Vaginal Birth After Caesarean

By Helen Bremner RN RM

The decision to undertake a Vaginal Birth After Caesarean (VBAC) can be difficult for some women. As the rate of caesarean section grows in this country (1), more women may seek the option of VBAC for subsequent pregnancies.

VBAC (pronounced vee-back) is not a new concept. For over fifty years a few doctors have advocated allowing labour after a previous caesarean (2).

Not all doctors share this opinion however. Supporters of VBAC do so with a wealth of medical research behind them. Research that proves categorically that 70%-80% of women are able to achieve VBAC(3).

In contemplating VBAC there is much information to gather. Sometimes it
might seem a lot easier, and more appealing to repeat a familiar experience. This decision may be made rather than taking on a whole new set of unknowns in VBAC.

However, repeat caesarean section (C/S) can pose risks for the mother. As early as 1971, Avery remarked that repeat C/S can lead to increased pain, depression, infection,
haemorrhage, adhesions, injury to adjacent sturures, blood transfusions, aspiration pneumonia, cardiac arrest and death (4).

Repeat C/S may be unavoidable. If the condition causing your previous C/S still exists, it may be doubtful that you are a candidate for a vaginal birth. Two such conditions include a misshapen pelvis and chronic high blood pressure.

The reasons for one caesarean do not necessarily reoccur in subsequent pregnancies. These would include breech or any other malpresentation, failed induction, fetal distress , prolapsed cord, multiple births. placenta praevia, abruptio placenta and toxemia. (5)

Putting all the information into persepective, there can be risks with VBAC. One of the greatest concerns most people have (doctors included) is the risk of uterine rupture. The very word rupture can elicit fearful responses form the most educated people.

Uterine rupture refers to any separation in the wall of the uterus. The statistical risk of rupture is cited at less than 1% for women who have had a previous lower segment C/S. (NB the external incision scar may not be the same as that on the uterus) (6)

In many ways fears about delivery are experienced by pregnant women. Because there is never a ‘’no risk’’ situation in pregnancy and childbirth, decisions should be made based on facts plus your own preferences and feelings.

Whatever you decide, you will almost certainly have ambivalent feelings. You may wonder whether you have made the right decision and feel anxious over how the decision will affect your baby and yourself.

Here in Brisbane two groups offer support to women as they work through the decision making process. The Childbirth Education Association (Brisbane) Inc. provides a VBAC support line where you can speak to someone who has already experienced a VBAC.

Birthtalk provides a forum for women to discuss the birthing options available and endeavours to empower women by providing them with access to current and accurate literature and information.

In other states there may be organizations that offer VBAC classes. Your local hospitals should be able to furnish you with details of what is available in your local area.

Information about VBAC can be obtained from a plethora of books. Titles that are well worth a read are;
• Silent Knife, Caesarean prevention and VBAC by Cohen,N , Estner L.
• Birth after Caesarean -The medical facts
by Flamm B, MD
• Open Season by Wainer-Cohen, N
• Natural Childbirth after Caesarean by Crawford, K, Walter, J.
• Trust your body Trust your baby by
Henkant, F.

In 1991 Kirk et al investigated the reasons why women were choosing VBAC. Their research showed women preferred VBAC because of
• Shorter recovery 44%
• Risks of C/S to the mother 41%
• Wanting to experience vaginal birth 27%
• Risks of C/S for baby 29%
• Other factors 18%
• Financial reasons 7%
(7).

Enkin et al support this research and further add that VBAC
• Lower mortality/morbidity rates than repeat C/S
• Less risk of infection
• Faster recovery time
• Less use of pain relief
• Better breastfeeding outcomes
• Less postnatal depression
• Increased personal growth
• Greater feelings of well- being
• Enhanced bonding(8).

There are many people who might influence your decision. They are your doctor, partner, midwife, friends, parents, childbirth educator and your siblings. Everyone will seem to have an opinion which ever way you decide. There are some steps you can take to ensure your decision is right for you!

These are;
1) IDENTIFY THE PROBLEM
In this case, not wanting a repeat C/S
• Find out the reason for your previous C/S
• Identify the reasons for wanting a VBAC

2) GATHER INFORMATION/ INVESTIGATE THE ALTERNATIVES
• Understand what VBAC is about.
o Read books and literature about VBAC.
o Do a web search.
• Look for a supportive Doctor or hospital. Ask them about what is routine management.
• Be aware of what good preparation involves
o Knowledge of normal childbirth
o Emotional preparation
o Good nutrition and exercise
o The effects of intervention
o Read what you can about preventing a repeat C/S
o Practise coping with pain and stress
* relaxation techniques
* breathing
* visualizations
* massage
o Write up a birth plan
o Find out about labour support groups
• Talk to others about previous feelings about C/S. Try to come to terms with unresolved conflicts that may hinder this labour.

3) ANALYSE THE INFORMATION
• Write each option down on a piece of paper
• Weigh up advantages / disadvantages of each option
• Visualise a scale … which way does it tip?

4) CHOOSE YOUR OPTION
• Do this according to your beliefs, values and goals.

5) IMPLEMENTATION
• Get ready to put all you have learned and practised into play

6) EVALUATE
• Whatever the outcome, being involved in the planning of your labour is an empowering thing.
• You may find you emerge from the birth with good feelings about your role
• This in turn can afford a greater degree of optimism about the future.

Having a VBAC is worth it! YOU CAN DO IT! Everything is not within our control, however, it is within all of us to prepare ourselves as best we can to maximixe the chance of VBAC. (9).

ACKNOWLEDGEMENTS.

Not all the words in this document are my own. I have utilized the marvelous work of Kathy Keolker’s paper ‘Vaginal Birth After Caesarean’ ICEA 1981.

I have edited and paraphrased many of her sentences to provide this synopsis of her work. Although written twenty years ago many of the points she makes in the original paper are still applicable and valid today.

Additional information has been gathered over a five year period through my own reading on this important topic.

I urge you , if you decide on a VBAC to become truly knowledgeable on the subject so that you will be able to make informed choices.

Helen is a registered nurse, midwife and mother. She is actively involved in the Childbirth Education Association and the birth reform movement in Brisbane.

REFEERNCES.

(1) Senate Community Affairs Refences Committee. 1999
Rocking the Cradle: a report of childbirth procedures.
Canberra Commonwealth of Australia

(2) Flamm B MD 1990
Birth After Caesarean; The Medical facts.
A Fireside Book Simon & Schster,
New York.

(3) Cohen N, Estner L 1983
Silent Knife – Caesarean Prevention and VBAC.
Bergen & Carvey.

(4) Sufrin- Disler C 1990
ICEA Review- Vaginal birth After Caesarean.
IJCE Volume 14 No3 August 1990

(5) Avery ME
‘Does delivery by section matter to the infant?’
NEJM 285:917 1971

(6) Flamm B MD 1990
Birth After Caesarean; The Medical facts.
A Fireside Book Simon & Schster,
New York.

(7) Kirk et al cited Daniels, C, Oldman,K, Riggs,K, and Allen, J
Birth After Caesarean; Unlimited possibilities
1997

(8) Enkin Kierse Nielson, Crowhter, Duley, Hodnett, Hofmey 2000
A guide to effective care in pregnancy and childbirth.
Oxford University Press. UK

(9) Homebirth Services
How to prepare for a VBAC
www.homebirthservices.com.au/vbac.html