Tuesday, 28 May 2013
A VBAC is a vaginal delivery after you have had a caesarean. In the past women have been told ‘once a caesarean, always a caesarean’, this is because of the risk of uterine rupture from the strain of labour contractions on your caesarean scar. But this view is changing all the time. Some doctors feel it is safer for women to attempt a VBAC (pronounced vee-back) because of the strain on the scar tissue that any repeat caesareans may have.
Seventy per cent of mothers who attempt labour after a caesarean go on to have successful VBACs. The general rule is, if the same reasons you had the first caesarean exist with your second pregnancy, for instance your baby is breech, you have twins or multiples, you have a very large baby or you fall into a high-risk category, you will probably have a caesarean again. If you have a straightforward pregnancy (or your last baby was breech and this one isn't) there is no reason why you shouldn’t attempt a VBAC.
Some doctors or midwives call a VBAC delivery a ‘trial of labour’, or ‘trial of scar’, because you will be monitored throughout to see if your body and baby can attempt a VBAC. Check the hospitals policies about a VBAC delivery and if you are being persuaded against trying it, do consider finding another hospital, which is willing to let you try to birth vaginally.
You are more likely to have a successful VBAC if your previous caesarean was because your baby was breech, or if you have already delivered vaginally in the past.
The success rates are lower if you have already had one caesarean, or you had a C-section because your pelvis was too small. If you had oxytocin to induce labour you may be less likely to attempt VBAC.
Can I have a VBAC if I have had two caesareans?
You will have to talk this over with your healthcare provider, and assessed based on your past deliveries, but it is possible. Some women have successfully attempted a VBAC after two previous caesareans, so it should never be ruled out. Each woman and her circumstances are different so even though you've heard of it happening, it may not be suitable for you.
What if my consultant and hospital staff advises against a VBAC?
You can find an independent midwife who will stay with you throughout your labour and birth in hospital, who supports your decision to have a VBAC and is willing to help. The private midwife comes with you to the hospital and stays with you through the entire journey from the start of labour to when you give birth to your baby. Private midwives exist in every area and your health visitor or GP may be able to help you find someone who is comfortable taking on a VBAC delivery. Bear in mind that your will have to pay for a private midwife.
What are the advantages of a VBAC?
The advantages of a VBAC can help you to decide if it is right for you and your baby:
- You recover more quickly from a VBAC and your hospital stay isn't as long.
- You will feel a sense of achievement this time as you were able to delivery vaginally.
- You are less at risk of infection and needing a blood transfusion with a VBAC.
- You are less likely to experience blood clots; something you are more at risk from following a Caesarean.
- Your baby is less likely to experience breathing difficulties after a vaginal birth.
What are the disadvantages of a VBAC?
- Although rare, some women are more at risk from experiencing uterine rupture
- You will probably be monitored throughout your labour and you cannot be induced because of the risk of uterine rupture (see above), so although it will be your choice you may feel less in control.
Should I be worried about Uterine Rupture with a VBAC?
If your uterus carries a scar from previous surgery (fibroids or a previous caesarean) there is a small risk of uterine rupture in subsequent pregnancies. Studies show that the rate of uterine rupture in women who have previously had caesareans is 0.09 to 0.8 per cent - so it is very rare. A classical caesarean section scar (a large vertical incision across the abdomen, rarely used now) is more likely to rupture than a lower segment scar (a vertical cut at the top of the bikini line, which is far more common), which is why an elective caesarean before term is advised for these women. However more and more women are choosing to have VBACs following a previous Caesarean section and luckily hospitals, consultants and midwives are supportive of this decision.
There are two types of ruptures, the first is called a Dehiscence rupture and describes a partial rupture where the scar starts to undo. Neither the mother nor the baby will be affected by this.
The second type of rupture is called a symtomatic rupture and describes a scar that has completely ruptured. Symptoms are likely to be severe bleeding, severe pain and foetal distress, but often the rupture will be silent and painless. Ruptures tend to happen during labour but can happen beforehand. During labour your blood pressure my drop and you may experience pain in one area even if you have had an epidural. Any time you experience bleeding or abdominal pain it is advisable to seek medical help immediately. With this type of rupture your baby is likely to be delivered by caesarean section immediately. Other signs of uterine rupture can be dips in your baby's heartbeat or fetal distress which can be picked up with a fetal monitor. Sometimes women experience a bulge in their abdomen just prior to a rupture, but your midwife should know the signs to look out for.
Is there anything I can do to prevent uterine rupture?
You will have to discuss your options with a midwife, but most hospitals won't induce labour because there is evidence that using the drug prostaglandin to induce labour can increase your risk of rupturing. You will have to discuss with your midwife about what happens when you reach your due date and your baby has not arrived. Some hospitals will let you go over by a few days and wait for labour to start naturally and some will suggest you have a repeat caesarean. Ultimately the decision is up to you based on you and your baby's health, so if you definitely want a VBAC and not a caesarean let everybody know.
If you do go into labour naturally, it is likely that you will have to have a great deal of fetal monitoring, which means you are less likely to have an active labour or give birth in the position of your choice; fetal monitoring means being strapped to a monitor and lying on a bed. Although this is frustrating, monitoring your baby means the medical staff can check for any dips in her heartbeat, or fetal distress - one of the first signs of uterine rupture.
Your midwife or GP can check your existing scar on antenatal visits if you are worried.