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  • Writer's picture Suzanne Fowler Evans

VBAC v Caesarean Birth - How can you choose?

Your first birth was a caesarean, for whatever reason, and these are plentiful!

In my local maternity units, Royal Surrey County Hospital and Frimley Park, their caesarean section rates hover at around the 25% mark. Maybe you had a breech baby or a pre-existing medical condition, so a caesarean was planned or maybe you had an unplanned caesarean, due to something that happened during your labour? Many women who had planned for a spontaneous vaginal birth may still have a caesarean, and this includes women who labour in a birth centre or labour ward.

So many things can increase your chance of having a caesarean and these often start with what I refer to as the Cascade of Intervention. In layman's terms, anything that disrupts the natural, hormonal and instinctive nature of your labour. This commonly starts with induction and as we know, many women are offered an induction for all kinds of reasons. I am going to estimate around 30% of women are induced, which in my mind is a high number, when often they were considered low risk at the start of their pregnancy. Why is this ?? So many women are offered induction because they have gone over their due date, waters have broken, developed signs of pre eclampsia, lack of fetal movement, big baby, small baby, gestational diabetes ….. It could just be that your first impressions of the room you were labouring in did not help you produce oxytocin so your labor slowed down, some fetal monitoring that caused concern or a vaginal examination that was uncomfortable - all of these things can disrupt how your labour flows and in turn lead to interventions of one kind or another.

Most women I speak to post birth are really pleased with their birth experience and that is great news, especially when they had discussed their birth preferences with their midwives and this led to planning a caesarean birth. Recovery from a planned caesarean is often easier than from an unplanned, as if you know what to prepare for and expect it is easier to think about your recovery and who might be around to support you. Sadly, some women can feel that they failed in some way when they give birth by caesarean unexpectedly, and this can lead to a higher chance of feeling low, not bonding as well with your baby or other symptoms of postnatal depression.

Regardless of why you gave birth by caesarean, when it comes to your next baby, choices are there for you to make. Your first option may be to just have another caesarean, very often this makes the most sense, especially if you have a toddler running around. At least when you have a date in your diary you can arrange child care and make allowances for when you come home. The alternative, and one that is being discussed more and more with midwives is to have a VBAC - Vaginal Birth After Caesarean, formerly referred to as a Trial of Scar. I much prefer the first offer, the words trial and scar should never be included in a sentence around birth and informed decision making! Saying that, I am not trying to make light of the importance of information around the risks of a VBAC.

A Cochrane review in 2013 highlighted the risks associated with both planned caesarean birth and VBAC. They carried out a randomised trial involving 33,699 women who had given birth previously via caesarean section. Just over half 53.1% had a VBAC while 46% opted for a planned caesarean. The conclusion of this study is that there was no significant difference in outcomes, including mental health, wellbeing and satisfaction for either group. The risks of caesarean section on both mum and baby are commonly known but the main risk for a woman having multiple caesareans is difficulty during surgery with adhesions and possible damage to the bladder and bowel. There is also an increased risk to fertility after surgery.

The main risk with a VBAC is the chance of uterine scar rupture (the scar tissue from previous surgery is not strong enough to withstand the force of the contractions), which affects approximately 0.2 - 0.7% of women. Another risk is that it may still result in another unplanned caesarean and for some new mums and their families, this might just be a risk too high to contemplate.

So as with many things communication is the key!

When deciding how you would like to give birth to your next baby, reflect on your previous birth and go armed with questions for your midwife or consultant. If you know you want to have a caesarean again this time, that is absolutely your right and maybe discuss having a family friendly or more natural caesarean. However if you would like to have a vaginal birth, ask how your birth will be managed, will you be considered high risk, what are the chances if you being induced and will you have constant monitoring. Can you use the midwife led unit, labour in the pool or give birth at home?

Once you have had a discussion, go away and use your BRAIN (Benefits, Risks, Alternative, Instinct, Nothing) then go back and have another chat to ensure you are offered the birth you want based on proper, unbiased information.

As always, if this blog has raised any questions or you would like to have a chat through your options, or what questions to ask or health care providers, please get in touch :-)

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