VBAC (Vaginal Birth After Caesarean)

Husband helping wife through labor painCurrently the caesarean-birth rate in England is more than 1 in 5 women, so a significant number embark on their subsequent pregnancies with a decision to make regarding whether or not to attempt a VBAC or have a planned caesarean birth.

Most couples, regardless of whether they’ve had a baby before or not, have some concerns about labour and birth, of course.  Those planning a VBAC often have increased anxiety and doubts.

The flag that’s raised is concern over uterine rupture.  It’s worth quickly mentioning that this can happen at any birth, and the risk is increased if syntocinon (synthetic oxytocin) is used to augment (speed-up) labour.

Generally, this risk is quoted as being around 0.5% for a woman who’s had a previous caesarean birth. A recent UK study found that the overall risk of uterine rupture for a woman who has had a previous caesarean is 0.2% –  overall  meaning without considering other factors that affect an individual’s risk, such as induction of labour or syntocinon being used.

So, the risk may be lower in labours that are not induced or augmented (the statistic above is a mixture of all labours).  In fact, studies show an increase in rupture with these interventions.

A slight increase was found for women who had had 2 or more previous caesareans.

So, 0.2% will experience uterine rupture, but 99.8% wont!

This statistic looks different again when you consider that the vast majority (94%) of the 0.2% of scar ruptures don’t cause major problems for mum or baby – serious complications are very rare.

Another way to look at it is this: All labours (like life) carry risks: For all women the risk of cord prolapse is around 1% (so more than double that of caesarean scar rupture) but that’s not a risk that’s emphasised to all pregnant mums – in fact most women will go through pregnancy, labour and birth without even hearing this risk being mentioned from care givers.

So, I have to admit to being slightly baffled by the massive deal that’s made about the risk of uterine rupture in a VBAC birth.

Most information and guidelines compare the risks of uterine rupture between VBAC and a planned caesarean.  Planned caesarean wins hands-down here with a 2 in 10,000 rate compared with the 20 in 10,000 I’ve mentioned here earlier.  But, of course, it’s not that straightforward when we consider all the risks associated with a caesarean and their higher occurrence rate. Blimey! So much to get one’s head around!

As a doula, when I support a woman planning a VBAC, the issues that require addressing are:

  • these women have often found their previous birth experience to be traumatic. Recognising this and giving her the opportunity to de-brief that birth is helpful to her, and also to me to understand what she’ll need during labour. Also, If the reason for her previous caesarean was a non-recurrent cause, once we’ve talked it through she can put that birth to one side and separate it from this different baby and birth.
  • they are labeled ‘high risk’ and with that comes an implied ‘disaster-waiting-to-happen’ tag – not just from care providers but from their partners, friends and family.  They’re dealing with everyone else’s worries as well as their own. Best to discuss and contextualise risks with mum and partner and provide them with evidence-based information so that they can make informed decisions.
  • Usually women planning a VBAC have already begun arming themselves with the above information and done extensive research, which is great, but it’s really important to encourage them to also seek out positive VBAC stories from other parents, and I can put them in touch with my previous clients who’ve had a vaginal birth after a caesarean to hear their experiences
  • make sure that parents understand what actually happens if the uterus ruptures rather than leaving it to their imaginations which may be filling their minds with all sorts of horrific visions.
  • mum needs to take pressure off herself to ‘succeed’ and there’s no need for her to tell everyone she’s planning a VBAC, she can just tell friends etc. that she’s going to go to hospital and see how it goes. Appreciating that a repeat caesarean may have nothing to do with the previous one is important, as is really understanding what she can do to increase her chances of a successful VBAC, for example avoiding induction, having belief in her body’s ability to birth her baby and surrounding herself with others who do too.
  • making sure that parents are aware that most women who choose a VBAC do go on to have a vaginal birth. The rate varies between hospitals but most record VBAC rates of 70-90%
  • hospital policies – what they are locally, what she’s happy to accept, what she’s not and how to reduce any impact they may have on birth unfolding naturally.  For example she may decide that she will go to hospital as soon as labour begins, that doesn’t mean that she’ll have to accept further interventions, it just means that she needs to be prepared to politely decline them if her and her baby are well.  Parents might need the reassurance of the continuous monitoring that will be recommended, that doesn’t mean that mum will be immobile.  And, if hospital protocol dictates that her labour is ‘taking too long’ but she and her baby are well a discussion can be had, she doesn’t have  to accept all procedures suggested.

On the subject of continuous monitoring in labour – NICE guidelines suggest that continuous monitoring in labour should be offered, although this isn’t based on firm evidence as there have been no reliable studies to discover if it makes VBAC safer and a Cochrane review found that it is no more effective in detecting distress in babies than intermittent monitoring

Numerous clinical studies have found that women who have the support of a doula during labour tend to have shorter labours and fewer interventions and almost everywhere I’ve looked for suggestions on increasing your chances of a successful VBAC, that continuous presence of a trained, experienced supporter is highlighted as being key.

VBACs are wonderful to attend because they are often immensely healing and empowering for mums – I always smile remembering one mum in particular who really just gave her baby a cursory glance as he was passed to her, and then beamed at her partner and me and squealed “I did it!”

 

By Louise Daniels

 

 

Further Reading:

AIMS (Assoc. for Improvement in Maternity Services) have a booklet that you can order

The VBAC Handbook

The Royal College of Obstetricians and Gynaecologists in the UK 

Childbirth Connection: a US-based not-for-profit organisation

 

 

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