VBAC – Vaginal Birth After a Caesarean

VBAC – Vaginal Birth After a Caesarean

By Jane Weideman *

More and more women are exploring the possibility of a VBAC** (Vaginal Birth After a previous Caesarean birth), either because they feel their previous caesarian was unnecessary, or because although the previous caesarean may have been required they how have a healthy normal pregnancy and would therefore like to attempt a natural vaginal delivery.

Birth is a major life event that significantly impacts a mother’s physical and emotional well-being. A caesarean can be a life-saving procedure for a mother and/or her baby, but overall, birth by caesarean puts healthy pregnant women at risk for medical complications. Recent evidence suggests that caesarean birth, particularly if it was unexpected, may also put women at increased psychological risk.

According to the International Caesarean Awareness Network (ICAN), the risks of Caesarean section include:

• increased risk of maternal death;
• haemorrhage;
• infection;
• damage to internal organs;
• complications caused by anaesthesia;
• adhesions;
• long-term pain;
• and bladder problems.

Women who undergo caesarean sections may also be subject to increased risk of future reproductive problems including the risk of secondary infertility, scar tissue, uterine rupture, placenta previa (where the placenta is very low lying – covering the cervix) and placenta accreta (when the placenta attaches too deeply into the uterine wall) . Aside from physical risk, ICAN says a Caesarean delivery can increase emotional and psychological complications, such as clinical depression and difficulties with bonding, breastfeeding and family relationships.

The Center for Disease Control has identified caesarean section as a risk factor for the initiation of breastfeeding. Medications and procedures administered to the mother during labour affect the infant’s behaviour at the time of birth, which in turn affects the infant’s ability to suckle in an organized and effective manner at the breast.Breastfeeding has been linked to several life-long health advantages for both mothers and babies. Mothers who give birth by caesarean can initiate, establish and continue breastfeeding particularly if they are encouraged, educated and supported by breastfeeding specialists.

Every childbearing woman is a giver of life, and as such deserves our support, respect, and admiration. Every child is precious no matter how she or he is born. Based on the available information, every woman can decide with her caregiver what best meets her needs.

However, this article is not about all the risks and horrors of caesarean, and neither is it about achieving vaginal birth at all costs. It is intended to provide balanced and truthful information about VBACs allowing parents to make an informed decision about whether it is something they want to pursue. Then to provide support, guidance and encouragement for those that decide a VBAC is what they would like for themselves.

During much of the last century, a woman who had a caesarean section almost always had a planned repeat caesarean and not a VBAC for any births that followed. Doctors were concerned that the scar from the past cut in the uterus could open during labour (uterine rupture), and cause serious complications for mother or infant. The phrase ‘once a Caesar, always a Caesar’ became common, and was believed to be true.

During the last 20-30 years, however, many health professionals, advocates, pregnant women, policy makers and researchers encouraged vaginal birth after caesarean (VBAC) in light of:

• a change in location of the uterine cut to an area much less likely to open during a VBAC labour
• growing body of research establishing the safety of VBAC
• growing recognition of c-section risks.

Now the pendulum is swinging back from vaginal birth after delivery, with new calls for routine repeat caesareans. This reversal leaves many women with caesarean scars struggling to make sense of conflicting, incomplete, and sometimes misleading information about the safety of VBAC vs. repeat caesarean and about what birth plan to make this time around.

The truth is that unless your previous caesarean was a medical necessity (true in 12-15% of all births) and/or the same or another medically justified condition exists in a subsequent pregnancy, a VBAC is perfectly possible.

Many Doctors however scare parents with horrors stories of the risk of a uterine rupture. Their concern is that multiple caesareans lead to a weaker uterine scar and that risk of rupture is therefore increased. However there is a lack of research evidence to support this theory.

Uterine Rupture risks
The scar from a previous caesarean is strong. While many people fear that the scar will rupture, and cause the death of the Mother and/ or her Child, medical studies have shown that this risk is greatly overstated.

The only way that VBAC differs from other labours is the small increased risk of uterine rupture – about 0.4% (one in 250). The risk of uterine rupture prior to elective repeat caesarean is 0.2%

To put this risk into some perspective, consider that the probability of requiring a caesarean section for other emergency obstetric situations (not related to the previous caesarian section), such as acute foetal distress, cord prolapse or ante partum haemorrhage is up to 30 times higher.

Although women are often told that they can’t have a VBAC for a variety of reasons, there are very few cases where a VBAC is not a real and a reasonable option. The article Caesarean Myths Exploded deals with the issues of VBAC when you are thought to have had CPD (cephalopelvic disproportion – where the baby’s head is believed to be too big to go through your pelvis) and VBAC when you have a non LSCS (Lower Segment Caesarean Scar) such as a classical or a low vertical uterine incision.

There are many reasons women are given for not being able to have a VBAC including having had more than one caesarean (see Can I have a VBAC if I have had two or more caesareans?), having a gap between pregnancies that is considered too short (see How long after a caesarean should I wait before having another baby?), your baby is breech or you are expecting twins, you are too old, too fat; the list is endless.

Really the only reasons that you would need to have a repeat caesarean is if you had a reason in the current pregnancy that would warrant a caesarean even if you had not already had one. Ask your doctor to explain clearly why it is that you NEED to have a caesarean, if that is what you are told. (These reasons include placenta previa, true CPD (rare), toxaemia, positioning of the baby – particularly transverse, but most doctors prefer breech babies to be delivered by caesarean too, severe infant distress or growth retardation etc. The reasons are covered really well in the book Birth After Caesarean by Jenny Lesley.) Remember there are times where a caesarean really is required and is literally life-saving!

Many women are told that if they have already had two or more caesareans, that any future babies will need to be delivered by repeat caesarean. This need not be the case. Loads of women have had VBACs after 2 or 3 caesareans. Some women have even had a VBA3Cs (Vaginal Birth After 3 Caesareans) and at least one who has had a VBA4C; obviously the numbers after 1 or 2 caesareans are much much larger.

Many woman have even had successful VBACs at home, and/or water, however your caregiver may feel more comfortable for you to be in a hospital setting, for peace of mind, that should any intervention be required, it is close at hand.

How can I get a VBAC?

If you are hoping to attempt a VBAC it is important to find a primary caregiver (Doctor/ Gynaecologist/ Mid-wife) who is both supportive and trusting of and also experienced in VBAC deliveries. It is imperative that your caregiver be comfortable and confident in order for you to feel safe and trusting in them and their judgement. You may find that your regular care provider is not prepared to consider a VBAC, so you would then need to search for someone who you can work with.

Once you have a good caregiver, who is happy to work with you towards achieving a VBAC, your pregnancy and labour should progress just like any other. However as with any woman planning a vaginal birth, you will need to prepare yourself for it.

The Preparation
In addition to a supportive caregiver, several factors will increase the odds for a successful vaginal birth after caesarean.

You need to be totally committed to your desire for a VBAC. Read as much as you can on the subject, until you feel comfortable and confident about it. Particularly as you may find many people will try to scare you or discourage you from your decision. Knowledge is your best defence and ammunition here.

Some recommended books are “Silent Knife,” “The VBAC Companion” and “Birth After Cesarean: The Medical Facts.”

Be informed. Take childbirth education classes. The best classes are those that specifically address VBAC and promote birth as a natural process.

Know your rights regarding Informed Consent. Which requires that your caregiver get your consent before performing any procedures and certainly surgeries on you, and your right to refuse these, or ask for reasonable alternatives and/or at least a dialogue about it before hand.

Informed Consent Questions
Here is a list of questions to ask when interventions or unplanned procedures are proposed at any point during your pregnancy or the birth of your child:

• Is this an emergency or do we have time to talk?
• What are the benefits of doing this?
• What are the risks of doing this?
• If we do this, what other procedures or treatments might we need as a result?
• What else can we try first or instead?
• What would happen if we waited before doing this?
• What would happen if we didn’t do this at all?

Keep your body fit and healthy, by following a healthy diet and lifestyle. Practising yoga is an excellent way to prepare for birth (see the Yoga articles in our archives). Relax and take time to imagine your birth and how you would like it to unfold. Use affirmations (there are some in our resources section) and read positive VBAC stories to inspire you. See some VBAC birth videos if you can (there is at least one example in our lending library ).

Consider hiring a doula, an experienced, knowledgeable woman who believes in your ability to give birth. The more support and positive influence a woman has, the greater her belief in herself and in her body’s ability to birth.

Some women who have had an extremely difficult or frightening prior birth experience or other traumatic experiences such as sexual abuse find that thinking about labour brings up such strong emotions that it interferes with their ability to make decisions. Unresolved issues can interfere with the smooth progress of labour as well. If you feel that you have unresolved emotional issues, you will want to work through them so that they don’t get in your way when planning for or experiencing your next birth. Keeping a journal, talking through the troubling events and your concerns with a friend or relative who is a good listener, or getting peer support from other women with similar experiences may help with this. Getting professional counselling from a competent mental health professional who is well-informed about maternity issues proves very helpful in resolving extremely deep fear and anxiety for many women. Your doula can help you to work through these feelings in preparation for your birth as well.

Consider, too, what you will need during this birth to feel safe and well-cared for. If you were dissatisfied with your previous care, you will want to pinpoint the sources of your dissatisfaction and plan to do things differently this time.

The odds are that you will go on the have a successful and satisfying VBAC. However if at the end of the day even if your VBAC attempt only results in a trial of labour followed by a caesarean birth your baby will still benefit greatly from being born when ready on his actual due date (as determined by the natural onset of labour) and will have benefited from all the good physiological effects of labour.

Furthermore your doula will be able to work with you to plan for the event of a repeat caesarian allowing you to make the experience as pleasant and healing as possible for you. Having a birth experience that is as much like a satisfying vaginal birth as possible and having good pain control after the surgery are keys to a satisfying caesarean birth experience. Discuss these options beforehand even if your birth plan is for VBAC.

• Participate fully in decisions about the birth: The difficulty or ease of the birth and whether the baby was born vaginally or by caesarean have little to do with how women feel about the birth. Women are most likely to feel satisfied with their births when they feel a sense of accomplishment and personal control and when they have a good relationship with caregivers. A good relationship includes such elements as being treated with kindness and respect, getting good information, and having the opportunity to participate in decisions about care. You should feel free to question your caregiver as and when you feel it is necessary.
• Keep your partner and any labour companions with you throughout: You can benefit from the support of your partner and any other labour companions during what may be an anxious and stressful time. This is particularly true during preparation for surgery and administration of the epidural or spinal anaesthesia, which many women find more stressful than the surgery itself. Your partner and support team will also have the opportunity to share in moment of birth and to greet the baby.
• Keep your baby with you after the birth, in skin-to-skin contact: Unless your baby has problems at the birth that require care in the nursery — and few babies do — there is no reason not to keep your baby with you so that you and your partner can enjoy and begin to get to know your baby, and you and your baby can get breastfeeding off to a good start. Skin-to-skin contact can contribute to breastfeeding success and your early relationship.
• Work with your caregivers to carry out your preferences: For example, you may wish to:
  • videotape the birth or the time just after the birth
  • play the music of your choice
  • not have your arms strapped down
  • have the drape that screens your view of the surgery placed low enough that the baby can be laid on your chest; if your arms are free, you can hold and touch your baby.
  • have a doctor or nurse explain what is happening throughout
  • have the drape lowered or have a mirror at the time of the delivery (your belly will be covered so you will see your baby lifted out of an opening in the sheet)
  • announce or have your partner announce the sex of the baby or be the first to speak to the baby (versus a member of the care team doing these things)
  • take the placenta home (some people bury the placenta and plant a tree or bush over the site; if of interest, bring a sealable container to contain this)
• Have your baby and your labour companions with you in the recovery area: Holding and breastfeeding your baby soon after delivery helps both you and your baby get started on the right foot and may avoid problems with breastfeeding.
• Have your partner able to be with your baby in the nursery: This includes the newborn intensive care nursery. If your baby must be separated from you because of concerns about the baby’s health, it will be comforting to know that your partner can provide a reassuring presence and can bring you word of your baby’s condition.
• Begin drinking and eating again when you feel ready: Access to food and drink when you feel ready will help you feel more normal and can avoid hunger and thirst.
• Get help with breastfeeding: Breastfeeding can be more difficult right after surgery and while your incision is healing. A knowledgeable person can help you find ways to be more comfortable during breastfeeding sessions. Your partner or others can help with switching sides, burping, and nappy (diaper) changing.

VIDEO CLIPS:

There is a lovely inspirational VBA3C photo video here.

HBAC– This is a very moving birth of a mom who had a medically managed vaginal birth with her first son, followed by a Caesarean birth with her second son. Less than a year later she had a successful home vaginal birth after a Caesarean (VBAC) with twin girls!

Feel free to Contact Us should you require more information on the doula service we can offer to a VBAC mother, as well as those caregivers we know in the Cape Town area who do provide VBAC support.

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* References and information taken from the following sources:
http://www.vbac.com/
http://www.childbirth.org/section/VBACindex.html
http://www.childbirthconnection.org/article.asp?ck=10212
http://pregnancytoday.com/reference/articles/canvbac.htm
http://www.homebirth.org.uk/vbac.htm
http://www.caesarean.org.uk/

Another great source of matter of fact and easy to digest info is :
Pushed Birth – Previous C-section?

**The term VBAC was first coined and used by Nancy Wainer Cohen author of Silent Knife:Cesarean Prevention & Vaginal Birth After Cesarean. It was chosen as the best book in the field of Health and Medicine by the American Library Association in 1983.

*** Medical disclaimer: Note that this web site is not a substitute for medical advice. The content provided here is for informational and educational purposes, and is not intended as advice or instruction. It is provided to help you to make informed choices for yourself. You should consult your primary care provider regarding your specific medical symptoms or advice. Birth Buddies is not engaged in rendering medical advice, diagnosis or treatment. Any medical decisions should be made in consultation with your caregiver or other trained medical personnel. We will not be liable for any complications, injuries, loss, or other medical problems arising from, or in connection with, the use of, or reliance upon any information or products on this web site.