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Vaginal Birth After Caesarean

Monday, March 24, 2008
Image: Snapper Media

Can we? Should we? Will we?

There are many reasons a woman may want to have a vaginal birth after a caesarean (VBAC). Some of these reasons are to avoid the physical effect of a caesarean section and others are the emotional desire to give birth vaginally to a baby. Becoming pregnant after a previous caesarean section can be a time of worry for women. They may not know where to turn for balanced information or support. Every woman wants to do the best thing for herself and her baby when it comes to the birth.

According to the latest Australian statistics, nearly one in three (30.3 percent) women giving birth in Australia have a caesarean. The reality is many women who have a caesarean will go on to have another baby. While we know the likelihood of a woman having a successful VBAC is between 70 and 80 percent, in Australia around 83 percent of women will have a repeat caesarean. This varies between hospitals and even states and appears to be more to do with the attitude of doctors and institutions to VBAC than the abilities or desires of women to have a vaginal birth.

Why are some doctors reluctant for women to have a VBAC?
The main reason behind the decline in VBAC is the risk of litigation. A couple of successful malpractice suites involving VBAC have made obstetricians nervous. The fact they rarely get sued for doing a caesarean makes VBAC seem like a safer option for them. If safety guidelines are followed the reality is VBAC is as safe as planned caesarean for the baby, safer for the mother, and much safer for both during future pregnancies.

The facts

  • Most women can birth vaginally after a caesarean (70-80 percent). This is about the same chance of having a vaginal birth as a woman having her first baby.
  • With proper care and caution, VBAC is equally safe for the baby and safer for the woman.
  • Inappropriate obstetric management, especially the induction and speeding up of the labour makes VBAC most dangerous for women and their babies.
  • Caesarean section, especially multiple caesarean sections, increases risk to women and babies.
  • Women are more likely to breastfeed successfully after a vaginal birth and less likely to be depressed.

Who is a candidate for VBAC?

  • If you have had a low transverse incision on both your abdomen and uterus then you are a good candidate for a VBAC.
  • Having your baby with its head pointing downwards and wanting a VBAC increase your chance of success.
  • Women who have had two previous low-transverse caesarean sections can consider a VBAC, but the risk of uterine rupture increases.
  • Women who have had a vaginal birth at least once before or after their previous caesarean are the most successful candidates for a VBAC.

What are the risks of repeat caesarean section?
Compared to VBAC, caesarean section carries different risks for both the mother and baby, such as:

  • Increased pain and a longer recovery period.
  • Increased risk of infection, injury to other organs, bleeding, and blood clots.v
  • Increased likelihood of having a hysterectomy (need to remove the uterus).
  • Increase risk of infertility, miscarriage, placental abruption (placenta detaching before the birth), placenta previa (placenta overlaying the cervix), placenta accreta (placenta grows through the muscular wall of the uterus) and ectopic pregnancy (where the embryo implants outside the uterus) occurring in future pregnancies.
  • Increased likelihood of negative emotions, postpartum depression and post-traumatic stress syndrome. v
  • Increased difficulties bonding with the baby and breastfeeding.
  • Lower chance of becoming pregnant again.
  • Higher incidence of stillbirth in the next pregnancy.
  • Increased chance that babies need admission to neonatal intensive care units for breathing problems.
  • With a caesarean the risks increase with each surgery whereas with VBAC the risks decrease with each birth. For this reason women planning to have several children should seriously consider having a VBAC.

What are the risks of a VBAC?
The reality is neither a repeat caesarean or trial of labour is risk free. Many of the scary articles about the dangers of VBAC are misleading and don't follow women into future pregnancies and measure the ongoing risks of more caesareans.

  • When VBAC is successful, it is associated with fewer overall problems than a repeat caesarean delivery — when it is not the risks being to rise.
  • The greatest risk of a VBAC is uterine rupture (the old scar line on the uterus coming apart). Sometimes this happens before the onset of labour, but having contractions increases the likelihood of uterine rupture.

How can VBAC be made safer?

  • Inducing or speeding up labour with synthetic hormones increases the risk of the uterus rupturing, so this should be avoided wherever possible.
  • Having an epidural increases the likelihood of needing a caesarean as well as the need for the labour to be sped up, so it is best to avoid them if possible.

Planning for a VBAC
There are several things you can do to increase your chances of a successful VBAC:

  • Eating a balanced diet, exercising and educating yourself are important.
  • Pick your support people carefully and make sure they are in tune with what you want and are committed to helping you achieve your goals.
  • Take responsibility for your pregnancy and birth and don't hand this over to anyone.
  • Be prepared to stand your ground, and remember you make the decision and live with the experience.
  • Work on the fear you will have and prepare yourself and your support people for the critical times in labour where it is hard to stay positive, such as when you reach the point you ''got stuck'' last time, or you arrive at the hospital and all those memories of the last birth come rushing back.
  • Choose a midwife or obstetrician who supports your choice.
  • Talk to women who have experienced VBAC.
  • Check out ICAN Vaginal Birth After Caesarean Checklist for more information.

Having a VBAC feels like you are embarking on a marathon. It takes lots of hard work but when you get to that finish line most women discover it really is worth it!

VBAC Resources

Useful Websites:

Useful books and pamphlets:

  • Silent Knife by Nancy Wainer Cohen and Lois J Estner
  • Open Season by Nancy Wainer Cohen
  • The VBAC Companion by Diana Korte
  • Birth Choices by Allison Shorten

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