Had a caesarean? You’ll need one for any other births, right?

Wrong!

After the birth of my son by emergency caesarean, I could not believe how many people automatically assumed I would have an elective caesarean with my next pregnancy.

So many people believe that once you have one caesarean section that you are then required, you must, have a caesarean section for any other births. While this was often the case back in the ‘olden’ days, but with the way caesareans are performed now, it’s a different story. A vaginal birth after caesarean section (VBAC) is a very real option today for many women and families.

A woman’s uterus is made up of two sections, a lower section and an upper section. Most caesareans performed here in Australia are called lower uterine segment Caesarean section (referred to as a LUSCS). A LUSCS is a horizontal cut, low down near the public line, only making an incision in the lower section of the uterus. If a woman has had a classical incision Caesarean section (very uncommon these days) this means that a vertical incision has been made through both the lower & upper segments of uterus.

I will be referring to statistics and information regarding VBAC in relation to one previous LUSCS only. The statistics and risk factors do change for women wishing for a VBAC after 2 or more previous caesareans.

The VBAC success rate here in Australia is approximately 70%, with huge variation due to a number of factors including previous VBAC or vaginal birth, BMI, place of birth & nationality.

Currently in Australia, vaginal birth rates are approximately 70% in non VBAC women. Therefore leaving women wishing for a VBAC approximately the same chance of achieving a vaginal delivery as non VBAC birthers.

 

Why would you want a VBAC?

There are many reasons why women would want to have a VBAC. There are both physical and emotional reasons, and both are equally valid. Many women can be left feeling traumatised, or have feelings of being ‘ripped off’ following a caesarean section-especially if it was unplanned.

There are also some physical benefits for most women birthing vaginally, such as less pain post birth, quicker recovery, easier to look after other children and baby and a shorter hospital stay. The evidence suggests that women who have a vaginal delivery have better breastfeeding outcomes, mainly due to being able to have immediate skin to skin and having less blood loss at birth (normal vaginal blood loss approx. up to 500ml, normal expected blood loss in caesarean up to 1000ml).

Are there any risks of VBAC?

As with everything in life there are always pro’s and con’s. Birth, and mode of delivery are no different. It is so important that we are informed of the risks of VBAC while it is equally important to be informed of the risks for a repeat caesarean also.

One common risk factor discussed when attempting a VBAC is uterine rupture. This is where the uterus ‘gives way’, partially or fully ruptures, often on the previous scar line, as that tissue and muscle is slightly weakened by the previous incision. The evidence on this varies but RANZCOG (Royal Australian and New Zealand college of Obstetrics and Gynaecology) state that this risk is approximately 5-7 for every 1000 VBAC attempts (or 0.5-0.7%).

The risk of uterine rupture is 0.1-0.2% for women who have not had a previous caesarean. Of the 0.5-0.7% of women that suffer a uterine rupture a very small amount of babies will suffer brain damage or death (1 in 7 of the 0.5-0.7%), which is comparable to any first time labour.

If an induction is required, then the risk of uterine rupture increases by 2-3 times, and the risk of needing an emergency caesarean increases by 1.5.

 

What if I want an elective caesarean?

Of course, this is a choice that you can make. A very real choice that you may choose. Just like women wanting a VBAC, many women decide that an elective caesarean is the right option for them. The positives of having an elective Caesarean is a decreased risk of blood loss compared to requiring an emergency caesarean, and there is a reported decrease in pelvic floor issues. The families emotional state must also be considered, and some will feel that a planned caesarean is the best option for them.

Like I mentioned before, with every decision we make there are pro’s and cons. I believe that it is absolutely vital that we always know the pros, cons and alternatives of all procedures so we can make the best decision for our unique family and situation.

Caesarean section is major abdominal surgery. There are always risks involved with major surgery, including DVT, blood loss and infection rates post Caesarean are approx. 5.2%.

There is also another risk factor with Caesarean section, placenta accreta. Placenta accreta is where the placenta attaches and grows into the uterine wall, typically where a previous scar line is. This is a very big concern for women, families and care providers. It can cause major bleeding, increasing the risk of requiring a hysterectomy at delivery & problems in future pregnancies. After the 1st c/section the risk of placenta accreta is 0.24% with the next pregnancy, and gradually increases up to 6.7% with the 6th pregnancy.

What can I expect with my care if I want a VBAC?

There are a couple of protocols that most care providers will request that you consider when having a VBAC.

Currently in Australia it is recommended that all women having a VBAC would be:

  • Monitored with continuous fetal monitoring once in established labour.
  • Vaginal examinations to be done at least every 4 hours or more frequently if progress is suspected to be not efficient.
  • An IV (intravenous line) would be inserted on admission to gain bloods, and have quick access if required.
  • Diet could be restricted once in established labour.

As an interesting note, NICE guidelines (UK guidelines) have changed their national VBAC policy. They now do not require constant fetal monitoring (unless induction is taking place) or IV access and they allow the use of a birth pool.

You will find there is research that could support or suggest different evidence than what I have mentioned here. It is important for you to do your own research in relation to different topics to see what you feel will support an evidence based birth for you.

 

What next?

It is so important that you communicate with your care provider as soon as possible that you want, or want to consider a VBAC. Your care provider will be a huge factor in achieving the kind of birth that you want, so please make sure they are actually supportive of your wishes. Asking them what their VBAC, caesarean and induction rates are, and why, are great questions to help you make an informed decision about your care provider.

By being informed, educated, doing your own research and making sure you have a supportive team (including partner and family) is paramount to achieving a positive birth.

When preparing for my VBAC, I firstly discussed my desires with my partner and care providers, and clarified what their’s were. Once these were established, I set about preparing both my mind and body. I debriefed my previous emergency caesarean experience, to really find out what and why certain things raised emotions. My caesarean was positive, but I had an overwhelming feeling of being ripped off for not even getting to feel labour! Maybe you are thinking that’s just because Im a midwife, but I have spoken to lots of other mums who say they felt the same too. I also had a toddler now, so if possible I wanted to be able to care for him as best and most easily.

I had done Calmbirth before my emergency caesarean, and I actually did my Calmbirth educator training while pregnant with my VBAC. I used the Calmbirth scripts and positivity to build my confidence and mental preparedness.

For my second VBAC I regularly saw an osteopath, had regular acupuncture and did clinical prenatal pilates from about 25 weeks. I truely believe all of these things helped create my vaginal birth experiences.

So if you are considering a VBAC, commit to it whole heartedly. Give it your all and know that your body is totally capable.

You’ve got this!

 

 

 

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