Vaginal Birth after Caesarean

Contrary to popular belief, vaginal birth after a caesarean section is possible. The previous belief of 'once a caesarean, always a caesarean' has been discarded. If you desire to try a vaginal delivery after having had a caesarean, you should be encouraged by knowing that 90% of women who have undergone caesarean deliveries are candidates for vaginal birth after a caesarean (VBAC).

In most published studies 60-80% of women who have previously undergone caesarean birth can successfully give birth vaginally. Recently, the American College of Obstetricians and Gynaecologists (ACOG) stated that VBAC is safer than a repeat caesarean, and VBAC with more than one previous caesarean does not pose any increased risk.

Why would I want a vaginal birth?
There are many reasons to opt for vaginal birth instead of a caesarean section - some may be medical, some emotional, while others may be financial.

Maternal reasons

• Potential complications may occur during surgery, such as:

- blood loss
- infection
- injury to other organs (bowel, urinary tract, etc.)
- blood clots in legs (deep vein thrombosis).

• Breastfeeding is normally experienced as easier to establish after a vaginal birth.
• Feelings of guilt or inadequacy may sometimes be caused by surgery in obstetrics.

Foetal reasons

• Vaginal birth prepares the baby for life outside the uterus.
• Injuries to the baby may occur, such as cuts.
• Vaginal birth after a caesarean results in fewer foetal deaths than elective, repeat caesareans.

Costs

• Vaginal birth costs less than a caesarean birth.

Who are candidates for vaginal birth after a caesarean?
You may be a candidate for a vaginal birth after a caesarean if you:

• Have the willingness to prepare for vaginal birth after a caesarean.
• If the original reason for a caesarean delivery is not repeated with this pregnancy
• Have an adequately-sized pelvis
• No more than two previous low transverse caesarean deliveries.
• No additional uterine scars, anomalies or previous ruptures.
• Your health care provider is prepared to monitor labour and perform or refer for a caesarean if necessary.
• You have no major medical problems
• The baby is a normal size
• The baby is head-down

Preparing for vaginal birth after a caesarean
There are many things that you should do to prepare yourself for vaginal birth after a caesarean. Mental, emotional, physical and general preparation is essential for successful vaginal birth after a caesarean.

• Consult your doctor, do a risk assessment with him/her, take your personal medical history into account and plan the delivery.
• Get as much information on the topic as you can. Obtain a personal copy of your medical records from previous births.
• Ask your doctor to explain anything that you don't understand.
• Talk to other mothers about their experiences. Read books and journals on the subject.
• Prepare your body physically by doing the correct antenatal exercises, upon instruction and in consultation with your doctor. If you are in a good physical condition, it should speed up the labour and healing process. Regular exercise and special birth exercises are good ways of doing this.

Frequently asked questions about vaginal birth after a caesarean

What if my pelvic bones are too small?
No more than 20% of women have pelvises that are of a different shape than the normal female pelvis, but only a percentage of these women require a caesarean section. Women who had polio or pelvic fractures have a higher need for repeat caesarean sections.

What if the baby is too large?
The pelvis and the baby's head are not rigid structures. Both mould and change shape to allow the birth to occur. The treating doctor will assist you in evaluating the size of your baby.

What about rupture of the uterus?
The greatest concern for women who have had a previous caesarean is the risk of uterine rupture during a vaginal birth. This is a common fear among women who have had a previous caesarean. Most of this fear dates back to the time when the cut used for the original caesarean was made vertically into the uterus, i.e. top to bottom. Nowadays, most incisions are of the low transverse type into the uterus, i.e. across. According to the American College of Obstetricians and Gynaecologists (ACOG), if you had a previous caesarean with a low transverse incision, the risk of uterine rupture in a vaginal delivery is 0.2 to 1.5%, which is approximately 1 chance in 500.

References

1. CHILDBIRTH. Website: http://www.childbirth.org/
2. FINLEY, BE & GIBBS, CE. November 1986. Emergent caesarean delivery in patients undergoing a trial of labour with a transverse lower-segment scar. American journal of obstetrics and gynaecology. 155(5) 936 - 9.
3. HEALTHY PREGNANCY. August/September 2004.
4. PAUL, RH & PHELAN, J. 1985. Trial of labour in the patient with a prior caesarean birth. American journal of obstetrics and gynaecology. 151(3) 297 - 304.
5. ACOG. Practice Bulletin, No. 5, July 1999
6. ACOG. Midwifery Today. Winter no36. Page 47.
7. Levine, EM et al. 2001. Mode of delivery and risk of respiratory diseases in newborns. Obstet Gynecol. 97(3):439-42.
8. International Cesarean Awareness Network