Pregnancy, Birth and Beyond

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Vaginal Birth After Caesarean

There are many reasons why a woman may want to have a vaginal birth after a caesarean. Some of these reasons are to avoid the physical impact of caesarean section and others are the emotional desire to give birth vaginally to a baby.

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Pregnancy - Contiplating a VBAC

“When Belle was born I went through such a mixture of emotions,” says Angela. “On the one hand I had this beautiful baby, and should have been so grateful, but on the other hand I had all this grief about what I had missed out on and what could have been. When people asked me about the birth I would say ‘I had to have a caesarean’ and they would often say ‘what a shame’. You know all I heard when they said that was ‘shame on you.’ It was silly, I know, but I yearned for a normal birth. It actually obsessed me.” Looking back Angela sees things more in perspective now but she believes it took the normal vaginal birth of her son Sam two years later to make her let go of the pain surrounding that first birth. “Birthing Sam was such a pinnacle in my life,” she says. “I felt so powerful after that, I felt I could have literally done anything. I mean vaginal birth isn’t the only way to have a baby, I know that, but it is important to many women and that needs to be acknowledged.” 

There are many reasons why a woman may want to have a vaginal birth after a caesarean. Some of these reasons are to avoid the physical impact of 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.

More than 1 in 4 women giving birth have a caesarean in Australia. This varies depending on where a woman gives birth and whether or not she has private health insurance. For women who give birth in public hospitals the caesarean section rate is around 23 percent compared to nearly 34 percent for women who give birth in private hospitals. Many women who have a caesarean will go on to have another baby. For them the choice of having a vaginal birth after a caesarean (VBAC) or having a repeat caesarean may be difficult. While we know the likelihood of a woman having a VBAC is between 60 and 80 percent, in Australia around 25 percent of women have a VBAC. 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 VBACs?

Since the early 1980’s the rate of VBAC has risen steadily as research showed its safety and women voted with their feet. In the mid 1990’s there was an increase again in the promotion of elective repeat caesarean by doctors as a safer option. The increased safety of caesarean section over the years has certainly made this a more reasonable option for women. The main reason behind the decline in VBAC, however, is the risk of litigation. A couple of successful malpractice suites involving VBACs made obstetricians nervous and the fact they rarely get sued for doing a caesarean makes VBAC 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 any future pregnancies.

Who is a candidate for VBAC?

The facts

1. Most women can birth vaginally after a caesarean (60-80%)
2. With proper care and caution, VBAC is equally safe for the baby and safer for the woman
3. Inappropriate obstetric management, especially the induction and speeding up of the labour contributes to increased morbidity to women and their babies.
4. Caesarean section, especially multiple caesarean sections, increases risk to women.
5. Women are more likely to breastfeed successfully after a vaginal birth and less likely to be depressed.

If you have had a low transverse incision on both your abdomen and uterus then you are a good candidate for a VBAC. Caesarean incisions are divided into two main types: classical (up the middle of your abdomen) and lower segment (along your bikini line). Lower segment caesarean sections are the most common incisions used. Having your baby with its head pointing downwards and wanting a VBAC are also important prerequisites. Women who really want a VBAC are more likely to be successful. Women who have had two previous low-transverse caesarean sections can consider a VBAC. The risk of uterine rupture increases with the number of previous caesareans. Women who have had a vaginal birth at least once before or after their previous caesarean are the most successful candidates for VBAC.

What are the potential benefits of a VBAC?

Caesarean section results in more pain and a longer recovery period for women compared to a vaginal birth. It increases the risk of infection, injury to other organs, bleeding, and blood clots. These complications increase the likelihood of a longer hospital stay, hysterectomy (need to remove the uterus), readmission to the hospital, and the mother dying (2-11 times greater).

The more caesareans you have the more scar tissue builds up. In the future, caesareans can lead to chronic pain or bowel problems. They also increase the risk of infertility, miscarriage, placental abruption (placenta detaching before the birth), and placenta previa (placenta overlaying the cervix). With placenta praevia the risk seems to double with each successive caesarean. The risk of placenta accreta (placenta grows through the muscular wall of the uterus) also increases with each caesarean and is potentially life threatening for the mother and baby. The more caesareans you have the higher the risk of ectopic pregnancies (where the embryo implants outside the uterus) occurring in the future.

One in ten women report problems with normal activities two months after a caesarean, and one in four report pain at the operation site as a major problem. Around one in fourteen women still report pain around the operation site six months or more after the caesarean.

Women who have caesareans are more likely to experience negative emotions about the birth and develop, postpartum depression or post-traumatic stress syndrome. Some mothers express feelings of fear and anxiety about their caesarean as long as five years later. This is particularly so if the caesarean is unplanned. Mothers are more likely to have difficulties bonding with the baby. This may be because women are less likely to hold and breastfeed their infants after a caesarean and have difficulties caring for a baby while recovering from major surgery.

Women having caesarean sections are less likely to decide to become pregnant again. Whether this is mainly due to choice, the trauma of the experience or a secondary infertility following the procedure is still being investigated.

Babies born by caesarean are also more likely to have breathing problems needing admission to the intensive care unit. The risk of life threatening respiratory distress syndrome in babies born by caesarean section is around seven times higher than for a vaginal birth and this increases the earlier in the pregnancy the caesarean occurs. Having some labour before the caesarean section reduces your baby’s risk of respiratory distress syndrome. One to two babies per 100 will also be accidentally cut during the surgery.

The real message health professionals should be heeding is not to preform more repeat caesareans but preform fewer first caesareans. Sadly, once you have a scar on your uterus the subsequent pregnancy becomes more risky whatever you choose. Preforming more caesareans does not eliminate this risk but adds more risk to the subsequent pregnancy.

What are the potential harms of a VBAC?

The reality is neither a repeat caesarean or trial of labour is risk free. When VBAC is successful, it is associated with less overall problems than a repeat caesarean delivery. 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.  A low transverse incision holds the lowest risk of subsequent uterine rupture and is the most common caesarean performed. Uterine ruptures are more likely to occur if the labour is induced or sped up.

A recent study, sensationalised in the media, made VBAC seem like a very dangerous option for the baby. The reality was the risk of a baby dying with a VBAC was 4 in 10,000 at term. The risk with an elective caesarean was 1.4 in 10,000. Some women in the VBAC group may have had a stillbirth and been encouraged to give birth vaginally rather than have a caesarean, making these statistics hard to make any sense of. Let’s put this in perspective. The chance of losing a baby following an amniocentesis is around 1 in 200 procedures. No one is recommending banning amniocentesis; in fact, many doctors are encouraging of this procedure. Many of the scary articles about the dangers of VBAC are completely misleading and don’t follow women into future pregnancies and measure the ongoing risks of more caesareans.

How can VBAC be made safer?

If your labour needs to be induced with synthetic hormones like prostaglandins or oxytocins you need to consider the fact that the scar of the uterus is more likely to open up. Labour should never be induced unless the risks of the pregnancy continuing outweigh the risks of inducing the labour.

We know using epidurals increases the caesarean section rate and 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. As with any pregnancy eating a balanced diet, exercising and educating yourself are important. Getting a copy of your previous birth medical records and asking your health provider to explain anything you don’t understand will help you make an informed choice and also clarify the reason for the caesarean.

You need to 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. Most important take responsibility for your pregnancy and birth and don’t hand this over to anyone.

Going into labour after a previous caesarean can be an emotional experience. There are all the expectations and fears that you bring to the experience to deal with, let alone the reality of labour. Women often point to critical times in the labour where it is hard to stay positive, such as when you reach the point you ‘got stuck’ last time, or when your water breaks. Arriving at the hospital can also bring memories of the last birth rushing back. You may be afraid of labour, especially if you had a long or frightening experience the first time. You may also feel that caesarean section feels familiar to you and therefore safer.

Some women are very excited about the thought of a VBAC, while others feel forced into having a VBAC by their care provider. You may encounter resistance from people that are either very for a VBAC or very against it. Be prepared to stand your ground, and remember you make the decision and live with the experience. Talk to women who have experienced VBAC and the health professionals who care for you.

Can you have a good repeat caesarean?

Some women would rather have a repeat caesarean, than deal with the worry of attempting vaginal birth that could end in a caesarean anyway. Women who choose a repeat caesarean often find the experience less distressing than the first one as they are prepared and feel more in control. You can have a good caesarean birth when you are informed and in control of the decision.

Support and counselling

Some women feel very upset over their first caesarean. They may feel cheated or somehow not a ‘real woman’ because they did not give birth vaginally. These are very real emotions and need to be explored and dealt with rather than bottled up. There are many support groups available throughout Australia that you can contact (see below).

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!

Resources

Useful Websites:


Useful books and pamphlets: