Pregnancy can be an exciting and anxious time in equal measure. If you have had a previous caesarean delivery, there is an added dimension to your pregnancy in that you now have to choose between another c-section and a vaginal birth after c-section (VBAC).
Simply put, VBAC means giving birth vaginally when you've had at least one baby via a c-section.
A VBAC pregnancy may also be referred to as trial of labour after caesarian (TOLAC). TOLAC refers to the attempt to deliver a baby vaginally before a c-section is initiated; if successful, the pregnancy would be a VBAC pregnancy.
What Are The Risks?
Health professionals agree that a VBAC pregnancy is still the safer option compared to a c-section and that there are only a few circumstances in which it is not advised. There are some disadvantages; in extreme cases, an attempted VBAC could result in the scar in your womb tearing and whilst most tears can be repaired, there is a rare risk of severe bleeding which could result in your uterus being removed (hysterectomy).
If you opt for a VBAC, you are likely to be monitored more closely so that health professionals can identify if there are likely to be any complications such as outlined above. If you feel you have started labour, you should call your hospital immediately so they can advise on next steps.
It has also been reported that 25% of women will require an emergency c-section during an attempted VBAC. This is usually because labour is not progressing as planned, i.e. too slow or monitoring of the baby identifies concerns. Unplanned c-sections are difficult to predict, and the risk for VBAC pregnancies is only slightly higher than women who are giving birth for the first time.
Risks to your baby of brain damage or of dying because of a VABC is very small. The risk of your baby dying is no higher than if you were labouring for the first time, but it is higher than if you opted for another c-section delivery.
Should I Have a VBAC or Another C Section?
If you elect to have another c-section, your health professionals will discuss a planned delivery date with you. This is usually arranged for the week you are due, i.e. your 39th week of pregnancy unless there are extenuating circumstances which result in your procedure being bought forward.
The risks of a VBAC versus another c-section need to be considered carefully. A repeat procedure is likely to be longer and more complex because of existing scar tissue. The scar tissue can also present complications which could lead to damage to the bladder or bowel. With each repeat caesarean delivery, there is increased scar tissue; a factor which can lead to problems during any future abdominal surgery.
Furthermore, after a caesarean delivery, there is an increased risk of your placenta lying low during your next pregnancy which could result in bleeding during and after pregnancy and has been known to impact on a baby being in the breech position during labour. Having more than one caesarean delivery also increases the chance of the placenta growing into the scar tissue, making it difficult to remove during future deliveries and in severe cases could result in a hysterectomy.
Other risks which are present in all caesareans regardless of the number are described as follows. Women who opt for birth by c-section are at five times greater risk of developing a blood clot than women who decide on a vaginal birth. Blood clots can be fatal. You are likely to spend longer in hospital after a caesarean delivery compared to a vaginal birth, and there is a longer recovery period as well, which is why support at home after a caesarean birth is more important as some household tasks will prove difficult to undertake.
Driving is also not advised after a c-section due to the wound impacting on the strength of your stomach muscles which are routinely used in braking and controlling a car. With caesarean delivery, there are also risks to the baby; breathing problems, although they don’t last long, are more common for the baby, in a caesarean delivery than a vaginal birth. There is a higher chance of allergies in babies born by c-section as well as an increased prevalence of diseases such as obesity and diabetes. Some of these risks can be mitigated by breastfeeding.
Having understood the benefits of a VBAC over a c-section, this may be something you are now thinking about. However, it is important to note that VBAC is not advisable if you have had three or more previous caesarean deliveries. There is also some debate surrounding the length of time between pregnancies, which may impact on your decision. Research highlights that gaps of less than six months had the highest risk (to scar tissue), but if the gap was less, there is still a good case for VBAC being the safer choice. It could be argued that deciding how long to wait between pregnancies should not be down to the risks involved in possible scar ruptures, but rather other factors carry heavier weight; such as your health, how ready you feel to have another child and when you will conceive.
A repeat caesarean delivery may be discussed with you as your preferred choice if you are more than 41 weeks pregnant, you are over 40 years of age, the gap between your pregnancies is short (although see above), your scans and measurements thus far predict a big baby or if MRIs of your lower womb have revealed that the area is weak.
Regardless of the cautions described, if a VBAC is something you decide on, your health professional should work with you to plan accordingly and go through any questions you may have.
How Successful are VBACS?
The evidence shows that a vaginal birth is likely to be highly successful, particularly if you have already delivered this way in a previous pregnancy and even more so if it was a VBAC. The success rate for a successful VBAC after one previous c-section is between 72%-75% and about 71% if you've had two previous c-sections.
The rate is much lower at about 40% if the following circumstances apply: labour is induced, all previous pregnancies have been via caesarean delivery, previously had a c-section if labour was slow and if at the start of your pregnancy your BMI is over 30. Induction of labour is possible during a VBAC, and the routine is not any different to if you had not had previous c-sections; however the risk for possible complications is greater – similar to if you were to have a repeat c-section, i.e. danger of the scar tearing open. If you were to be induced, you might be offered options that are not hormone-related such as the insertion of a cervical ripening balloon catheter whose job it is to assert gentle pressure on your cervix, softening it enough to start labour or for your waters to be broken.
If you decide this is the journey you want to take and to ensure that you give yourself the best possible chance of a successful VBAC, you should eat healthily and stay active. Some areas also offer VBAC antenatal classes which you may find useful. You should also prepare yourself with the possibility of another caesarean delivery; the goal at the end of a pregnancy is for healthy mother and baby and a VBAC may not be the solution in all circumstances when it actually comes down to it.
How To Prepare Your Body For a VBAC?
Preparing your body for a VBAC doesn’t require any specialist treatment or exercise, rather the recommendations are the same for if you were giving birth for the first time vaginally. Expectant mothers should do what they can to remain active; walking is known to be beneficial throughout and especially near your due date. The movement from walking will coax your baby into the correct position near your cervix, the pressure, in turn, could encourage your body to release oxytocin, a hormone that is known to initiate contractions.
Some mums find a birthing ball helps them throughout the pregnancy, as well as when preparing for labour. The ball is great for easing back pain and when used regularly in the months before labour, can actually reduce the pain of contractions. Having the birthing ball provides something else for you to focus on and therefore, when in labour could help to reduce anxiety.
There are many other methods which women swear by and what works for one person may not necessarily work for you. Caution is advised in some cases, and if you're not sure, do ask a health professional. Raspberry leaf tea is one example of this. There is a misconception that the tea prepares the body for labour by working to tone your uterus muscles, when, in fact, it could do more harm than good. Any sudden stimulation can result in strong contractions which can be harmful to your baby.
What Do Obstetricians Say?
Obstetricians agree planned VBAC is a clinically safe choice for the majority of women.
The National Institute for Health and Care Excellence states: if a woman chooses to plan a vaginal birth after she has previously given birth by caesarean section, she should be fully supported in her choice.
The Royal College of Obstetricians and Gynaecologists says that in making your decision between another caesarean delivery and a vaginal birth, previous pregnancies and medical history are important factors which should be taken into consideration.
Guidance from the NHS confirms that most women who have had a c-section can safely have a vaginal delivery and that to enable this to happen successfully, extra monitoring during labour will be undertaken.
For further information on any of the issues discussed or if you have other queries not answered here, take a look at one of the guidance pages linked above.