Independent midwives in Kent supporting women's choice

Vaginal Birth After Caesarean Section (VBAC)

We remember looking after Carol who was having her second baby following a caesarean section with her first. With the first baby she had a 30 hour labour with every intervention going and got to almost full dilatation before the operation was carried out to deliver her baby. You would be forgiven for thinking that she would not want to go through that experience again. However, during labour all she was reflecting upon was the painful and frustrating recovery from surgery and how difficult everything had been with a baby to care for.

This appears to be the case quite often and many women despite the reason for the previous caesarean section want to be able to experience vaginal birth. Very often there are feelings of guilt that their bodies have failed them and the need to give birth vaginally can become overwhelming. That is not to say women who choose to have a repeat caesarean section should feel or be made to feel guilty about their choice.

When making the decision about choosing VBAC or repeat caesarean section, women should be told about the risks involved with both. The evidence from research confirms the safety of VBAC in that it is associated with lower risk of complications for both mother and baby than a repeat caesarean. Although the risk of a mother dying with caesarean section is small, it is still about four times higher than with any type of vaginal birth. Other complications such as other operative injury, infection, bleeding, post natal pain and effects on future fertility are higher with caesarean section than vaginal birth. With VBAC the most important consideration of risk is scar rupture. Most scar ruptures are 'silent' or 'incomplete' - the scar stretches and thins but this does not harm mother or baby at all. Research has shown that the generally accepted risk of all scar ruptures is 0.5% or 1 in 200 births. It is very rare for a life- threatening complete rupture of the uterus to occur - between 0.09% to 0.8%. To put this into perspective, any labouring woman is about 30 times more likely to need an emergency caesarean section for another serious complication like a haemorrhage for example, than a woman needing one because of a complete scar rupture (Enkin 2000).

We always recommend that women carefully consider where they plan to give birth with a VBAC. All hospitals will have strict policies and guidelines for VBAC include continuous fetal monitoring, a 'drip' (with or without fluid attached) and the withholding of food and drink. Very often the clock will be ticking and time limits of labour will be imposed. All of these things are done on the understanding that a woman may require a repeat caesarean section and are questionable given the current evidence. Some women might feel that they are being 'set up to fail' as these policies may not allow then to labour naturally. Women should understand that they have a right to decline any intervention if they do not want it and hospital staff must respect and support their choices. Many women will decide to stay at home, because they feel that this is the safest place for them to labour more easily.

We actively support women choosing VBAC . We have cared for women who have had more than one previous caesarean. Most women have given birth at home; some have chosen water births. About 80% of our client achieve the VBAC they desired (have look at our statistics).

References

Enkin, M et al (2000) 'A Guide to Effective Care in Pregnancy and Childbirth' Third Edition, Oxford University Press.