Vaginal Birth After Caesarean (VBAC)
If you have previously had a caesarean birth you will have appointments with an obstetrician during your pregnancy, usually at 16 weeks and again at 36 weeks to discuss your birth options.
You me be wondering, should you have a vaginal birth after a caesarean (VBAC)? Or should you have a planned repeat section? Here obstetrician Vicki Medland explores the pros and cons to both to help you make an informed decision.
Specialist Clinic
If you have had a previous caesarean birth, you will have an appointment at an antenatal clinic with an obstetrician. They will explore factors in your history and the circumstances of your previous caesarean. Your team will have your previous birth notes at this appointment too look back at your last birth. This may help you make a decision on whether to have an elective caesarean birth or a VBAC.
What questions might they ask about your previous birth?
Here the specialist will be exploring exactly why you had a caesarean. They will ask lots of questions about your previous birth. What was the reason for it? Was it planned or an emergency? Were you in labour? Were you labouring well but baby got into distress? Or perhaps you were in labour but never got to fully dilated?
They will then explore any births you had before your caesarean. Have you had a previous vaginal birth? And was this before or after your caesarean? This increases your chances of having a Vaginal Birth After Caesarean (VBAC). They will also want to know about any complications that arouse. Were these at the time of surgery or during your recovery, including any anaesthetic complications?
How many weeks pregnant were you, and what kind of cut was made in your uterus? A very preterm caesarean, or sometimes one in which baby is tricky to deliver, may sometimes mean the cut is up-down rather than side to side. This is really important in helping to fully explore your options. Any cut into the upper part of the uterus would usually mean you’d be counselled against aiming for a VBAC. This is because the chances of the scar coming apart are much higher than in the more usual side to side cut.
They will also want to know what are your feelings about your previous birth? And how are you feeling about the birth ahead of you?
What questions might they ask about your current pregnancy?
Your current pregnancy is obviously important too. This includes whether your baby is growing well, is breech or head down, and whether there are any reasons why you might be recommended to have baby earlier than might be expected.
What questions might they ask about future risks and considerations?
Then there is your future reproductive life to consider. Are you aiming to have a large family? The risks increase with each caesarean section. If you plan to have several babies it may be advised to aim for a vaginal birth if possible. If you’ve had more than one caesarean and would like to discuss the possibility of aiming for a VBAC, you should have a detailed discussion with a senior obstetrician about the potential risks, benefits, and success rate in your individual situation.
Statistics for a Vaginal Birth After Caesarean (VBAC)
So, onto the stats. After one previous section, about three out of four women, or 75%, with a straightforward pregnancy who go into labour by themselves, will give birth vaginally. This includes by assisted vaginal birth (ie. forceps or ventouse). This is more likely to happen if you’ve had a previous vaginal birth. Especially if that was after your caesarean. A previous spontaneous vaginal delivery makes the chances of successful VBAC around 85%, or 8 to 9 women out of every 10. It’s more likely if your labour started on its own, and if your BMI is under 30.
What are the risks of a Vaginal Birth After Caesarean (VBAC)?
The risks to consider are that some – around 1 in 4, will need an emergency section. The background risk in a first labour is about 1 in 5. So this is not much higher than someone labouring for the first time. Most commonly this is because you don’t progress in labour, or that baby’s heartrate is abnormal. You have a slightly higher chance of needing a blood transfusion compared with someone having a planned repeat caesarean.
Another risk is your scar may open during labour. This can occur in 1 in 200, or 0.5% of women. The risk is increased to 1% if your labour is induced using oxytocin drip. If there are signs that the scar is coming open, known as a uterine rupture, you would be strongly advised to have an emergency caesarean for both your and your baby’s wellbeing.
The risk of your baby having a brain injury, or of a stillbirth, is the same if you aim for VBAC as it was your first pregnancy. However, this is higher than if you had a planned caesarean section. This is partly because planned repeat caesareans are done at 39 weeks, so if you continue pregnancy beyond then, you remain at risk of stillbirth when a caesarean birth would have already happened.
When aiming for a VBAC, there is a chance of needing assisted birth with ventouse or forceps, and of sustaining a perineal injury, including to the anal sphincter, known as a 3rd or 4th degree tear.
In some circumstances a VBAC might not advisable. This may be if you have had three or more previous caesareans, your uterus has previously ruptured, you have an unusual incision involving the upper part of your uterus, or you have other pregnancy complications that require a planned caesarean section.
The Pros of a Repeat Caesarean
There is a smaller risk of uterine scar rupture (1 in 1000- which is notably NOT zero). This is because your scar can come apart even during early labour, if you laboured prior to your planned caesarean date. Planned sections reduce the, albeit rare, risks of brain injury to the baby from lack of oxygen in labour. These happen in 2 in 1000 cases
You have some certainty over when it’s going to happen. However, 10% of women labour before the planned date. Other women may unfortunately need to have their caesarean cancelled on the day, should there be unforeseen emergencies in the hospital on the scheduled date.
The Cons of a Repeat Caesarean
Onto the cons of repeat caesarean. It may take a bit longer than the first due to the presence of scar tissue from the previous section. It can also make bladder or bowel damage a little more likely than in a first operation. There is the risk of wound infection, and you may need a blood transfusion if you have heavy bleeding. Albeit this risk is lower than with aiming for a VBAC. You have a higher risk of getting a blood clot in your leg or lung after caesarean than with vaginal birth.
Your recovery may take longer than if you have a vaginal birth, and need to check with your insurance company regarding what they say about driving post operatively. I personally counsel people that they need to be able to do an emergency stop before they’re safe to drive, regardless of what time restrictions their insurance company dictate.
In 2% of caesareans, the baby is caught slightly with the knife. This is more likely with emergency caesarean, if your waters have gone, or if your baby is breech, and usually heals well, but does appear on the consent form. A particular breathing difficulty called TTN is more common after caesarean but usually does not last long. Between 4 and 5 in 100 babies born by planned caesarean section at or after 39 weeks have breathing problems compared with 2 to 3 in 100 following VBAC. This is increased if you have a planned caesarean section earlier than 39 weeks.
Can I have a water birth VBAC?
The short answer is yes. The NICE guidelines state that a women should be able to have a water birth if she wants it. If you’re aiming for a VBAC and would like a water birth, talk through your options with your consultant.
“Support informed choice of a full range of options for pain relief for women who have had a previous caesarean section, including labour and birth in water.”
You can read the full guidelines here.
What about future pregnancies?
If you have a planned repeat section then you’re more likely to have caesareans in your future births. In those pregnancies you’re also more likely to have a pregnancy where the placenta implants into the previous caesarean scar tissue. This causes something called placenta accrete or percreta. These can cause complicated pregnancies possibly requiring a hysterectomy. All serious risks increase with increasing numbers of caesareans. It is really worth considering your planned size of family, and your contraceptive choices, if you are choosing caesarean birth.
What to expect with a planned VBAC
If you’re planning a VBAC and go into labour, you’ll be recommended to give birth in a hospital. This is because, whilst uterine rupture is rare, the outcomes of both mother and baby are mostly determined by your proximity to theatres to access emergency caesarean swiftly. Once you’re having regular contractions, the most recent NICE guidance states you should be offered continuous fetal monitoring. Most hospitals strongly recommended continuous fetal monitoring in labour if you’ve had a previous caesarean. This it would mean labouring on a consultant led unit. If you wish to negotiate your place of birth and how your baby is to be monitored in labour, do ask in clinic. This needs to be an individualised discussion based on your personal birth history. Your pain relief options may include hypnobirthing techniques, TENS, aromatherapy, gas and air, pethidine or diamorphine, and may include pool birth.
If you’re aiming to have a VBAC but don’t go into labour by 41, you can re-discuss your birth options. This includes awaiting labour, plus or minus having some cervical sweeps to encourage natural onset labour. You could discuss induction of labour and how this might be offered in your hospital in the safest way possible given your caesarean scar. Or you could discuss a planned repeat section should you not wish to await labour any longer, and don’t wish to be induced.
You should have a discussion about what you’re planning to do if you go into labour and were in fact planning on a repeat caesarean. This is because if you’re in early labour and still keen for a caesarean you would be offered one. However if you’re in very advanced labour it may be safer for you and your baby to have a vaginal birth.
If you want to read a positive VBAC birth story, head here to read Joycelyn’s Positive Birth Story – a quick hospital VBAC delivery!
Photo Creds @Jasminekerr.photography who captured this amazing image of VBAC mama moments after her baby arrived.
