Vaginal Birth After Caesarean
There are many reasons why it is important for some women to aim for a vaginal birth after having a caesarean (VBAC). The physical recovery after a vaginal birth, when compared to a caesarean, tends to be less complicated, more straightforward, safer and importantly, less painful. Statistics show that women who have vaginal deliveries are less likely to become depressed and more likely to breastfeed. There is also the significant issue, for many, of needing to feel they have done their best to achieve a “natural” birth.
Many women see the opportunity of having a VBAC as a chance to heal emotionally after a previous caesarean delivery. For some, this can be a traumatic experience and create real disappointment. Although the reasons can be very clear as to why a caesarean was necessary, dealing with the reality can be a separate matter entirely. Some women claim that by having a caesarean they felt disconnected from their baby’s birth, that it was “taken over” by the hospital staff and that they did not have the opportunity for an “authentic” birthing experience. Having a VBAC can do much to build a sense of empowerment.
In years past, it was routine for any woman who had had a caesarean birth to not be given any choice of delivery options for her subsequent babies. “Once a caesarean, always a caesarean” used to be the old adage because the risks of uterine rupture were too great. But this approach has changed over time in line with improved surgical techniques.
For some time now, the caesarean incision has been done into the lower segment of the uterus and horizontally e.g. from side to side whereas in the past, the uterus was cut vertically downwards. This meant that the uterine muscles were weakened along their entire length causing problems with the uterus contracting effectively. The lower segment of the uterus is not as involved in contractions, so the risks of rupture are reduced.
What are the chances of everything going well with a VBAC?
The estimate is that around 70-80% of women who attempt a VBAC are successful in achieving a vaginal delivery. This closely matches the incidence of any woman needing to have a caesarean section for any delivery. These numbers are realistic as long as there are no other complications and the reason for the original caesarean isn’t being repeated.
Current statistics show that around 83% of women will have a repeat caesarean section delivery though, rather than a VBAC. Although most women are aware of the possibility of having a VBAC, it does not always appeal.
Having a VBAC can be safer than a caesarean section delivery. This is especially the case if a woman is planning for more than two children and is likely to have repeated caesareans performed.
Around 1 in every 3 women in Australia currently has a caesarean section delivery. The aim of many maternity hospitals and obstetric care providers is to reduce this number.
What is a Uterine Rupture?
A uterine rupture is when the uterus separates and tears along the old incision line. Uterine contractions cause a stretching and thinning of the lower segment of the uterus and this causes stress on the weakened muscles. This is a medical emergency for both a mother and her baby.
Uterine rupture can happen either in the later stages of pregnancy, when the walls of the uterus become very thin, or when labour has already started. The risks are increased when a woman is carrying a very large baby, has a multiple pregnancy, or polyhydramnios.
Many studies have been done which have examined the incidence of uterine rupture following a previous caesarean section. In developed countries, the current risks are extremely low for rupture to occur and are estimated to be around 1%.
Reasons not to have a VBAC
- Personal choice factors strongly. Some women are not keen and are happy to have a repeat caesarean. This can suit their needs and requirements for all sorts of reasons.
- Some doctors are reluctant to support women to have a VBAC. Hospital policy can dictate VBAC procedures and the threat of litigation is a very real influence.
- If there are pregnancy complications such as eclampsia, breech presentation, multiple birth, gestational diabetes, prematurity, failure to progress in labour or a very large baby.
- If a mother has a vertical incision on her uterus from a previous caesarean section delivery. Occasionally, this is done when a baby is in distress as it is a quicker way of getting the baby out.
- If a woman previously had more than two caesarean section deliveries. This depends on the individual practitioner and the mother’s personal history.
Benefits of having a VBAC
- No extended recovery period – a caesarean section is a surgical procedure and carries associated risks.
- Less blood loss, risk of infection, pain and temporary loss of mobility as occurs with a caesarean.
- More bonding opportunities with the baby. Mothers who have a VBAC can start caring for their baby immediately after birth.
- Quicker onset of lactation. Mothers who have had a vaginal delivery can be more mobile and able to position themselves and their baby independently.
- Less time in hospital – mothers who have a VBAC can go home on the same day as long as there have been no complications.
- The emotional benefits of having a baby vaginally. For many women this is seen as a major sense of accomplishment, a more “natural” way of delivering their baby and gives them a sense of control and empowerment over how their baby is born.
- Babies who are born by caesarean section tend to have more breathing difficulties after birth. This is because they have not had the benefit of uterine contractions compressing their lungs, which helps to expel the amniotic fluid.
When a VBAC is not safe
- When a labour is not being carefully monitored by a midwife or obstetrician.
- During a homebirth; especially when immediate, back up emergency transfer to hospital has not been organised.
- If a pregnancy is complicated by other issues such as gestational diabetes, prematurity, hypertension or multiple birth.
- When labour is induced with synthetic hormones such as Syntocinon. Speeding up labour and increasing the intensity of the contractions increases the risk of uterine rupture.
- In women who are very large or overweight. Having a BMI over 30 increases the risks of complications.
- When a mother has her babies in rapid succession. Two consecutive caesareans under 12 months apart is not ideal.
- If the baby is not positioned head down. If it is breech or transverse, then the chances of having an uncomplicated VBAC are reduced. Ideally, the baby will be positioned head down; its body will be well flexed with its chin tucked into its chest and with its back towards the mother’s front.
Best chances of success with a VBAC
- Having had a previous, successful vaginal delivery.
- Not having a repeat of the reason why the original caesarean was necessary.
- If the reason for a caesarean in the past was because the baby was in a breech presentation.
- If previous caesarean was for placenta praevia.
- Having a baby at an institution where the success rates for VBAC are high.
- Going into labour spontaneously and at term.
Important facts to consider about VBAC
It is essential for each individual mother to consider her own risk factors. Consultation with her health care provider and making her own informed decisions regarding her delivery, form the basis for planning whether a VBAC will be suitable.
Although statistics can give an indication of safety and VBAC success, they do not cover every story. Staying informed and active in the decision making processes is very important.
What can I do to increase my chances of having a VBAC?
- Stay well during your pregnancy. Avoid gaining too much weight, do regular exercise and keep ante-natal appointments.
- Find a care provider who is supportive of you attempting a VBAC.
- Have a spontaneous onset of labour.
- Keep informed, read what you can and be an active participant in your own health care decisions.
- Talk to other women who have successfully had a VBAC. There are support groups available; both on-line and within communities. (Check contact information below).
What can make a VBAC as safe as possible?
- Keeping up a clear, open line of communication between yourself and your midwife or obstetrician.
- Be informed, educated and active in your own labour and delivery. Having a successful VBAC relies on involvement.
- Going to a maternity hospital where immediate help is available if needed.
- Make sure that the staff involved in your care and who are supporting you whilst you are in labour, are aware that you have had a caesarean section previously. Planning will need to be in place if you require an emergency caesarean.
- You being carefully monitored during your labour.
- Having your baby carefully and continuously monitored during your labour.
- Many maternity hospitals aim for VBAC delivery to have occurred within 12 hours of the onset of active labour.
Support is available through:
- www.canaustralia.net Caesarean Awareness Network Australia
- www.vbac.com VBAC Support Website.
For more information also check the WHO Systematic Review regarding the incidence of uterine rupture.