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Next birth after Caesarean Section (VBAC)

next; birth; vaginal; caesarean; elective; emergency; VBAC; after; following; NBAC;

A decision needs to be made about the way a baby is born if the mother has already had a caesarean section for a previous birth. It may be possible for her to have a vaginal birth after Caesarean (VBAC) or a repeat Elective Caesarean may be safer.

Contents


Introduction

This topic provides information to help you decide how you would prefer to give birth to your baby, having had a previous caesarean. This information is based on the best available evidence from both hospital data and research. You are encouraged to meet with an obstetric consultant early in your pregnancy, to discuss your birth options.

This topic provides detailed information. This pamphlet from the Department of Health, South Australia provides some briefer information about Vaginal birth after Caesarean section. A vaginal birth may not be best for you and your baby, and there is more information in this topic about the things that will need to be thought about.

The saying ‘Once a caesarean, always a caesarean' was coined in 1922 (Craigin) when almost all caesarean sections were done by a “classical incision” – that is, an up and down cut into the upper wall of the uterus. This type of incision would tear during labour for 7 in 100 (7%) women. This high risk of tearing led to most women who had had a caesarean section being advised to have another caesarean for any future pregnancies.

Since the mid 1950's almost all caesarean sections have been performed using a cut across the lower abdomen and the lower part of the uterus (Lower Segment Caesarean Section or LSCS), which have a much lower rate of complications if vaginal birth is later attempted. Because of this, most women today who have had a previous caesarean section will be offered the option of a vaginal birth after caesarean section (VBAC). It is important to understand that an up-down cut on your abdomen does not necessarily mean that you have had an up-down cut on your uterus.

Vaginal birth after Caesarean – VBAC

In South Australia, two out of three (67%) women who attempt a VBAC (vaginal birth after caesarean) are successful. This means that most women will not need a repeat caesarean for their next baby's birth, as the reason for the previous caesarean is not likely to happen again. This observation is supported by current research. VBAC is a safe and viable option for most women who have had a previous caesarean.

Why are caesarean sections done in the first place?

For 3 in every 100 (3%) pregnancies there is an absolute indication for a caesarean section. This means that in the following situations, a caesarean section is definitely the safest way for the baby to be born.

  • Placenta praevia – where the placenta is blocking the birth canal.
  • Abnormal position of the baby – the baby is lying in such a way that a vaginal birth is not possible, such as across the uterus (transverse) or feet first (footling breech).
  • There is a scar in the upper part of the womb (such as from a previous “classical” caesarean section or from other surgery such as a fibroid removal).
  • The mother is unwell or the baby is so ill that a caesarean is considered the safest option.

However, there are other situations in which it may be decided that a caesarean section is probably the less risky option, compared to a normal birth.
For example:

  • If a baby is assessed as being distressed during labour, or if the labour isn't showing signs of safe progress. 
  • A lack of progress in labour can be due to a number of reasons (usually a baby facing forward and/or with their head tilted back) or because the contractions are not effective.

It is actually very rare for a normal baby to be too big to fit through the birth canal – although this can occasionally happen.

Studies tell us that there are a number of reasons why women consider having an elective caesarean when there is no medical reason to do so.
These include

  • Anxiety or a sense of trauma related to their previous birth experience
  • The belief that caesarean birth is safer.

It is common for women who have had a stressful birth experience to lose faith in the process of birth and in the ability of their body to birth successfully.

When may VBAC not be an option?

There are rare situations in which there is a general agreement amongst doctors, midwives and the pregnant woman that having a VBAC has higher risks to the mother and baby than having an elective caesarean section. 

These include:

  • If there is an absolute indication (as outlined previously), such as the placenta blocking the birth canal (placenta praevia) or the baby lying crossways.
  • Where a previous surgical incision was made in the upper part of the uterus that went through to the cavity of the uterus, such as a “classical” or inverted T incision. Or if there had been surgery on the uterus, for example, to remove a fibroid.
  • If you have a history of attempting VBAC and the scar separated, leading to the need for an emergency caesarean.
  • If your baby is unusually small or unwell, or you have severe medical problems (such as heart disease causing shortness of breath).
  • If your labour needs to be induced for a clear medical reason but your cervix is not ready for birth. Usually prostaglandin gels would be used to make the cervix soft (favourable). However, it is not safe to use this medication in a woman who has had a caesarean because the prostaglandin gel may also soften the caesarean section scar, making it more likely that the scar will tear during a VBAC attempt.

What are the benefits of a successful VBAC?

  • The baby is less likely to have respiratory (breathing) problems following the birth, so it less likely that you and your baby will be separated. 6 in 100 (6%) babies have respiratory problems after a caesarean birth, compared to 3 in 100 (3%) following a vaginal birth.
  • More likely to be able to cuddle your baby and offer them their first breastfeed within an hour, when their hormones make them particularly wide awake and interested in sucking.
  • You and your baby are more likely to continue to breastfeed successfully.
  • Less pain and quicker recovery following the birth, with less time spent in hospital making it easier to look after your baby (and other children).
  • Option to go home on early discharge (4-6 hours after birth) if there is no medical reason to stay in the hospital.
  • Opportunity to experience labour and a normal vaginal birth.
  • More likely to feel satisfied with the birth experience. Studies have shown that women who have a vaginal birth are more likely to feel positive about their birth experience.
  • The body produces high levels of hormones with a vaginal birth, especially oxytocin, ‘the hormone of love', which can help with feeling bonded with your baby.
  • Less risk of complications such as bleeding, infection and blood clots, reactions to anaesthetics or accidental damage to internal organs.
  • Less risk to future pregnancies of placental problems, ectopic pregnancies and possibly stillbirth for unknown reasons (although this is quite rare), compared to having a repeat caesarean.
  • Driving a car and lifting up a toddler will not be a problem.

What are the possible risks associated with a VBAC?

  • There is a very small risk that the scar may separate or rupture during a VBAC. About 1 in 300 (0.3%) women attempting a VBAC may experience rupture of the scar on the uterus. Because of this, you will be offered continuous monitoring of your baby's heart beat during your labour if you decide on a VBAC. Studies have shown that the most common sign that a caesarean scar may be separating is a sustained drop in the baby's heart rate. Having continuous monitoring will reduce the risk of an adverse outcome to about 1 in 3,000 (0.03%). (This compares favourably to the over all risk of stillbirth for any pregnancy of 1 in 2,000). Other possible signs of scar separation that your caregivers will be looking for include continuous pain (strong pain between contractions as well as during them) and vaginal bleeding (although some vaginal bleeding in labour can be normal).
  • An emergency caesarean may be needed if problems develop during the labour. Emergency caesareans carry slightly higher risks than elective caesareans, eg for infection.
  • There may be a need for instrumental assistance to birth the baby, using forceps or vacuum extraction. This may increase the risk of developing incontinence. (For the years 2006 and 2007 at the Women's and Children's Hospital, 6.1% of all babies born at the hospital were birthed with assistance from forceps and 6.4% with vacuum extraction (ventouse).
  • From hospital data, the incidence of episiotomy (cut made to the perineal tissue between the vagina and anus) is 14 in 100 (14%) and is usually associated with instrumental assistance for the birth. The risk of a third degree tear is 3 in 100 (3%); the risk of having a fourth degree tear is 1 in 500 (0.2%).

Repeat Elective Caesarean

  • The term elective caesarean refers to a caesarean that is done before you go into labour. The most common reason for elective caesareans is that a previous baby was born by caesarean.

What are the benefits of an elective caesarean section?

  • Knowing when your baby will be born can assist with planning maternity / paternity leave and child-care.
  • Less risk of needing an emergency caesarean section during labour. One in three women attempting VBAC will have an emergency caesarean (which can have slightly more complications than elective caesarean sections e.g. infection). If an elective caesarean is chosen, an emergency caesarean would only be needed if labour starts prior to the date of the planned caesarean.
  • You have had a caesarean before so you have a good idea of what to expect.

What are the possible risks associated with a repeat caesarean?

  • Some women may find it takes longer for them to feel close to their baby following a caesarean, partly because the post-birth hormones that stimulate bonding tend to be lower with a surgical birth.
  • More babies are admitted to intensive care or special care nurseries for respiratory (breathing) problems after a caesarean (6:100 versus 3:100), which can delay the first breastfeed.
  • More chance of an infection developing in the wound. This infection may spread into the uterus, increasing the chance of being re-admitted to hospital with a health problem within a few weeks of going home.
  • Increased risk of bleeding that requires a blood transfusion.
  • Anaesthetic complications – less common if a spinal or epidural block is used.
  • There is a risk of accidental surgical damage to the bladder / bowel. (Accidental surgical damage to the urinary tract occurs in about 1 in 1000 caesareans). This may be associated with a higher risk of long term pelvic pain / bowel problems from scar tissue and adhesions.
  • Longer recovery time after the birth with a longer stay in hospital and more pain in the days, weeks and months following the birth. This can make it more challenging to care for your baby and family.
  • More risk of developing blood clots in the lungs or legs.
  • There is a higher risk of developing post-natal depression.
  • Future fertility - some women may have difficulty getting pregnant again.
  • There is an increased risk of ectopic pregnancy (where baby develops outside the womb and cannot survive – this is also dangerous for the mother); and a very, very small increase in the risk of stillbirth in a future pregnancy, for reasons that are unknown.

There is a slightly increased risk for future pregnancies of other problems but if these rare problems do occur, they can be quite severe. These include placental problems such as placenta praevia, (where the placenta grows across the entrance of the womb, increasing the risk of bleeding during the pregnancy and making it necessary to have another caesarean); placenta accreta (where the placenta grows into the muscle layer of the uterus, greatly increasing the risk of heavy bleeding after the birth); and placenta percreta (where the placenta grows through the wall of the uterus and can attach to other organs within the pelvis).

There are a range of risks and outcomes that are similar for VBAC and Repeat Elective Caesarean

  • In Australia, mothers dying during childbirth are quite rare. The overall risk to the mother of death is not significantly different whether VBAC or elective caesarean section is chosen.
  • 1 in 2000 (0.05%) women who have had a previous caesarean will need a hysterectomy because of scar rupture. The rate of women needing a hysterectomy is similar for women choosing a VBAC as for women having a repeat elective caesarean.
  • The number of women who experience stress incontinence (leaking urine when they cough, laugh or sneeze) is similar for women having a normal vaginal birth or a repeat caesarean. This number is about 4 women per 100 (4%) at 3 months after the birth.
  • About 1 in 5 (18%) of women report dyspareunia (sexual intercourse that is uncomfortable or painful) when their baby is three months old. This number is the same for women having a VBAC or a repeat caesarean.

How is an elective caesarean different from an emergency caesarean?

An elective caesarean refers to a caesarean done before labour has started. An emergency caesarean refers to all caesareans done after labour has started.

  • If you are planning to have your baby by elective caesarean, you will be booked in to see a consultant when you are 36 weeks pregnant. During your appointment, the consultant will talk with you about your birth options. If you have decided on a caesarean, the consultant will book your caesarean for some time after you are 39 weeks pregnant. In the past, elective caesareans were often booked when women were only 38 weeks pregnant. However, the chances of your baby developing breathing problems and needing time in the nursery is lessened if you are 39 or more weeks pregnant at the time of the caesarean.
  • You will also be booked in to see an anaesthetist when you are 36 weeks pregnant. The most common pain relief offered to women having an elective caesarean is a spinal block so you will be awake during the operation.
  • You will not have more than one scar on your abdomen if you have more than one caesarean. If you and your baby are well after the birth, you can ask to have skin-to-skin cuddles with your baby while your wound is being stitched. If your baby is well, he or she will stay with you in recovery and you will be supported to feed your baby.

Other considerations

  • One issue to think about when you are deciding whether or not to have another caesarean is how many children you are planning to have. The risk of developing complications in future pregnancies associated with having a caesarean does increase with each caesarean.
  • When thinking about how you want your next baby to be born, it can be helpful to be clear about why you needed a caesarean last time. If you don't really know, ask the midwife or doctor to look at your notes and explain it to you.
  • If you felt out of control, or that your body let you down, talk this over too. If you don't feel able to talk about this with midwives or doctors, you can contact the consumer organisations listed at the end of this topic. Many of these are run by women who have also had the experience of having a baby born by caesarean and are willing to listen to you and offer support.
  • Studies have also shown that birthing women are more likely to feel in control if they have a good relationship with the people providing their care. Ask about the options available to you, both within the hospital and out in the community.

Glossary

  • Classical incision:  the caesarean has been done using an up and down (vertical) cut on the wall of the uterus. An up and down cut on the womb is quite rare in Australia (usually only done if the baby is very premature or the baby is lying sideways). If you don't know what type of cut was made on your womb during your caesarean, your doctor or midwife will be able to check this in your hospital notes, or find out from the hospital medical records department if the operation was done in another hospital.
  • Elective caesarean:  is one that is done before you go into labour
  • Emergency caesarean:  is one that is done after your labour has started
  • Episiotomy: is a cut made to the perineum to make the vaginal opening
    bigger
  • LSCS (lower segment caesarean section):  a caesarean that has been done in which the cut was made from one side of the lower uterus to the other side (horizontal)
  • Third degree tear: a tear through the anal sphincter to the rectum (back passage), which does not reach the mucosal lining of the rectum
  • Fourth degree tear: a tear through the anal sphincter to the rectum (back passage), which reaches the mucosal lining of the rectum

Other useful resources

There are a number of resources available to help you make the best decision for you and your baby. Some of these are listed below.

Source

Women's and Children's Health Network, Department of Health, South Australia
 http://www.wch.sa.gov.au

Reference

SA Maternal & Neonatal Clinical Network (South Australia) 2018
'Vaginal birth after caesarean section'

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The information on this site should not be used as an alternative to professional care. If you have a particular problem, see your doctor or midwife.

 

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