the cervix is not ready, that is thick, firm and closed, prostaglandin preparations can be applied to the outer portion of the cervix.
  • If the cervix is very ready, that is thin, soft and already open to more than 2-3 cm, then simply breaking your water (amniotic sac) artificially can bring on labour.
  • After the cervix begins to dilate and soften, the most common way to induce labour is by an oxytocin infusion. This is given by intravenous (IV). It is connected to a pump and regulated by the nurse, to give the desirable strength and frequency of contractions. When switched off, the effects disappear quickly. It is, therefore, one of the safest methods.

Your doctor will review with you what is the right method for you.

We only do inductions when medically necessary. Inductions have not been shown to increase the rate of C-section. Learn more by reading a CMAJ research article.

Reasons you might need an induction

  • Being more than 7–10 days past your due date
  • Medical issue with the mother
  • Gestational diabetes on insulin
  • High blood pressure
  • A baby that’s not growing well
  • Concerns about the baby’s health
  • Your water has broken

If you are booked for an induction, you will be given a day, but not a time. On the day of your induction, the nurse will call and let you know what time to come in. If the labour floor is very busy you will be asked to come later in the day; if it is not that busy, you will be asked to come in the morning.

Remember, it can take 1–3 days from the start of induction to actually having the baby.


An episiotomy is an incision that is made at the opening of the vagina when:

  • More room is necessary to allow the baby to be born vaginally
  • When it looks like you might tear into your rectum, so a cut is made to divert the tear away from the rectum

Learn more about an episiotomy on the Mount Sinai hospital website.

An episiotomy is only done when necessary

The following situations increase the likelihood of needing an episiotomy:

  • First baby
  • Forceps birth
  • Large baby
  • Breech baby

Assisted vaginal birth

At the end of the first stage of labour, when the cervix is fully dilated, every mother should attempt to have a vaginal birth. The instruments commonly used for an assisted vaginal birth are the vacuum and forceps.


A vacuum extractor is connected to a small plastic cup that is put onto the baby’s head. The cup is applied to the baby’s scalp. The baby’s head will advance by the pushing efforts of the mother and the pulling efforts of the vacuum used by the doctor. Some tissue swelling on the baby’s head is common. It usually disappears within 1-2 days. A bruise or collection of blood under the scalp is an unusual complication, but not serious. Neither you or your baby can feel this; the feeling is the same as a spontaneous birth.


Forceps are spoon-like instruments that are placed on both sides of the baby’s head to guide it through the birth canal. Forceps allow a safe vaginal birth which otherwise would have resulted in a cesarean section. Sometimes attempts to deliver the baby still fail. To avoid excess force or injury to the mother or the baby, the doctor may recommend a cesarean birth. Forceps birth requires some form of anaesthesia. 

Reasons for an assisted vaginal birth

  • In spite of prolonged efforts of pushing, the baby’s head does not move down the birth canal
  • The mother is unable to push effectively
  • The baby or the mother’s medical condition may deteriorate if the birth is not imminent

Get more information from the Royal College of Obstetricians and Gynaecologists 

Cesarean section birth

A cesarean section is the birth of the baby through an abdominal incision. The objective of a cesarean section is to preserve the health of the mother and/or her baby when a vaginal birth is unsafe.

Most cesarean sections are done under spinal or epidural anaesthesia and the mother is awake (see anaesthesia for cesarean section). Your partner may be present for emotional support and to see the baby during the birth. An epidural blocks the pain, but you may still feel touch and stretching.

The baby is usually born within about 10 minutes and it take about 30-40 minutes to close the incision back up again. General anaesthesia may be necessary is it is an emergency situation, if the epidural is not working adequately or cannot be used. When general anaesthesia is used, the mother will not be aware of her support person, and therefore, this person is not usually permitted in the operating birthing room.

Reasons for a c-section

  • The baby’s head is too large to pass through the mother’s birth canal. There is no progress in cervical dilation or the baby does not come down into the birth canal despite good labour and effective pushing.
  • The mother has had a previous cesarean section.
  • The baby is not tolerating labour.
  • Unusual positions such as a breech presentation, transverse lie (baby lying sideways instead of up or down)
  • Placenta covering all or part of the cervix (placenta previa) or premature separation of the placenta (placental abruption)
  • Serious medical conditions which may affect the health of the baby
  • Induction of labour is unsuccessful or not possible
baby after birth

Preparing for an elective cesarean section

There are situations when your health care provider knows before labour that a cesarean birth is necessary. If you are having a planned cesarean birth, here are some suggestions:

In the weeks before your cesarean birth 

  • If possible, arrange for household help for several weeks after you come home with your baby
  • Pack your suitcase
  • If you go into labour before your scheduled cesarean section date, go to Labour and Delivery. Please do not eat or drink anything from the time you think you are in labour.

The day of your cesarean birth

  • Do not eat or drink anything, not even water after midnight.
  • Take a shower.
  • Do not wear any jewellery.
  • Arrive at Labour and Delivery two (2) hours before your scheduled cesarean time.
  • Your caesarean section is an elective procedure and delays are possible if any emergency occurs with another patient in the Birthing Centre. This will be communicated to you.

In the Assessment Room

  • Your nurse will ask you a few questions about your health.
  • During the admission process you will be given a hospital gown and asked to change into it prior to your surgery.
  • Your nurse will check your temperature, pulse, respiration, blood pressure and listen to your baby’s heart rate.
  • An intravenous (IV) will be started.
  • Your nurse will walk with you to the operating room and prepare for the birth.
  • The anesthetist will give you an anesthetic; a spinal is most commonly used.
  • Your nurse will insert a catheter into your bladder to keep it empty during the surgery.
  • In most cases, your support person is welcome to attend the operative birth. He/she will be asked to remain outside the room until you are comfortable with your anesthetic. Then he/she will sit at the head of the delivery bed to be a support for you. Other support persons will not be able to enter the recovery room and may be asked to wait elsewhere.
  • Your anesthetist may give you an ilioinguinal nerve block to provide additional pain relief after your cesarean section. Injections will be performed around your hip bone region while you are still frozen from the spinal or epidural. The medicine will freeze the area of the “bikini line” incision for a further 12–16 hours after the spinal/epidural has worn off. Side effects include transient leg weakness.

After the birth

  • When you reach the recovery room, your nurse will place your baby skin to skin and encourage you to hold your baby. Your nurse will also help you to start breastfeeding.
  • You will spend about an hour in the Birthing Centre’s recovery room and then you will be transferred to the Mother and Baby Unit.
  • Your baby will be with you in your room.
  • The nurses are always available to provide and assist with the baby’s care.
  • Expect to stay in hospital for 2-3 days.

Trial of labour after caesarean section 

What you need to know

When you have had a previous caesarean section you generally have two choices on how to deliver in your next pregnancy:

  • Trial of Labour after Caesarean Section (TOLAC): an attempt at a vaginal delivery. Most women will be successful and have a vaginal birth after caesarean (VBAC).
  • Elective Repeat Caesarean Section (ERCS): a planned repeat caesarean section (CS)

Overall, 50-80% of women who try will have a successful vaginal birth after c-section!

Are you a candidate for a TOLAC?

Most people who have had one previous CS can attempt a vaginal birth in their next pregnancy. You may not be a candidate if you have had:

  • Multiple CS
  • Previous classical CS (a longitudinal midline incision­) or uterine rupture
  • Pregnancy complications requiring a CS such as placenta previa or need for an urgent delivery
  • A CS less than 12 to 18 months ago

Increased change of successful VBAC if…

  • You have previously given birth vaginally
  • The reason for your previous CS is not a factor in this pregnancy (i.e. breech presentation, placenta previa)
  • Your labour begins on its own (spontaneous)
  • You are less than 40 years old with an uncomplicated pregnancy

Decreased chance of successful VBAC if…

  • You go past your due date
  • You are significantly overweight (body mass index > 40)
  • You need to have your labour induced
  • Your baby is estimated to weigh more than 4,000g (8lbs 13 ounces)
Baby in uterus

Reasons you may want to choose a TOLAC:

  • Shorter hospital stay, generally a quicker recovery, no activity restrictions (i.e. heavy lifting)
  • Desire to experience giving birth vaginally
  • Avoidance  of major abdominal surgery and the risks associated with ERCS (i.e. increased blood loss, infection, future surgical complications)
  • Greater chance of an uncomplicated birth in future pregnancies, as the risks of CS increase with each surgery
  • Earlier start to breastfeeding and better success with breastfeeding at three to six months
  • Lower risk of breathing problems in your baby immediately after birth

Reasons you may want to choose an ERCS:

  • Ability to plan the date and time of the birth and knowing what to expect based on past experience
  • Avoidance of labour and risks associated with TOLAC including risk of uterine rupture (0.5% with a TOLAC and 0.03% with ERCS)

Risk factors to consider

Risks associated with TOLAC:

  • Most common risk is requiring a CS during labour which has an increased risk of blood loss, surgical complications, and infection compared to an ERCS
  • Most serious risk is the scar on your uterus opening during labour (uterine rupture) which happens to 1 in 200 people who attempt a TOLAC (99.5% chance this will not happen), less if you have had a previous vaginal delivery
  • Uterine rupture can result in serious but extremely rare problems for your baby including death or brain injury (2-3 in 10,000 babies) or for you including increased bleeding or removal of your uterus (hysterectomy)

Risks associated with an ERCS:

  • Infection, bleeding, blood transfusion, and surgical injury to bowel, bladder, ureters
  • Increased risk of blood clots in lungs or legs around time of delivery
  • May require a CS for all future pregnancies
  • Each future CS carries increased surgical and pregnancy risks. The largest is the risk of an abnormal placenta in future pregnancies which may cause severe bleeding and require a removal of your uterus (hysterectomy) at your delivery
  • Death to the pregnant person is higher with a ERCS than a TOLAC but overall extremely low (0.013% with ERCS and 0.004% with TOLAC)

If you are planning a TOLAC:

Go to the Assessment Room in Labour & Delivery (2SE) if you are in labour or think your water has broken. When you are in active labour you will require continuous monitoring of your baby’s heart rate and regular cervical exams to ensure your labour is progressing safely. An epidural is encouraged in case a CS is required urgently. Oxytocin (a medicine to help give you contractions) can be safely used.

Can I have my labour induced if I had a previous CS?

Yes, although there is a small increase in the risk of the scar on your uterus opening (uterine rupture) during labour with an induction. The increased risk depends on the type of induction used and ranges from no risk up to double the risk (1.1% risk of rupture). There are methods to safely induce labour when you have had a previous caesarean section. This includes using a foley catheter (balloon) to open the cervix in early labour, breaking the waters and/or using oxytocin to give you contractions. Some people choose to have an induction of labour if they do not go into labour on their own while others choose to have a repeat caesarean section if they will require an induction.

If you are planning an ERCS:

You should discuss with your care provider what you want done if you go into labour before your scheduled ERCS. Going into spontaneous labour increases your chances of having a successful vaginal birth and many people who planned a CS will try a TOLAC if they go into spontaneous labour.

Key points about choosing between TOLAC or ERCS:

  • TOLAC and ERCS are safe options for future delivery after a CS as there is a very low risk of serious harm to you and your baby with either option
  • Successful TOLAC (VBAC) has the least complications for you and your baby while an unsuccessful TOLAC has the most risk for complications
  • TOLAC and ERCS are safe options for future delivery after a CS as there is a very low risk of serious harm to you and your baby with either option.

Making a decision

You may find it helpful to use the table below as you decide whether to plan a TOLAC or ERCS. Add checkmarks beside reasons you would choose a birth option based on what benefits and risks matter most to you. You can also add other reasons that are important to you.

❒❒❒ Doesn’t matter     ❒❒✓Only a little.    ❒✓✓Matters somewhat    ✓✓✓Matters a lot

Reasons to plan a trial of labour after caesarean section (vaginal birth) How much does it matter to you?Reasons to plan an elective repeat caesarean section How much does it matter to you? 
You have a greater chance of having a vaginal birth❒❒❒You can know the date your baby will be born❒❒❒
You have a greater chance of having an easier recovery and no heavy lifting restrictions❒❒❒You know what to expect from surgery❒❒❒
You have a smaller chance of surgical complications❒❒❒You have a smaller chance of having a tear in the scar on your uterus (rupture)❒❒❒
You have a greater chance of having uncomplicated future pregnancies/deliveries (fewer placenta problems)❒❒❒You avoid the risk of an emergency CS❒❒❒
You have a greater chance of having your baby with you after the birth (less admission to the nursery or NICU)❒❒❒You can book your CS with your obstetrician❒❒❒
  You have completed your family and you have decided to tie your tubes❒❒❒
 ❒❒❒ ❒❒❒


Learn more by watching our informative videos on YouTube, titled “Southern Ontario Obstetrical Network

References: See the document below that includes references that informed the content on this page:Trial of Labour after Caesarean Section (PDF)

TOLAC information translated

Breech birth

When the buttocks, knees or feet of the baby settle down into the mother’s pelvis, this is called a breech presentation. About 3-4% of all deliveries are breech births and in 1/3 of all twin births, at least one baby will be in a breech presentation. It is also most common in premature births.

A vaginal breech birth is more difficult and risky as the head which is the largest part of the baby is delivered last. Only very few obstetricians are trained in vaginal breech delivery and these are only done under certain circumstances. Speak to your doctor about which delivery is option is right for you.

Options when your baby is breech

  • Elective c-section
  • External cephalic version
  • Accupuncture
  • Vaginal breech delivery

Read about breech childbirth (The Society of Obstetricians and Gynaecologists of Canada). 



Twins occur in 1 out of 90 births. In fraternal twins, two separate eggs are fertilized. In identical twins, a single fertilized egg divides into two fetuses. Fraternal twins are more common. The use of fertility drugs, which stimulate ovulation, increases the chance that more than one egg will be released, and results in an increased chance of fraternal twins.

Certain complications are more likely to occur in twin pregnancy, such as premature birth, high blood pressure and smaller babies. During such pregnancies, it is advisable for the mother to limit excessive activity. Your health care provider can provide you with guidance about your appropriate activity. Ultrasound examinations are necessary to check the growth of the babies. More visits to your health care provider will be needed to detect early complications. 

Delivering twins requires complex decision making. Such factors as gestational age, position, condition of the babies and mother all need to be considered. The chance of having a cesarean section is increased. Multiple births always take place in the Operative Birthing Room, in case an emergency should arise with the babies or the mother. A paediatrician and respiratory therapist are always present at these births.