I support a lot of people wanting to have a vaginal birth after they’ve had one or more cesareans.
I suppose that’s not unusual as I am a certified VBAC Doula and VBAC is one of my passions.
It’s also not surprising that I work with a lot of VBAC clients when you consider that in Australia our C-Section rate hovers around 35%. Basically, one in every three Aussie kids is born via cesarean (AIHW’s Australia’s mothers and babies report 2016). This statistic is extremely disheartening considering the World Health Organisation recommends that the figure should be sitting around 10%.
When I meet new or potential clients who would like to have me support their VBAC I always take a full pregnancy and labour history to help me assess what I consider to be their chance of achieving their desired birth outcome. As they tell me their birth history I can usually pinpoint the exact moment that their birthing journey changed and they were headed for a cesarean.
Nine times out of ten it is a ‘failure to progress’ situation, often complicated by synthetic oxytocin and lack of position changes due to an epidural. Basically, the birth was hijacked by birthing in a hospital.
Now, I know this comes across as me being anti-hospital, but nothing could be further from the truth. I think that hospital births are a perfectly valid choice for birthing people who are extremely well prepared and ready and willing to push back and advocate for themselves.
All birth comes with risks, but having a VBAC does not in itself make your pregnancy or birth ‘High Risk’!
As a matter of fact, going back for a repeat cesarean significantly increases the risk of complications such as infection, organ injury, abnormal implantation of the placenta, increased and problematic adhesions and longer recovery times.
These complications are very rarely discussed but are definitely a reason to seriously consider a VBAC as an option.
How the statistics and information around VBAC are presented significantly alters the perception of risk. VBAC is often presented as much riskier than it actually is. This is most likely the reason that only 15.5% of people who have had one cesarean will go on to try for a VBAC.
But it wasn’t always this way.
VBAC rates have declined since 1999, when the American College of Obstetricians and Gynecologists changed its VBAC guidelines, recommending that only hospitals with immediate access to an operating theatre offer VBAC. Unfortunately, this had a ripple down effect on other countries including Australia where we once had a VBAC rate of 60%.
More recent ACOG guidelines recognise the restrictive aspect of the term “immediate access” and suggest VBACs can occur in other settings as long as logistical emergency plans are in place. However, this hasn’t had a reverse effect on the stats as it’s hard to change a well-established culture.
Uterine Rupture is the usual risk factor that doctors will use to argue you out of a VBAC.
So what exactly is ‘uterine rupture’? It is an extremely rare complication of childbirth where the muscular wall of the uterus tears or ruptures. There are two types of uterine rupture. An incomplete rupture, where the peritoneum (the membrane that lines the abdomen and covers the organs) overlying the uterus remains intact and the contents of the uterus remain within the uterus. This type of rupture is often discovered during a repeat c-section or after the baby has been born via VBAC. it is rarely a medical emergency and tends to heal on its own without medical intervention
The second type of uterine rupture is the complete rupture. This is where the uterine muscle and the peritoneum both tear and the contents of the uterus spill into the abdomen. This type of rupture is extremely rare and is a true medical emergency.
Just the thought of something in your body tearing open is enough to cause panic.
The cynic in me says that doctors tend to use this in their favour when they cite uterine rupture as the reason VBAC is dangerous and not recommended. However, they rarely cite the actual figures to support their claims, unless asked. Instead, they just mention ‘risk’ ‘increased risks’ and ‘high risk’.
The fact is that after one cesarean birth (with a lower abdominal scar) there is approximately a 0.5% chance of a uterine rupture and with 2 previous cesareans there is approximately a 0.7% chance of rupture, and evidence also shows that VBAC after 2 or more cesareans does not raise the risk any higher than 0.7%.
Another interesting fact that they don’t bother sharing is that first-time pregnant people can experience a uterine rupture too! And the risk level is almost identical to the risk of rupture during VBAC!
What this boils down to is that if you are in your first pregnancy or you are wanting a VBAC there is a 99.3 to 99.5% chance you will NOT experience a uterine rupture.
So basically there are risks with VBAC but nothing we do in life is risk-free.
The risk of rupture increases with the use of artificial oxytocin to induce or augment labour.
Given that the trend in obstetrics at the moment is to try to get everyone into hospital, hooked up to artificial oxytocin and birthed before 40 weeks, it sort of makes sense that doctors are tending to label VBAC high risk. If they don’t dissuade people from attempting VBAC then they don’t get to control the birth machine that is our hospital system.
This may seem like a VERY cynical statement to make, but the facts are that in the Australian medical system at the moment there is a distinct lack of support for VBAC. Finding a VBAC supportive doctor and hospital can seem near impossible.
Many doctors will say that they are supportive until you hit 37 weeks when suddenly they want to induce you which we know is counterintuitive to achieving a VBAC. If your doctor tells you that you need to schedule an induction, don’t be afraid to question why. And when you learn the reason, it is okay to do your research and make sure you feel good about that decision. And if you don’t, it is ok to say “No, thank you!”.
It is proven that your chances of a successful VBAC increase exponentially if your labour starts spontaneously and you manage to avoid artificial hormones.
I can write thousands of words on why this is important, but for the purposes of this blog, I will say that the cascade of interventions begins with the first drop of synthetic oxytocin.
Instead of being hooked up to Pitocin or Syntocinon, be patient waiting for labour to start naturally, and once in labour try to get your birthing hormones flowing naturally so that you don’t need artificial augmentation.
So who is a good candidate for a Vaginal Birth After Cesarean Section?
In my personal, non-medical, layperson only opinion, I think most people are great candidates for a VBAC unless they have a ‘special’ scar (that is anything other than a low abdominal incision), they have already had a uterine rupture, or they have a serious health complication like lung or heart disease.
Other than that, anyone who is willing to commit to their birth is a great candidate for a VBAC.
Even if you have had a long complicated labour in the past, there is no reason why you can’t attempt a VBAC. The main thing is to learn from and process your previous birth. This may mean working through any birth trauma or doing some fear release work to get you in the right frame of mind.
Preparation is key!
That is my mantra for all birth…prepare, prepare, prepare.
I often equate birth to running a marathon. They are both endurance activities that are by definition unpredictable. You have to be ready to face the unknown and deal with the unexpected. You can prepare for a marathon but you rarely run the entire distance before the marathon itself. Similarly, you can prepare for giving birth but you won’t get a rehearsal.
Both activities come with discomforts that need to be worked through and overcome to get to the finish line. Having a plan of the techniques you will use to help you get through is vital. For instance, will you use guided meditation to help you take your mind off contractions? Or would you rather use a TENS machine? Or are you going to use the birth ball as your main tool?
There is a boatload of evidence supporting upright positions for vaginal birth but what will this look like for you. Will it mean that you need to rethink the use of the epidural? If so, you will need to plan for what comfort measures you will use in its place.
I personally LOVE the ‘aquadural’! A birth pool can give you just as much pain relief as an epidural while enabling you to be mobile and upright.
Having the right team behind you is crucial!
Whether giving birth or running a marathon, having a good team around you is everything. You don’t necessarily need many people, you just need the right ones. Surround yourself with people who believe in you and your ability to birth vaginally.
Most people have a significant other in their life that they want at their birth. Maybe it’s the other birth parent or close friend to have a familiar face around, which is great but I am a huge advocate of also having an independent support person with you as well.
A doula or birthkeeper will support you and the rest of your birth team. They will help you make informed decisions, advocate, and offer insight and information that will help you achieve your VBAC.
Just as a doula is important in helping you achieve your desired vaginal birth, so is good independent childbirth education.
Most hospitals offer birthing classes, but honestly, they aren’t worth the time it takes to go to one. They are usually just a rundown of hospital policies and the time frames they will impose on your labour.
A good childbirth education class will teach you the ins and outs of birth. Think physiology, hormones, body mechanics, comfort measures, coping strategies, informed consent and advocacy and so much more.
When budgets are tight they often seem like an expense that can be skipped. But if you are serious about a VBAC I would be investing in good childbirth education and cutting costs elsewhere. Or ask your friends and family to put money towards your birth preparation, rather than unnecessary kit that you may never use.
So…are you ready to VBAC like a Boss?
If the answer is yes, good for you! I would expect you to have your plan and supports in place and be ready to have some difficult conversations with your care team.
But if you are still unsure, I would suggest you reach out. Give me a call or drop me a line. Or better yet book into one of my VBAC childbirth education classes and learn my 15 tips for how to VBAC like a Boss!
