Vaginal Birth After Caesarean (VBAC)
What is a VBAC?
VBAC stands for ‘vaginal birth after caesarean’. It is the term used when women give birth or plan to give birth vaginally after caesarean. Vaginal birth includes normal delivery and delivery assisted by forceps or vacuum cup.
Planned or elective caesarean (LSCS) refers to your baby being delivered by an operation normally after 39 weeks of pregnancy.
When you submit or complete a booking request form for Hillingdon maternity care please identify whether you have previously had an LSCS, this helps us to assess the pathway of care that your require.
Your initial booking will be completed by the midwife; this will either be a telephone or face-to-face booking. During the booking process you will be asked a number of questions, please answer as accurately as possible as this helps us to assess any other risk factors. After booking, if you have had a previous LSCS and depending on any identified risk factors you will be referred to either an Obstetrician (a doctor who specialise in care of the pregnant woman) or a Consultant Midwife (a specialist midwife) who will assess the next steps in your pregnancy pathway.
Following your last birth you may have been given a letter by the hospital who delivered your last baby about the reasons you required an LSCS, if you have a letter please bring this to your consultation. There are lots of reasons why you may have been advised to have an LSCS. In the majority of cases, this does not mean that you automatically need an LSCS in this pregnancy. The Obstetric Doctor or Specialist Midwife will discuss your options with you, and review your previous records if available or they will review your letter given to you after your previous delivery.
When is the decision made and what happens if you change your mind
The plans for your pregnancy are discussed with you at booking and again after referral to the specialist teams. The plan will continue to be reviewed and assessed at each visit depending on the progress of your pregnancy. At 36 weeks you will be assessed and this is normally the time that the plan is finalised, around mode and place of birth.
You can change your mind at any time in your pregnancy and this can be discussed with the team caring for you. If you have any concerns please speak to your midwife or obstetrician. As a woman you are involved in the planning and decision making about the mode/place of your birth.
Your options and choices will be discussed with you on an individual basis. Whilst the vast majority of women having a planned VBAC may choose a labour ward to birth baby, individual women may have a different preference and these options will be discussed with you, often with the consultant midwife.
What should I do in case of an emergency related to your pregnancy?
Please call: Maternity Triage 01895 279054
For further information/references:
RCOG Birth Options Information for you after previous caesarean
https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_45.pdf
https://www.rcog.org.uk/en/patients/patient-leaflets/birth-after-previous-caesarean/
NICE guidance on caesarean section: www.nice.org.uk/guidance/cg132
Advantages of a successful VBAC
If you have a successful VBAC it is associated with fewer complications than planned LSCS:
- your recovery is likely to be quicker, you should be able to return to everyday activities and return to driving sooner
- your hospital stay may be shorter
- you are more likely to have skin-to-skin contact earlier and commence breast feeding sooner
- your baby will have less chance of having breathing difficulties
- you have a greater chance of vaginal birth in the future
What are the disadvantages?
- you may need an emergency LSCS during labour. Approximately 25% of women who go into labour require an emergency LSCS. It is important to note that an emergency LSCS carries more risks compared to a planned LSCS.. You also have a slightly higher chance of needing a blood transfusion
- the scar on your uterus may separate and or tear (rupture). This occurs in about one-in-two hundred women and increases by 2-3 times if the labour is induced. This is a rare event.
internal and external bleeding can occur and it may be serious enough to affect your baby. If we are suspicious that this is happening, we need to deliver your baby urgently, which may mean by LSCS - serious risk to your baby such as brain injury or stillbirth is higher than for a planned LSCS, but to put it in perspective it is the same as if you were labouring for the first time
- you may need an assisted vaginal birth.
- you may experience a perineal tear involving the muscles that controls the anus (third or fourth degree tear).
When is VBAC not advisable?
Planned VBAC is not recommended where a woman has experienced a previous uterine rupture or has had a classical caesarean scar or another pregnancy complication that required a planned LSCS e.g. major placenta praevia, or if your previous baby was born by caesarean within the last 12 months.
Advantages of an elective/planned LSCS
In planned LSCS there is a smaller risk of uterine scar rupture (one-in-1,000). You are likely to know the date planned for the baby’s birth, this can change if you go into labour or for other reasons. It avoids the risk of labour and serious risks to your baby (two-in-1,0000).
Disadvantages of planned LSCS
The disadvantages include:
- the procedure may take longer as there may be scar tissue from previous surgery
- your baby is more likely to have breathing problems, the risks for the baby are higher if the delivery is before 39 weeks
- you may get a wound infection
- you have an increased risk of bleeding and you may require a blood transfusion
- you have a higher risk of clots developing in the lungs and legs
- you are likely to have a longer recovery period and may not be able to drive for six weeks
- you are more likely to need LSCS for any future babies
- there is an increased risk of placenta praevia and/or acreta in future pregnancies and of pelvic adhesions complicating any future abdominopelvic surgery
- your baby’s skin may be cut during the surgery, 2:100 babies but usually heals without any further harm
- you may experience bladder(1:1000) or bowel injury
- in very rare case you may require a hysterectomy to control the bleeding.
What happens when you are planning a VBAC?
You will normally be advised to give birth on Labour Ward in hospital. You should contact the hospital when you are contracting regularly or if your waters break.
When you are in labour you will be advised to have your baby’s heartbeat monitored continuously. You can choose from a range of pain relief options including entonox (gas & air), injection or an epidural. You will be advised about having intravenous access when you are in labour. If you choose not to give birth in hospital you will be referred to the Consultant Midwife who will discuss your choices and create an individual plan with you.
What happens if your labour does not start naturally?
If labour has not started by 41 completed weeks, the obstetric team will see you this may be between to 40-41 weeks to discuss further options. Depending when you are seen this may include continuing to wait until 41 weeks for labour to start naturally. Offering induction of labour (IOL), or offering a planned or elective LSCS.
Induction of Labour (IOL)
IOL can be offered to women who have had a previous LSCS, the options will be discussed with you on an individual basis and include:
- prostaglandin pessary
- prostaglandin gel
- using a balloon catheter
- break your waters artificial rupture of membranes (ARM)
- using a synthetic drug (oxytocin) to stimulate the uterus to contract.
Any decision on IOL is based on your individual risk assessment and preferences and will take into consideration any risks for you and your baby
Facts about VBAC
More than one in five women in the UK may have experienced birth by LSCS. Around half of these are planned and the other half as an emergency. Planned vaginal birth after caesarean (VBAC) can be offered to the majority of women with a singleton pregnancy with the baby in the head down position at 37 weeks or more who have had a previous lower segment caesarean delivery, with or without history of a previous vaginal birth. When we discuss the plans for your current pregnancy we will consider these factors:
- reason for previous LSCS
- whether you have had a previous vaginal birth
- whether you had any complications at the time or during your recovery
- where the cut was made on the uterus (womb)
- how you felt about the previous birth
- whether your current pregnancy is straightforward or whether there are problems or complications
- what your future plans are for your family.
What are my chances of success?
About 75% of women with a straightforward pregnancy (three out of four women) will go into labour following a previous LSCS and deliver vaginally. A number of factors make a VBAC more likely including your weight (BMI), and your labour starting naturally. Women who have had a successful VBAC in the past have an 85-90% chance of success of a repeat vaginal birth.
Women who have two or more LSCS can be offered the opportunity for VBAC after counselling. There is no significant difference in the rates of uterine rupture and success rates are similar (60-75%). Birth is recommended in a consultant led labour ward.