Vaginal Birth After Caesarean (VBAC)

By , 30 August 2013

Vaginal Birth After Caesarean (VBAC)

 

 

"I've had a caesarean before - do I always need to have one now?"

 

Not necessarily; under the right conditions, and with appropriate care and management, a vaginal birth after a caesarean section (commonly called a VBAC) is a safe and frequently successful option.

Much like having another caesarean birth (often called an elective repeat caesarean section, ERCS), there are risks and benefits which need to be carefully considered and  discussed with your maternity care provider.

 

 

Benefits and risks of attempting a VBAC

Benefits of a successful VBAC include:

  • A better recovery for you, a shorter hospital stay, and generally a faster return to usual activities.
  • Higher chance of VBAC success in subsequent pregnancies.
  • Slightly lower risk of temporary breathing problems with baby.

An additional purported benefit is a sense of achievement and active participation in your child's birth.  While this is certainly the case, it is important to be aware and acknowledge that many women will end up requiring another caesarean section, despite the best efforts of themselves and their obstetrician.  Many factors in labour can be managed, but not necessarily controlled - such as concerns with baby, a small pelvis, or emergencies such as a uterine rupture.  I therefore feel it is important to focus on the goal of a healthy mother and baby, rather than necessarily achieving the planned method of birth; otherwise we risk engendering feelings of guilt and failure at a time when a woman should be feeling the absolute opposite: she has achieved the birth of a healthy baby after caring for her baby for nine months of pregnancy - and this is an amazing accomplishment, whichever way baby makes an entrance!
 

Potential risks of a VBAC include:

  • Unsuccessful attempt, requiring a repeat caesarean section after the onset of labour.
    • Attempts are most likely to succeed among women who have had a successful vaginal birth before, especially a previous successful VBAC.
    • Poor success rates are seen when labour is induced, or when the previous caesarean section was due to obstructed labour.
  • Uterine rupture - this is the most serious risk, albeit thankfully quite rare, affecting about one in 200 VBAC attempts.
    • This involves the forces of labour causes the scar on the uterus (from the previous caesarean section) to tear open.
    • Although rare, uterine rupture has serious consequences, including a high risk of death or neurological injury to baby*.
  • Slightly higher risk of death for baby, mostly attributable to uterine rupture (rare).
  • About double the risk of infection or requiring a blood transfusion, compared to ERCS.

* Although this sounds alarming, this needs to be put into context: the risk of a baby dying is about 1 in 2000-3000; this is similar to the risk of infant death among low risk women in labour with their first child.

 

Benefits and risks of an ERCS

Benefits of a planned ERCS include:

  • Virtually zero risk of uterine rupture.
  • Lower risk of maternal infection and blood transfusion.
  • Avoiding concerns regarding an emergency caesarean section in labour.

Potential risks of an ERCS include:

  • 5-10% chance of going into labour before the date of your booked caesarean section.
  • Surgical risks of caesarean section.
  • Reduced favourability for attempting VBAC after two previous caesarean sections.

 

How do I make a decision?

In addition to these risks and benefits, the most important things to consider when planning your next birth are:

  1. Your previous obstetric history - especially the circumstances of your previous caesarean section.
  2. Your intended family size (two or three children, or more than four?).
  3. Your beliefs, values, and personal feelings. 

Factors in your history may influence your chance of a successful VBAC, or may increase the risks.  Although these factors are not absolute, they may help you have a frank discussion about your particular situation, and this may help guide your decision-making.  I am always keen to look carefully at previous labour and delivery medical records to help you understand why a caesarean was required previously, and how things may be different this time. 

Intended family size is quite important, as some of the risks of caesarean section tend to increase with increasing number of caesarean sections; if you are planning a family of six children, the cumulative risk to you of six caesarean sections starts to become very high.  Conversely, if you are planning a relatively small family, the benefit of VBAC in avoiding repeat caesarean sections is more modest.  Obviously, your beliefs and value around childbirth are very important in your decision making, and I would always seek to discuss these with you during a consultation.

It is also worth considering or discussing your feelings around attempting labour - do you feel you should give it go?  Or would you be more concerned about attempting labour but then ending up with a caesarean section again?  In the end, it is a personal and individual decision, and open communication between you and your obstetrician is essential.

 

David is a strong advocate of women's informed choice in their health care, and supports safely attempted VBAC.

 

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Vaginal Birth After Caesarean (VBAC)
 

About Dr David Moore

Vaginal Birth After Caesarean (VBAC)

David is a Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and undertook his specialist training in Queensland.  He is highly skilled in the management of complex and high-risk pregnancies, and has special training in minimally-invasive surgery, endometriosis, pelvic floor and incontinence surgery.  David has completed a Master of Reproductive Medicine and is skilled in the assessment and management of fertility problems, and can offer the full range of assisted reproductive treatments.  He is a Senior Lecturer with The University of Queensland Medical School, and has published both medical journal and textbook contributions.

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