Birth after caesarean section | Real Life Midwife

Birth after Caesarean Section

Welcome to one of my most favourite topics! My absolute passion is helping and supporting mamas to have a satisfying pregnancy, birth and postpartum experience. Birth after a caesarean section is a consideration for many mamas - as the caesarean section rate is around 1 in 3 in Australia, and climbing. This article was written for the many women who requested to know more, and help inform their decisions for their next birth.

The WHAT

This article might contain a few medical terms and abbreviations, so I'm just going to quickly cover them here:

  • VBAC = Vaginal birth after caesarean section (referring to mums who've had a caesarean section in the past, but who want or achievea vaginal birth in the future

  • CS = caesarean section (birth of the baby through abdominal surgery)
    --> elective CS/repeat CS = when a caesarean section is planned and scheduled
    --> emergency CS = an unplanned CS is performed (sometimes when in labour, but can also be before labour if something arises that means labour and birth is not safe)

  • TOLAC = trial of labour after caesarean. I despise this term, because the word 'trial' implies medical dominance ("we'll allow a trial of labour") and a predisposition or likelihood of failure. However, it is a term in use and refers to the attempt to have a vaginal birth after a previous caesarean section. I don't know why we tried to move away from the term 'VBAC'. I think  VBAC is a more 'mum-friendly' term.No mum says "I want a trial of labour". But mums do say "I want a vaginal birth!". *Face palm*.

  • SOL = spontaneous onset of labour - when labour starts on its own

  • IOL = induction of labour - when labour is started artificially through medical or surgical methods

The WHY

Why do we care about the choice between VBAC and repeat CS? Is there a standout choice? 

Well, the answer will be different for each mum, and influenced by her previous birth/s. Here's a summary of the pros and cons of both VBAC and elective CS:

I haven't included emergency CS above, because nobody is advocating for that! It carries additional risks...increased risk of infection bleeding (and need for a blood transfusion), as well as blood clots in the legs. Likewise there may be risks for the baby associated with the complications of labour and having an emergency CS. 

You'll see above that the big risk of VBAC that will get shouted from the rooftops is the risk of uterine rupture (where the uterus tears or splits, and can be at the area of the old caesarean section scar). This is the reason given to most mums to avoid VBAC.

The thing is, uterine rupture is incredibly rare. It's true that a VBAC increases the risk, but it's still rare. 

A study of over 20,000 women at the Royal Women's Hospital compared outcomes of VBAC mums to first-time mums [2]. In the whole time of the study, there were only 5 cases of uterine rupture. 1 case occurred in the first-time mums group, and 4 occurred in the VBAC group. And all of the VBAC rupture cases had no other complications, and did not require a hysterectomy (a complication of rupture where the uterus needs to be removed). The problem is that many hospitals (and obstetricians, it has to be said) will quote different statistics, and sometimes use fear-mongering, in an attempt to persuade someone into elective CS. The national obstetric body, RANZCOG, quotes uterine rupture rates of 0.5-2 cases per 1000 births in those without previous caesarean section, and 22-74 in 1000 births for VBACs (wildly up from the large study of 20000+ women!) - but their sources for these figures are often studies that are well out of date. Another study looked at rates of rupture in women who'd had 2 previous caesarean sections - this group had a uterine rupture rate of 1.36% (74 cases in 5421 births) [3]. This study concluded that the risks of VBAC after 2 prior c-sections were similar to the risks of a third repeat CS.

You'll see above also, the major risks of an elective CS, including complications such as hysterectomy and risks in future pregnancy such as placenta previa. Many of the risks of both VBAC and elective CS relate specifically to the risks of labour/birth or caesarean section, so I have included those below, to help guide your decision making on each option. Keep in mind that around 30% of women will experience a maternal or neonatal complication during their birth (whether vaginal or caesarean).

So now you have the overall risks associated with either option - you can see the greatest risks are associated with caesarean birth, which is why you might perceive that midwives and doctors "push"(no pun intended!) for vaginal birth more overall. However labour and vaginal birth is not free from risk either, just less likely. Studies have also demonstrated that with CS birth, there is less chance of skin-to-skin happening after the birth, and a decreased likelihood that baby feeds in the first hour after birth (which is pretty crucial for them and mum!) [4]. Emergency CS birth also shows an increased likelihood of sexual dysfunction following birth (which is surprising - many women would assume this is associated with vaginal birth), but no difference in reporting pain after birth, and postnatal depression (compared with vaginal birth) [5]. One of the biggest concerns about CS birth is the risk to future pregnancies/births, which includes decreased fertility, and increased miscarriage/stillbirth risk, however the most worrisome is arguably the risk for placenta praevia (or rarer but more dangerous forms of placenta accreta/increta/percreta). This condition means the placenta has implanted near or over the cervix, and carries a large risk of bleeding. Placenta accreta/increta/percreta are dangerous conditions where the placenta grows abnormally into the uterine wall, which means it is difficult to remove and therefore can cause many complications at birth (such as bleeding and hysterectomy). Although rare, previous CS is a known risk factor for these conditions, and the more CS births you have, the more your risk escalates with each pregnancy. This is why doctors are keen to avoid multiple CS births, and the best way to avoid multiple CS births is to avoid the first CS altogether.

This gives you a decent overview of the facts, risks and benefits around VBAC and CS births. However, the only person who can really tell you what the right choice for you, is YOU! This is real life midwife after all, and the decision entails more than just facts and figures. It depends on access, options for care, child care (hence the convenience of planned caesarean birth is attractive!), and how you feel about your last birth.

If you've read my story, you'll know I've had a caesarean birth. My preference is definitely for a VBAC in future, and this is because I want to catch, cuddle, skin-to-skin and feed my baby immediately after birth. However, I experienced some serious complications in my pregnancy last time, and if these occur again, VBAC is unlikely.

The HOW

Now that we've covered the what and the why part of the VBAC vs CS decision making process, now I'll move on to the 'how' - how can you help your chances of achieving your desired birth? Well, if you think elective CS is your best option, then the good news is that in your subsequent pregnancy, when your care providers offer you the choice, an elective CS will just be planned for you if you choose this option. Most women in Australia choose to have an elective CS instead of a VBAC. Most women who want a VBAC are usually successful (around 76% success rate) [6].

If you choose VBAC, they will still support you for this decision, but obviously there's a bit more water to go under the bridge before that is achieved! So I'm going to look at the factors that improve success (or don't) rates for VBAC.

First up: the public versus private healthcare sector.

It might surprise you to learn that where you are booked to have your baby has a huge impact on your outcomes. Paying money does not equal better outcomes. It might mean continuity of care (your choice of doctor) and reasonable hospital meals and a hotel stay afterwards. But again, you'll have to decide what's most important to you. 

Now, in the public sector in Victoria, the around 28% of women with a previous CS birth chose to attempt a VBAC, and over half (54.4%) were successful. In the private sector, only 14% of women with a previous CS birth attempt a VBAC, and 43% are successful [7]. Safer Care Victoria, which published this data, attributed these statistic to a "lack of choice, rather than better care". In other words, women aren't given much choice, or they don't have access to care that would allow them the choice. Similarly, it's an incorrect assumption to think that the private sector has a higher risk factor which contributes to lower rates of intention to VBAC and success - in fact, the public sector has more high risk pregnancies. So my first point is - if you want a VBAC, choose the public health care sector, or choose very carefully which obstetrician and private hospital you book with (and ask for recent statistics on VBAC). You can read more about your best options for maternity care here.

Secondly: your history

Perhaps unsurprisingly, your history when it comes to having babies will impact on your likelihood of a successful VBAC. If you've had a baby vaginally before (let's say your first baby was born vaginally, the second was an emergency CS for fetal distress), then your chance of a VBAC is well over 90%. Likewise, having a low-risk, healthy pregnancy increases your luck, and SOL (your body starting labour naturally - you can read my top tips for starting labour naturally here) increase your chances of successful VBAC.

Things that decrease the likelihood of a successful VBAC include previous difficult birth (dystocia), having your labour for VBAC induced (started artificially), maternal, fetal or placental complications in pregnancy, having a BMI above 30, a baby weight of 4kg or more, being an older mum, being short, or having more than one previous CS [1].

Now I do need to point out here, that many of these factors are a bit hard to define. Some will define an older mum as more than 37 years old, some might say it's when you're over 40. I think it comes down to the individual and how healthy they are when they fall pregnant (because a fit, healthy-eating, active 40 year old with no medical conditions probably has more chance of successful VBAC than an obese 35 year old with diabetes and high blood pressure). Likewise, it's impossible to predict the baby's weight before birthUltrasounds are notoriously inaccurate, especially the closer to your due date you are (meaning they are quite accurate at estimating size at 20 weeks, but not at 38 weeks). Please don't accept anyone's attempt to tell you your baby is big if it's based on them feeling your baby through your belly (inaccurate), or a one-off ultrasound. If you have an ultrasound in the weeks before your due date that suggests a big baby, please request a formal ultrasound by a skilled sonographer as a second opinion. Also - consider the size of your previous baby/babies - if they were well over 4kg, then chances are this one will be too. Each subsequent baby you have tends to be a little bigger than the last. Likewise, boy babies tend to be bigger than girls, so take that into account too if you know what you're having.

Another really important predictor of success is whether you've laboured before. The thing about labour and cervixes is - if it has dilated before, it will dilate much more efficiently and quickly in a subsequent birth. So if you've never laboured before, then you'll need to have patience in labour, as your cervix is doing everything for the first time. If you dilated to 7cm in your previous labour, then your cervix will dilate quickly to 7cm, then will do the rest of the birth as if it were your first labour/birth. If you laboured to 10cm (fully dilated), then it gets a bit tricky, and depends on the reason for your caesarean. If you were fully dilated, and pushing for hours and hours and your baby got stuck hence the CS, then that might tell you that perhaps babies don't fit very well through your pelvis. BUT, if your baby got stuck and was in the wrong position and got stuck, then you might be successful if your baby is in a good position for birth (and you'll need to hit up spinning babies to get your bub in perfect position!). In any rate, women who've dilated to 7cm or more in a previous birth are more likely to have a VBAC than those that haven't [9]. 

Well done on getting to this point! Take the time to enjoy this beautiful post-birth image before reading the last bit of this article!

Now, we move on to the various recommendations around care for VBACs in labour. Because lots of studies and guidelines exist, however they don't all agree. This means there are big differences between doctors/midwives/hospitals/countries in how women wanting VBAC are cared for in labour. I'm just going to point out some of the differences, so you can see what is the same everywhere, and where you might have some leeway for discussion and advocating for the type of care/birth that you want. I do need to point out here that I'm not advocating for any particular option here, just giving you the facts that your hospital or health practitioner might not give you or be aware of. Similarly, Australia is a fairly conservative country when it comes to obstetric guidelines, whereas the United Kingdom's National Institute of Clinical Excellence [NICE] tend to be more progressive, which you'll see below.

Highlighted in green are things that may increase your chances of a VBAC, or are progressive/less restrictive recommendations. In red are more restrictive practices or things that may decrease your chances of success. The point of this comparison is to point out that there's no such thing as 'standard' or 'routine'. If your maternity care provider tells you that it's 'hospital policy' for a certain practice, you can see that you have some leeway to advocate for your wishes. I get many women asking me about VBAC in water. Australian guidelines are very against this (to the point of not mentioning it so that it's not even an option!), however the UK governance says water birth is a valid option for VBAC. RANZCOG are so conservative that they say to limit oral intake to clear fluids only - a practice that is arguably outdated and irrelevant unless there's a bigger than normal chance of CS with a general anaesthetic rather than a standard spinal anaesthetic. NICE are so progressive that they are saying VBAC women don't need a cannula routinely, and don't need continuous fetal monitoring (via a CTG or fetal scalp electrode - essentially monitors that are strapped to you for the duration of labour, but without evidence of improved outcomes). NICE are so confident of the level of research informing their recommendations, that they say VBAC women don't need an IV or continuous fetal monitoring as routine. I like this approach - it moves away from the "one size fits all" perspective, and instead offers an individualised type of care. Like a woman having her first baby - there's no need for an intravenous cannula until there's an indication for one. The baby can be monitored intermittently (every 15-30 minutes via a Doppler, for at least a minute), and then monitoring switched to continuous if concerns arise.

I have not included US guidelines above, because the US healthcare system is so markedly different from Australia and the UK. However, Canadian guidelines agree that induction of labour can be considered for VBAC (though it is associated with less chance of success), and state that continuous fetal monitoring should be used [13].

It should be noted that the reason that continuous fetal monitoring is suggested, is because of fetal heart rate changes that occur as a sign of uterine rupture. This happened in almost 3 in 4 cases of uterine rupture [14]. However, there are usually other signs of rupture as well, including abnormal pain, bleeding, increased or decreased uterine tone/contractions, and there are reasons other than uterine rupture that would result in fetal heart rate changes.

Final Points

It's totally ok if you've gotten to this point overwhelmed or still undecided - there's a lot to take in and consider, and many individual factors which will impact your decision making. Interestingly, a "VBAC success likelihood" calculator has been created as a result of some research, and you may like to have a play around with your individual factors to see how your chances of VBAC look. You'll find the calculator here.

Also, there are some cases in which VBAC is definitely not recommended. If you've had a classical CS birth before, then this is not a regular CS, and it is associated with a huge chance of rupture. If you're not sure, chances are you've had a standard CS birth (especially if your scar is horizontal), but you can request your operation notes from the previous CS birth just to check. What if you have twins, or your baby is breech (upside down)? Strictly speaking, neither of these preclude you from having a VBAC, but I'd recommend a chat with a supportive obstetrician based on your individual circumstances - such as how many caesarean sections you've had, the type of twin/breech pregnancy and so on.

My final note would be to say, if anything, this emphasises how important preventing that first caesarean is! If we can reduce the chance of an initial caesarean section, then we avoid all the concern, discussion and indecision around VBAC vs planned CS birth. Plus, the added bonus is that labour/birth usually gets quicker and more efficient with each subsequent birth (when you see the news stories of babies born on the side of the road - they are always the second baby!).

I hope this has been a helpful read. Please share the love by sending this post to a supermum or supermum-to-be, who might benefit from this article. And I would love to hear your thoughts and experiences in the comments below!

Want more? Click the below links to read related topics!

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Sources:

1. RANZCOG (2019). Birth after previous caesarean section. Retrieved from https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Birth-after-previous-Caesarean-Section-(C-Obs-38)Review-March-2019.pdf?ext=.pdf

2. Rozen, G.; Ugoni, A.M.; & Sheehan, P.M. (2011).  A new perspective on VBAC: a retrospective cohort study. Women & Birth 24(1): 3-9

3. Tahseen, S.; Griffiths, M. (2010). Vaginal birth after two caesarean sections (VBAC‐2)—a systematic review with meta‐analysis of success rate and adverse outcomes of VBAC‐2 versus VBAC‐1 and repeat (third) caesarean sections. BJOG 117(1); 5-19

4. MacDorman, M.F.; Declercq, E.; Menacker, F.; & Malloy, M.H. (2008). Neonatal Mortality for Primary Cesarean and Vaginal Births to Low-Risk Women: Application of an ‘‘Intention-to-Treat’’ Model. Birth 35(1): 3-8

5. Prado, D.S.; Mendes, R.B.; Gurgel, R.Q.; de Carvalho Barreto, I,D.; Cipolotti, R,; & Gurgel, R.Q. (2018). The influence of mode of delivery on neonatal and maternal short and long-term outcomes. Rev Saude Publica 52: 95

6. Australian Institute of Health & Welfare (2019). Australia's mothers and babies 2017 in brief.  Perinatal statistics series no. 35. Cat. no. PER 100. Canberra: AIHW.

7. Hunt RW, Davey M-A, Ryan-Atwood TE, Hudson R, Wallace E, Anil S on behalf of the Maternal and Newborn Clinical Network INSIGHT Committee 2018, Victorian perinatal services performance indicators 2017–18, Safer Care Victoria, Victorian Government, Melbourne.

8. Keag, O.E.; Norman, J.E.; & Stock, S.J. (2018). Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PLoS Med 15(1): e1002494. https://doi.org/10.1371/journal.pmed.1002494

9. Obeidat, N. et al (2013). Vaginal birth after caesarean section (VBAC) in women with spontaneous labour: Predictors of success. Journal of Obstetrics and Gynaecology 33(5): 474-478

10. National Institute of Clinical Excellence [NICE] (2019).  Caesarean section. Clinical guideline CG132. Retrieved from https://www.nice.org.uk/guidance/cg132

11. NICE (2019). Intrapartum care for women with existing medical conditions or obstetric complications and their babies. NICE guideline NG121. Retrieved from https://www.nice.org.uk/guidance/ng121

12. Safer Care Victoria (2018). Maternity e-handbook: birth after caesarean. Retrieved from https://www.bettersafercare.vic.gov.au/resources/clinical-guidance/maternity-ehandbook/birth-after-caesarean

13. Dy, J.; DeMeester, S.; Lipworth, H.; & Barrett, J. (2019). Journal of Obstetrics & Gynaecology Canada 41(7): 992-1011

14. Vandenberghe, G.; et al (2015). Nationwide population-based cohort study of uterine rupture in Belgium: results from the Belgian Obstetric Surveillance System. BMJ Open 6(5): e010415. doi:10.1136/bmjopen-2015-010415

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