VBAC or elective Caesarean | Joondalup, Perth

If you have had a Caesarean with us previously, you may be thinking about how to give birth next time. Whether you choose to have a vaginal birth (VBAC) or a Caesarean, either choice has different risks and benefits that need to be discussed. In considering your choices, your medical history and your previous pregnancies & labours are important, in addition to what is going on in this pregnancy:

• The reason you had the caesarean and what happened – was it an emergency?
• The type of cut that was made in your uterus (womb).
• How you felt about your previous birth. What are your concerns?
• Whether your current pregnancy has been straightforward or have there been any problems or complications?
• What is the state of play at the end of the current pregnancy. Relevant factors are ultrasound thickness of scar; size of baby; station of head; favourability of cervix; the health of the pregnancy.
• Your age & medical history

Taking all of this into account, together we can consider your chance of a successful vaginal birth, your thoughts on the risks of both courses of action, your personal wishes, and future fertility plans, when making a decision.

Your choices

1. Elective Caesarean

Elective means a planned Caesarean section ie. the date is usually planned in advance. The Caesarean usually happens in the week before your due date at Joondalup Private Hospital in Perth, unless there is a reason why you or your baby needs an earlier delivery.

What are the advantages of an elective Caesarean?

The advantages of elective repeat caesarean delivery include:

• Very small risk of uterine scar rupture.
• It avoids the low risk of your baby suffering possible brain damage or stillbirth (1/500) from lack of oxygen during labour.
• The pelvic floor, vagina & vulva is not stretched, torn or traumatised.
• Knowledge of the date of delivery. This is often important for family afterwards, especially if your partner works outside of Perth eg FIFO work.

What are the disadvantages of elective repeat Caesarean delivery?

The disadvantages of elective repeat Caesarean delivery include:

• The risks of surgery – infection, bleeding, getting a DVT in rare cases. However a planned Caesarean has fewer risks than an emergency Caesarean. Generally, a planned Caesarean has a reasonable recovery ie feeling mostly fine at 2 weeks for most women.
• You may need extra help at home and should avoid driving for about 2 weeks.
• Some help for your baby’s breathing is occasionally needed – 3% for Caesarean babies versus 2-3% for VBAC babies.

2. VBAC

VBAC stands for ‘vaginal birth after Caesarean’. It is the term used when a woman gives birth vaginally, having had a Caesarean in the past. Vaginal birth includes birth assisted by forceps or ventouse.

What are the advantages of a successful VBAC?

The advantages of a successful VBAC include:

• The satisfaction of a vaginal birth (which might include a forceps or a ventouse delivery – about 10-20% of VBAC women have one of these).
• A possibly shorter recovery and a shorter stay here in Joondalup Private Hospital (if you want)
• Less abdominal pain after birth.
• The chance of avoiding surgery.

What are the chances of a successful VBAC?

Overall, about 50% of Perth women with no additional risk factors with a straightforward pregnancy who go into spontaneous labour give birth vaginally following one caesarean delivery. A number of factors (risk factors) make the chance of a successful vaginal birth less likely. These are when you:

• Have never had a vaginal birth.
• Don’t go into labour spontaneously.
• Did not make progress in labour last time and needed a caesarean delivery.
• Are overweight. A high BMI makes a VBAC much less likely.
• Are older. C-sections are more likely when you’re older.
• Have a large baby – however this is often difficult to judge as estimates of size can be inaccurate.

What are the disadvantages of VBAC?

• Scar weakening or scar rupture. There is a chance that the scar on your uterus will weaken and open. If the scar opens completely (scar rupture) this may have serious consequences for you and your baby (see above). This occurs in about 1:200 women as long as the labour is being correctly monitored. If there are signs of these complications, your baby will be delivered immediately by emergency caesarean delivery. However brain damage or death may not be prevented and some babies have very poor outcomes.Risks to your baby. This is the most important risk. The risk of a stillbirth between 39 and 41 weeks whilst waiting for labour is 1:1000 or 0.1%. Additionally, the risk of your baby dying or being severely brain damaged due to scar rupture if you undergo VBAC is an additional one in 500 or 0.2%. Overall the risk of a very poor outcome or stillbirth is about 1:330 or 0.3% overall.
• Emergency Caesarean. There is a fair chance you will need to have an emergency Caesarean delivery during your labour. This happens in about half of women. The usual reasons are labour progress stopping, or if there is a concern for the wellbeing of the baby. In some cases a general anaesthetic is needed for speed to save the baby – meaning you won’t be awake for the birth.
• The risks of labour and birth. All the risks of normal birth apply. These include:

1. Incidents happening during the labour, like fetal distress, bleeding, or the shoulders getting stuck.
2. The pain of labour and birth itself: variable but is significant for many women.
3. There is a 10-20% chance of needing forceps or ventouse delivery for the baby.
4. Tears. During the birth the pelvic muscles, tissue and vaginal skin are stretched and may be torn, sometimes badly – there is a small risk of a 3rd degree tear.
5. Prolapse of the womb or vagina is more likely after vaginal birth.
6. Women choosing VBAC have a higher chance of needing a blood transfusion or having an infection in the uterus.

When is VBAC not advisable?

• If the chances are not good for a successful VBAC then a planned Caesarean is often overall wisest. Because of the rare but terrible risk of death/serious injury to the baby, a VBAC should carry a fair likelihood of success. Addtionally, for the mother an emergency Caesarean is somewhat more difficult than an elective Caesarean with more infection, bleeding, risk of hysterectomy and poorer recovery overall.
• The uterus has ruptured during a previous labour
• There is a high uterine incision (classical caesarean) or have had a significant myomectomy operation.
• There are other pregnancy complications that require a caesarean delivery.
• In older women, the risks of vaginal birth are much magnified with greater risk of serious pelvic floor trauma. Since the risk is 50% in women who are  approx. 40 years old, C-sections are usually advised.

What happens if I go into labour when I’m planning VBAC?

• Contact Joondalup Private Hospital here in Perth as soon as you think you have gone into labour or if your waters break.
• Once you are in labour, you and your baby’s heartbeat will be monitored continuously. Our wireless monitors allow you to walk around to help the baby’s head descend, and to help you deal with the labour. You may go in the shower with the monitor on.
• You can have an epidural if you choose but try not to have it too early, as it can interfere with the mechanisms of labour.
• Consistent labour progress is required for safety. Long labours are associated with increased risk of rupture and decreased success.
• Abnormalities with the baby’s heart rate are associated with impending scar rupture, and are an indication for immediate Caesarean.

What happens if I do not go into labour when planning a VBAC?

This happens about 30% of the time. If labour does not start by 41-42 weeks, different options are:

• Induction of labour. The drugs used in induction significantly increase the risk of scar rupture, and lower the chance of a successful VBAC, hence anything apart from “breaking the waters” is not offered by us. Even then, success rates are much lower.
• Repeat elective Caesarean birth. This is usually the safest option.

Summary

A good overall plan is to aim for a VBAC if labour is spontaneous, but have a repeat Caesarean delivery if nothing happens by about 41 weeks.