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Vaginal Birth After Caesarean by Dr Rachael Rodgers

Dr Rachael Rodgers and her Daughter Lily

Dr Rachael Rodgers and her Daughter Lily

BornOnline would like to Welcome Dr Rachael Rodgers to the team. Dr Rodgers has come on board as one of our regular bloggers to talk about Pregnancy and Birth related topics that require some Doctor input. Welcome Rachael.

Hello everyone, welcome to my first blog for BornOnline. My name is Rachael, I’m one of the obstetric doctors from Royal Prince Alfred (RPA) Hospital in Sydney. I was lucky enough to work with Zoe, Ebony and Alinta (the midwives who run BornOnline) for six months last year. Let me say from the start that I think they’re fabulous (they didn’t pay me to say that, they didn’t even ask!). Why? Because not only are they lovely people in themselves, but also because I have a huge amount of respect for them professionally. In my opinion, they manage to strike the right balance between keeping things natural and playing it safe.

Childbirth is a strange thing. On one hand, it’s a natural process that women have been doing it for centuries. Something beautiful and bonding. On the other hand, nature is cruel, and many hundreds of thousands of women and their babies have died during pregnancy and childbirth over these centuries.

So where do we draw the line between keeping it safe and keeping it natural? That’s what I’m going to try and tackle in my series of blogs. For this first blog, I’m going to leap straight into the topic of Vaginal Birth After Caesarean section (or VBAC as we call it for short).

Edwin Cragin back in 1916 claimed that “once a caesarean, always a caesarean”. NSW Health, on the other hand, direct that their health service providers should “provide or facilitate access to vaginal birth after caesarean section operation (VBAC) that is supported by a written vaginal birth after caesarean section operation policy/guideline and health care staff with the skills necessary to implement this policy/guideline”.

So which is it? No wonder patients I see are confused about which way they should deliver after having had a caesarean section.

The bottom line is this… VBAC carries with it the risk of uterine rupture. An attempt at a vaginal delivery after one prior caesarean section carries with it an approximate risk of 1 in 200 for uterine rupture. The scar on the uterus that is present from the previous caesarean section is a weak point on the uterus, and contractions can make it tear. How serious is a uterine tear? It ranges from not much of a problem, to a very serious problem.

In a nutshell, the risk associated with an attempt at a vaginal delivery after a caesarean section is small, but if you’re the unlucky person it happens to, the consequences can be very serious.

So what should you do? The answer is “it depends”…

If you definitely want a large family, then you should probably give VBAC a go, as we can’t do unlimited caesareans on a patient, and the risk of complications associated with caesareans increases as the number of prior caesareans increases. The surgery is technically more difficult, the anatomy can be distorted and there is a greater chance of us having problems with the placenta (eg, placenta accreta is more common after multiple caesarean sections – I’ll explain placental problems in a separate blog). Also, the recovery after a vaginal delivery is generally much faster and easier than after a caesarean, so if you have little kids to chase around after, VBAC is well worth considering.

If you aren’t planning any further pregnancies and you are very worried about the risks of VBAC, then an elective caesarean sounds like the right option for you. I have met patients who have been persuaded to attempt a VBAC despite having strong reservations. These patients inevitably turn up to delivery suite at 2am after having a few contractions and proceed to freak out (and demand an immediate caesarean section) because they think they are going to rupture their uterus imminently. Which, in some respects is fine, because a caesarean section can be arranged at 2am, but lets be honest here, you’re better off having an elective caesarean during working hours, rather than having an emergency caesarean at 2am with a tired registrar who has very little recourse to immediate assistance should any complications arise. I’m not saying that you shouldn’t have a caesarean at 2am if you need one – all of us obstetric registrars have done many caesareans at 2am without any complications – but don’t plan for one if you can avoid it.

What is the chance of success of a VBAC? Most studies report a success rate of about 60-80%. Success rates differ with different indications for the previous caesarean section. If you had an obstructed labour with a small baby in your previous pregnancy, then your chance of a successful VBAC is decreased. However if you had a caesarean for a breech baby or low lying placenta or for an obstructed labour because the baby got itself into a difficult position, then your chance of a successful VBAC is higher.

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To get back to the question as to what you should do, here are my thoughts… By all means, if there are no contraindications to a VBAC, and you are keen, give it a go. But do it safely. By safely I mean do it in a hospital which has an operating theatre available at short notice should any complications arise (please, please don’t attempt a VBAC at home!). Agree to continuous monitoring of the baby throughout the labour. Agree to pull out of the VBAC attempt if concerns arise – these include slow progress (ideally, whilst in labour the cervix should dilate at 1cm per hour – if this doesn’t occur at this rate during a VBAC attempt, I’d be keen to pull out and head off to the operating theatre to safely deliver your baby).

And one last thing, if you don’t go into labour naturally, induction of labour using medications (and augmentation of labour) approximately doubles the risk of uterine rupture. If you want to go down this path, get your head around the risk of complications and make sure you’re prepared to accept this risk.

Good luck! I wish you all the very very best, however you choose to have your baby. Just because I have focused on outlining the complications in this blog, doesn’t mean I’m against it. I’m very much for it in a safe and controlled manner with a low threshold to pull out should concerns arise. After all, 199 out of every 200 women attempting a VBAC, don’t rupture their uterus. So its unlikely to happen – you just need to know that it can. And don’t forget, all of the above cannot be medical advice for you, as I’ve never met you and don’t know your individual circumstances. Talk to your obstetrician about what they think the best way for you to deliver is as they’ll know the details of your specific situation.

Dr Rachael

(This article contains general information only and is not intended to replace advice from a qualified health professional. All information is written from the experience and knowledge of the person writing the post).