How to have a successful VBAC? First and foremost, I think that we really need to work to minimise the number of women who ever need to have a VBAC by minimising the number of primary caesareans. I think that preventing the first caesarean would be the best place to start. Evidence suggests that this is best done with continuity of carer: that is where a woman is cared for by one person throughout her pregnancy, birth and new parenting experience. Ideally, a woman will have her own midwife and obstetrician so that she has complete support and confidence.
Assuming the woman is well supported and goes on to have a caesarean, in my practice, women find it really helpful to discuss exactly what happened (as best as we know) and why as this helps women to make sense of their experience. It can be helpful to draw diagrams, use a model doll and pelvis to visually show the position of the baby in the woman's pelvis, review the notes that were taken through the labour and answer all of her questions. The other really vital thing is to let her know that she can absolutely plan a vaginal birth next time, provided that there are no "absolute contraindications", ie things like a placenta praevia which make a vaginal birth very unsafe for the mother and baby. These things are rare and for the most part, women who have had a caesarean with their first baby can very safely plan a VBAC with their next pregnancy.
Now to the next pregnancy ... a planned VBAC. It's important again that the woman has continuity of carer, and preferably this care will be from one midwife and one obstetrician. It will give the woman reassurance and confidence to know that her care will be from two people who know her and understand her wishes.
I have found that women who plan a VBAC need lots of time to talk and debrief their last experience. It's not uncommon for women to feel that their body is broken, that it doesn't work, that they are incapable of birthing their baby. They may feel a range of emotions: frustration, anger, disappointment, hurt, fear, powerlessness and perhaps distrust. Talking through these emotions goes a long way to paving a clear emotional path for a successful VBAC. I always recommend to my clients that they attend a Calmbirth (R) course and that they read, read and read. The more knowledge a woman has, the more confident she feels and the more relaxed she will feel going into labour - and all of this is really important for a successful VBAC.
In labour, active birth is emphasised - upright positions, movement and so on. We use a form of monitoring that means women can still labour in the bath or the shower. It doesn't interfere. Hydration and nutrition are important for maintaining fluid and energy levels. Waterbirth is a great option, but land births are great too. I find most women birth their babies in an all-fours or kneeling position and these positions are best for helping the baby move down through the pelvis. Spontaneous pushing is preferred, where the woman pushes according to her body's cues - and I find that this reduces the chance of tearing. The baby's entrance should be smooth and gentle and straight into its Mother's arms.
Following a successful VBAC, women often feel triumphant and amazing. In time, sometimes other emotions surface - things like anger (directed at self or others), guilt (perhaps feeling that the last baby didn't experience the calm birth that the current baby has experienced), regret (if only I had done xyz ...) and so on. Sometimes it's helpful to write these feelings down and talk so someone trusted - a friend or family member for example.
And as a final note, there is no such thing as a "failed" VBAC. VBAC is not about the destination, it is about the journey. It is about the courage and determination and the innate ability of a woman to make the very best choices that she can make at the time. Sometimes a caesarean is the best way for the baby to be born safely, and we honour the journey and the wise decision making.
Melissa Maimann is an endorsed eligible midwife in private practice in Sydney. One of the first eligible midwives in Australia, Melissa now offers a range of care options for women including private midwifery care, antenatal shared care and birth support. Visit Melissa's website to learn more about her services.