Birth Choices: VBAC

There are always choices during your birth planning. This is no different if you have had a previous Caesarean Section (CS) and are looking into your options for your next birth. It is a very personal decision whether to book a repeat CS or whether to wait for labour and have a vaginal birth after having a previous Caesarean (VBAC)


Quite often people are told that ‘once a caesarean, always a caesarean, but the evidence just doesn’t support this as the blanket recommendation for all people and in fact, the chances of having a vaginal birth after a previous CS are actually quite high. Research has actually shown that risks increase with each CS birth and that a vaginal birth is actual a safe option for people after one or more CS births


Common reasons that an initial CS are performed is for breech presentation, a slow progress or your care providers have caught the “failure to wait” bug, it is most likely that your baby was in an awkward position (back to back or a tilted head) not necessarily because they wouldn't fit out or your body was faulty. Baby position is variable with each pregnancy - the good news is that you can look into ways to help make the right space for baby to tuck into a better position, here is the link of a site with some excellent resources;

https://www.spinningbabies.com/


Why consider a VBAC?

A review of evidence of births from 1996 to 2009 assessing over 200 research papers, rates of adverse outcomes in either Elective Repeat Caesarean Birth {delivery} - I hate that term) or ERCD and Trial of Labour (TOL) state that;

“...Each year 1.5 million childbearing women have cesarean deliveries, and this population continues to increase. This report adds stronger evidence that VBAC is a reasonable and safe choice for the majority of women with prior cesarean…”

https://europepmc.org/article/nbk/nbk44571

A VBAC generally results in;

  • Less blood loss

  • Eliminates the associated risks of major abdominal surgery

  • Reduction in chance of infection

  • Generally a faster recovery

  • A shorter hospital stay

  • Reduces the risk of the baby experiencing breathing difficulties after birth that require admission to the neonatal intensive care unit

  • Knowing that the baby has come when ready

  • Fewer complications/risks in future pregnancies

  • Even if a CS is required you know that you have been part of the decision making

  • Experiencing labour and associated hormones are good for baby to breathe, improve their circulation and alertness following birth

  • Potential exposure to the vaginal microbiome of good bacteria that are a key part of baby’s immune system

Considerations for VBAC

As with all birth, there are always potential risks. These need to weighed up as you come to a decision that feels right for you;

  • The scar is potentially a weakened area on the uterus that can open. This can be potentially life threatening to the mother and the unborn baby

  • When the CS scar is on the lower part of the uterus (the non-contracting part), the incidence of a full thickness scar separation is less than 1% (0.4 - 0.7%) or a 99% of your uterus NOT rupturing though studies do not differentiate between true full-thickness uterine rupture and uterine dehiscence (which is a partial opening of one of the layers, which is not associated with adverse outcomes) or uterine rupture during pregnancy

  • To put this into perspective- the risk of uterine rupture is less than many other complications for women in labour i.e. Baby becoming stressed, shoulder dystocia (the shoulders get stuck after the head is born), hemorrhage or cord prolapse (where the umbilical cord drops out before the baby) - the chance of a cord prolapse is actually almost DOUBLE that of uterine rupture

Signs of the uterus opening include:

  • A sudden drop in the baby’s heart rate that takes a long time to recover after a contraction. This is taken very seriously and an emergency CS may be advised

  • Abnormal vaginal bleeding (a small amount is normal in labour as the cervix opens, but continuous bright bleeding is not normal)

  • Scar pain/tenderness or shoulder tip pain that continues throughout the rest period in between contractions

  • Blood stained urine

  • A sudden change in regularity/strength or duration of contractions

  • The Birther feels something is wrong (their intuition)

If it is suspected that the old scar is opening, it will be recommended that you head immediately to theatre for a CS. Uterine rupture is not necessarily a life or death emergency - check out this article discussing research on rupture and outcomes;

https://vbacfacts.com/2012/04/03/confusing-fact-only-6-of-uterine-ruptures-are-catastrophic/#:~:text=Uterine%20rupture%2C%20also%20called%20true,wall%20and%20the%20overlying%20serosa


What if I end up in theatre again?

Some people who have had a previous CS after a long and protracted labour are often fearful of the same thing happening again, concerned that they will go through another long and arduous labour again only to potentially end up with an emergency CS. This is what needs to be individually weighed up - is the chance of having an uncomplicated birth worth the risk of a repeat emergency CS - or


Do you book a repeat CS and take that possibility off the table completely? In most cases - especially if you have laboured and your cervix has begun to open during your first/previous labour, second and subsequent labours are often way quicker and smoother than the first!

If an emergency CS is advised, evidence tells us that in most cases no serious harm comes to the mother or baby. Sometimes there may be an increased amount of blood loss requiring transfusion may be required when emergency CS is compared to a vaginal birth though the rate is similar whether VBAC and ERCS

https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/aogs.13504


What makes a VBAC more likely?

  • Choosing a truly supportive care provider (the most important part)

  • Having given birth vaginally before

  • Investing in a Doula

  • Have no complicated medical problems

  • BMI less than 30

  • Go into labour naturally prior to 41 completed weeks of pregnancy

  • Baby weighing less than 4kg (which cannot be known definitively until birth)

  • Baby in an optimal position for birth (https://www.spinningbabies.com/ )

  • Going into labour naturally

What may reduce your chance of VBAC (though VBAC is STILL an option!)

  • Induction of labour (also slightly increases risk of scar rupture, depending upon IOL technique)

  • Birthing in a private hospital/with an unsupportive healthcare provider

  • BMI over 30

  • Not having a previous vaginal birth

  • Previous CS for ‘no progress' especially if you reached 10 cm dilation AND baby was in a good position i.e. head well flexed with chin tucked in and back facing towards belly button/anterior (most FTP is for malpositioned babies who may likely have birthed perfectly fine if they were in a better position...not because your body failed and was incapable of birthing vaginally - I have heard this WAAAYYY too often)

  • ‘Guesstimated’ baby weight of over 4000g

  • Any scar other than a lower segment; Previous classical caesarean • Previous T-incision caesarean • Prior uterine rupture • Extensive transfundal uterine surgery as the risk of uterine rupture is higher in this group - although the decision is still up to the the risk assessment of the birthing person

Hospital Policy/Provider Opinion

Your birth facility will have a policy or protocol written specifically for VBAC clients. It is important to have this information as you prepare for your birth so you can decide and discuss any deviations you would like to take from hospital/provider policy. Remember- Hospital policy is not LAW and is based on global population stats - not on your individual circumstances. You are within your rights to request care related to your wishes that may sit outside of hospital policy. The impacts of the decisions you make are for YOU to experience - not your Doctor’s, so they need to feel right for you and your family


Many people tend to go back to the previous care provider, who will actually profit more from birth if they convince you to book a repeat CS! Who you choose as your care provider has the BIGGEST impact upon whether or not you will have a VBAC, not the actual danger of the situation or your inability. Care providers often speak from opinion on what THEY think is best, not what the evidence suggests. The link below shares some information on some considerations;

https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Patient%20information/Vaginal-birth-after-caesarean-pamphlet.pdf?ext=.pdf


This is why YOUR assessment of risk/benefit is individual to what is important to you, and should be central to all of the decisions you make regarding your care. Below are what some care providers stipulate, plus some related reading on evidence/lack thereof and a lot of it is not based upon good quality evidence;

https://www.ajog.org/article/S0002-9378(14)01368-4/fulltext?fbclid=IwAR2CA3gTwxcSEbMzLW60kHzbRTDc9q0J8ItJ4d2qJJRJODTaiiFQIo6szPY#sec3 )

https://www.researchgate.net/publication/7564862_Safety_and_Efficacy_of_Vaginal_Birth_After_Cesarean_Attempts_at_or_Beyond_40_Weeks_of_Gestation)

Most of these recommendations/policies do not have a base of quality research - if your care provider is stating any of these, you are well within your consumer rights to ask for a Cochrane review of the evidence to support their recommendation (the Cochrane database is an independent review of literature). If they are interested in evidence based care, they should have no problem providing you with it - but let me tell you they will not find any gold standard evidence to show you! If you want to know more about choosing a truly supportive VBAC care provider, check out these blogs;

http://wholewoman.com.au/birth/vbac-will-you-spot-a-bait-and-switch

https://improvingbirth.org/2016/09/10-steps-to-finding-a-vbac-supportive-provider/

https://birthingbeautifulideas.wordpress.com/vbac-scare-tactics/

https://vbacfacts.com/2009/06/06/interviewing-care-providers-questions-to-ask/


Had more than 1 previous CS?

Even if you have had more than 1 previous CS, evidence suggests that the risks of either a VBA2C and ECS are fairly similar - the incidence of hysterectomy was slightly higher with ECS, blood transfusion rates were almost the same and the morbidity rate was also comparable

https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1111/j.1471-0528.2009.02351.x


Consider your options and planning ahead


As with all birth, it can be unpredictable. It is worth exploring your options for your labour and vaginal birth PLUS the scenario that a CS may be required during your VBAC labour. You may draw from your previous experience to create a plan to help your care providers support you - this has been proven to enhance birth experience, however it unfolds. Discuss the many possibilities with your birth partner well ahead of your ‘guesstimated’ date and note anything you feel is important to you


Every decision can slightly change the course your birth takes. For example, if you decide to have your labour induced, it is not as though you are having your labour ‘switched on’ and it tracks along with what would have happened if you were in labour spontaneously. Induction invites the possibility of other side effects and risks which add to your journey


The word PLAN is what throws people, when we think of a ‘plan’ we tend to think of systematic steps done in a particular order with a definite end point or product. This notion and birth are not really compatible, as birth tends to unfold as a result of many factors, some of which can change very quickly depending upon who your care provider is, the position of your baby and the choices that are made along the way. This is why it is best looked at as creating a map. You have a starting point and the destination is birthing your baby. You may need to take detours along the way, but at each stop you will have enough knowledge to make informed decisions that feel right for you and know about the potential ‘terrain’ ahead


Consider;

  • Independent Birth Education classes, including VBAC ed.

  • Take a Hypnobirthing course

  • Whether you would consider induction of labour & in what circumstances

  • The use of analgesia during labour - Why, what & how

  • An vaginal examinations - yes or no

  • Wearing your own clothes or a gown

  • Creating a calm birth environment - what makes you feel more comfortable?

  • Letting your waters release on their own

  • Continuous baby monitoring or intermittent monitoring

  • Having a cannula placed upon arrival/or not

  • The use of water during labour - what are your options?

  • Having a Doula present (1000000%)

  • Optimal cord clamping

Covering all bases

Some people prefer not to consider the possibility of requiring a CS after the commencement of labour, as they do not want the idea in their headspace. There are still so many possibilities to consider and a possibility that a CS may be advised, so it is important to at least consider ways to have a family-centred and unique CS


In the event of an unplanned CS have you thought about;

  • Who you would like to be there when the anaesthetic is being administered

  • Who will be supporting you in theatre, when the baby is born

  • ‘Maternal Assisted Caesarean’ https://www.belleverdiglione.com.au/blog/the-birth-of-leilani-a-maternal-assisted-caesarean

  • ‘Gentle Caesarean’ https://www.mamanatural.com/gentle-cesarean/

  • Whether you would like some music of your choice playing during the surgery

  • If you would like the drape to be lowered to have a view of your baby emerging

  • For baby to be passed to you directly after birth for immediate skin-to-skin (providing all is well with baby)

  • You may like to announce the sex of the baby yourself

  • Delaying the clamping of the cord so baby receives as much of their total/intended blood volume as possible (providing all is well)

  • To have a clear line of sight to the cot, in the incidence of the baby needing any assistance by the Midwifery/Paediatric team

  • Request that the baby remains with you after birth, while stitching is taking place and while in recovery room, for skin-to-skin and the first breastfeeding

  • Have the baby stay with you in recovery. This may be subject to staffing availability

Mapping out your desires on paper is a great way to communicate your birth preferences to your care team. Better yet, be sure to discuss this well ahead of time and hand it to your Midwife/Doctor prior to labour commencing. This ensures that they will be well prepared to accommodate your desires throughout your birthing journey. Remember to bring another copy with you once you are in labour/admitted or have it on the door/wall right next to your vision board!


Further Reading

https://www.facebook.com/ICANonline/

http://www.childbirthconnection.org/giving-birth/vbac/resources/

https://www.facebook.com/groups/342851302473349/


I'm Hayley, I am a mother of 4, I have been a birth worker for over 10 years. It is my life’s work to help new parents have the best birthing and early parenting experience as possible by providing a birthing & postpartum Doula service, and Birth and Early Parenting education. Let me help you navigate this journey with confidence and help you settle into life with your new baby. I am available for in person or online support


I am based in the Perth Hills and cover all of Perth Metro area, regional areas by arrangement

ritualbirthco@gmail.com

www.ritualbirthco.com.au

https://www.facebook.com/ritualbirthco


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