VBAC: Vaginal birth after caesarean
This article covers:
What is a VBAC?
What if I get pregnant soon after a birth by caesarean?
I have had two (or more) previous caesareans – is it still possible for me to go for a VBAC?
Will my midwife and obstetrician support me in having a VBAC?
What are the chances of my having a vaginal birth this time?
What monitoring is recommended during a VBAC labour?
Can I choose a VBAC home birth?
A vaginal birth after a caesarean section is usually referred to as VBAC (pronounced ‘vee back’). Vaginal birth has physical as well as psychological benefits for both mum and baby; and women who are pregnant after a previous caesarean sometimes have a strong desire to experience a vaginal birth. However, some women are apprehensive about VBAC, especially if they previously had a difficult birth experience.
VBAC can be safer for a woman than a repeat caesarean, because a caesarean itself carries extra risks. For example, there is an increased risk of infection and a longer stay in hospital.
There are implications for future pregnancies too, including risks of placental problems, which increase with the number of caesareans a woman has, and a greater risk of needing an emergency hysterectomy (removal of the uterus).
As long as there isn’t a particular medical reason not to have a vaginal birth; VBAC can be a good option for you and your baby.
The scar on the uterus can cause a weakness in the uterine wall and the stretching that occurs during pregnancy or the strong contractions of labour can cause the scar to become thin or begin to separate.
This can happen among 0.5 to 2% of women. This is known as ‘scar dehiscence’ and it doesn’t usually cause any problem. However, if the uterine scar tears open, causing bleeding and other complications, it is called ‘uterine rupture’ and is a serious risk to both mum and baby.
Rupture happens in 0.35% of VBAC labours (approximately one in every 300), but good care and observation in labour means that if a rupture looks likely to occur, a woman will have a caesarean very quickly. An experienced midwife will monitor the baby’s heartbeat and mum’s pulse. This, along with watching for abnormalities, such as bleeding, or pain that lasts between contractions, allows an early warning of potentially serious problems.
Research seems to show a small decrease in scar separation rates with a longer gap between pregnancies. However, the risks are small in all cases and most women who have a short gap between pregnancies don’t have problems.
If your caesarean section was not done with a low, horizontal cut in the uterus, you will need more information to make a decision. Ask your midwife and/or consultant about this.
It is possible to go for a VBAC after two or more c-sections? Yes and the research on this is encouraging. The likelihood of women having a vaginal birth after more than one previous caesarean section is about the same as that in women who have had only one previous section, and there is little difference in the risk of uterine rupture.
They should, but this does vary in different parts of the country and between different obstetricians and midwives. If you want a vaginal birth this time, discuss it with the healthcare professionals caring for you during pregnancy. If your midwives and obstetrician are not supportive, you have three options:
- Go along with what the midwife and obstetrician advise, if you feel this is best for you.
- Ask the midwife or your family doctor to refer you to a different obstetrician, or contact your supervisor of midwives to discuss your plans and seek support.
- Stay with your current caregivers but decline their advice and choose a vaginal birth. They should support your right to make an informed decision.
Most women who choose a VBAC do have a vaginal birth. Studies show that the rate varies a lot between different hospitals, but most record VBAC rates of 70% to 90%.
Women whose first caesarean was carried out because their pelvis was thought to be too small for their baby also have similarly high VBAC rates, as do women who have ‘failed to progress’ (as it’s termed) in a previous labour. There are a number of things you can do to maximise your chances of having a vaginal birth and these are exactly the same as for any woman giving birth:
- Choose carers and a birthplace with which you are comfortable.
- Discuss with your midwife a birth plan, which sets out your requests for support in the choices below.
- Allow labour to start naturally without induction (which also avoids increasing the risk of scar problems).
- Stay at home for as long as you feel comfortable and confident.
- Wait till your waters break spontaneously.
- Choose to have the baby’s heartbeat listened to with a stethoscope or a handheld Sonicaid (a ‘Doppler’) rather than being strapped to an electronic fetal heart rate monitor.
- Avoid having an oxytocin drip to ‘speed up’ labour.
- As long as your labour is progressing, tell your midwife you do not be tied to strict time limits on how long the first or second stage of labour should be.
Keep moving around, changing position, being upright – follow your instincts. If you have one-to-one support throughout your labour, this will also reduce the chance of your having a caesarean. In many maternity units midwives are caring for more than one woman at once, so it may be helpful to have someone with you who can support both you and your partner. This could be a female friend or relative who is confident and relaxed about vaginal delivery, or a trained doula or NCT Birth Companion.
The National Institute for Health and Clinical Excellence (NICE) caesarean section guideline says continuous foetal monitoring (CEFM) should be offered to women having a VBAC. However, as there have been no reliable studies to find out whether CEFM makes VBAC safer this recommendation is not based on firm evidence.
The Cochrane review of Continuous Electronic Fetal Monitoring (CEFM) found that it is not more effective at picking up distress in babies than intermittent monitoring and does not reduce the number of babies that die or have cerebal palsy. There was a very small reduction in the number of neonatal seizures, but no long-term health differences. However, this review shows clearly that continuous monitoring increases the number of unnecessary caesareans carried out. This means that CEFM may reduce the chance of VBAC. Talk about this with your carers to help you make a decision.
Any woman can choose to remain at home to have her baby. The risks of serious problems are not greatly increased by a previous caesarean.
However, you might like to consider how long it would take for you to be transferred to hospital. Current recommended practice for women with a uterine scar is that they need to be in a setting where the baby can be delivered within 30 minutes if an emergency arises.
NCT's helpline offers practical and emotional support in all areas of pregnancy and early parenthood: 0300 330 0700. We also offer antenatal courses which are a great way to find out more about labour and life with a new baby.
NHS Choices offers a section on caesarean birth, including VBAC.
The Royal College of Obstetricians and Gynaecologists gives information on birth after a previous caesarean.
NICE offers evidence-based recommendations on caesarean.
The site www.caesarean.org.uk offers research-based information and support on all aspects of caesareans and vaginal delivery following caesarean section.