When you have a vaginal birth following a previous caesarean section, or you are planning on trying this, it is commonly known as ‘VBAC’, literally Vaginal Birth After Caesarean. The good news is that it is now a real option for a lot of women; in fact, typically 70-75% of women who attempt a VBAC are successful. If you are pregnant or considering your next pregnancy and thinking about a VBAC, then you can discuss this with your midwife. Details about your previous birth will inform your own decision-making and your midwife can help you with this. In order to make an informed decision it is important to know the risks as well as the benefits of a VBAC.
The advantages of a VBAC include:
- Being able to plan for and have a vaginal birth. Achieving this can be very empowering and the psychological and emotional benefits of a vaginal birth can be significant.
- There is a faster recovery time after a vaginal birth and this is a major benefit if you are running around after your older children.
- If you opt for a hospital birth then you will usually spend less time there following the birth.
- No uterine scar means it can’t get infected.
- A successful VBAC reduces the chance of needing a caesarean section in a future pregnancy. It is common practice to recommend a repeat elective CS in women with two or more previous procedures. Repeat caesarean deliveries are usually longer and are possibly more difficult operations.
- The risk in a future pregnancy of having a morbidly adherent placenta (a condition where the placenta is abnormally strongly attached to the wall of the uterus) will be reduced by avoiding a second (or subsequent) caesarean section.
There are some risks to attempting a VBAC.
- The risk most commonly talked about is uterine scar rupture. This is when the previous caesarean section scar comes apart during labour and occurs in two to eight women in 1000 (around 0.5%). Being induced increases the chance of this happening. Uterine rupture is associated with significant morbidity and mortality for both mother and baby – in other words, if the scar opens completely there may be serious consequences for you and your baby. If there are signs that this is happening, your baby will be delivered by emergency caesarean section.
- You may still need to have an emergency caesarean section. According to the Royal College of Obstetricians and Gynaecologists (RCOG), the chance of this being necessary is about 25% which is only slightly higher than if you were labouring for the first time, when the chance of an emergency section delivery is around 20%.
- Attempting a VBAC is associated with a small increase in the chance of uterine infection and there is also a greater likelihood you will need a blood transfusion.
- The RCOG recommend a repeat caesarean section if you have had three or more of them previously and/or if your scar has previously come apart. If you have never had a successful vaginal birth before, needed to be induced, do not make progress in labour, or have a BMI of over 30 at booking, your chances of having a successful VBAC are less likely, and these risks need to be discussed fully with your obstetric team. If your pregnancy is complicated for any reason, you may be advised to have an elective caesarean delivery.
What about homebirth?
A homebirth may be an option depending on the reason for the previous caesarean. Increasing amounts of women are considering a homebirth VBAC and this is something you can discuss with your NHS or Independent midwife. You may also choose to have a discussion with a local Supervisor of Midwives if you feel you are not getting the support or information you require. It is important to acknowledge, however, that there is reason to suggest that risks to both mother and baby will be increased if a home VBAC is attempted by (a) not being able to monitor continuously, and (b) the potential for delayed intervention in the event of complications. These are issues that you will need to consider in your discussions with your midwife when making your decisions.
Will anything be different in labour?
The RCOG recommend that your baby’s heart rate is monitored continuously in a VBAC labour. This is because a dip in the baby’s heart rate is an early warning of scar rupture though the risk of this is minimal. This does not necessarily mean you cannot move around in labour, many hospitals now have wireless continuous monitoring. You can still use a TENS machine with this type of monitoring as well as other ways of coping with labour such as massage, alternative therapies and breathing techniques. If you decide to have a homebirth then the midwife can listen into your baby’s heart rate intermittently.
What if I go overdue?
If your pregnancy goes over 41 weeks then you have further decisions to make. You can choose to wait and see if you labour spontaneously, you could discuss the induction procedure available at the Trust you have booked with (though induction does carry a higher risk of your scar weakening), or you can choose to have a repeat elective caesarean section. And finally, remember that this is your pregnancy, your body and you should be at the centre of all decision making.
RCOG (2008) Birth after previous caesarean: Information for you
NCT (2012) Vaginal Birth after Caesarean: VBAC
NHS (2013) Caesarean Section
Independent Midwives (2008) What is an Independent Midwife?