Is VBAC riskier than elective repeat caesarean?

Two articles have suggested that women who have had a caesarean section for their first child's birth face more health risks if they attempt a vaginal birth with their second. This is based on Australian research of more than 2,300 women at 14 hospitals in Australia who were preparing for their second child.

Half of the women chose a VBAC, and the other half chose to repeat the surgery. The research found that women who planned an elective repeat caesarean (ERCS) had a significantly lower rate of complications than women who chose a VBAC (vaginal birth following a previous caesarean). The study found a 2.3% risk of death or serious complication in the VBAC group, compared to 0.8% per cent in the ERCS group. This included such things as major bleeding and uterine rupture.

The study authors felt that

"The information from this study will help women, clinicians and policy makers to develop health advice and make decisions about care for women who have had a previous Caesarean."

In other words, they felt that the study adds to the weight of evidence supposedly against VBAC, and encourages midwives and obstetricians to recommend ERCS to their patients.

What do we know about VBAC in Australia?

We know that less than 15% women who have previously had a caesarean will go on to have a VBAC in their next pregnancy. This is despite the fact that up to 75% women cared for in the general hospital system (ie, not supported by the care of one midwife from early pregnancy to discharge with their baby at 6 weeks) and 90% in women cared for by private midwives will achieve a VBAC.

The study found that among women who wanted to try a VBAC, only 57 per cent actually achieved this. In other words, this was even lower than what is achievable.

At what point do we ask how what the hospital system does (or doesn't do) as a whole, contributes to these findings?

This research is likely to convince more women to avoid trying a VBAC, and to encourage more obstetricians and midwives to attend VBACs on very cautious conditions. In other words, the VBAC rate would decline and the ERCS rate would increase.

What effect would this have on future successful VBACs? Well, the rate would only decline further.

A little-known fact is that VBAC is so very different to other types of birth. It is very different to a first-time birth, and it is very different to birth in a woman who has previously birthed vaginally. A women birthing for the first time is highly impressionable. If she has a good experience of her pregnancy and birth care, she will go to her next birth confident and empowered. A woman who has birthed vaginally before knows she can do it, because she has done so before, so she doesn't question her ability. But what about women who had a caesarean for their first birth? What messages do they take away? Often times I will hear women say, "My body failed me"; "I couldn't do it"; "My body is broken"; "I don't believe I can give birth". And all of this is very valid. It does, however, take oodles of time to unpack the last experience and instill in women the knowledge and strategies that can be helpful in a VBAC labour. the other important part is continuity of care. I don't mean having care with a team of people; I mean one midwife the whole way through. So that the woman can be absolutely sure of who will provide her care in labour, and that her wishes will be respected. I wonder if this form of care had been provided to the women in these studies? Probably not, and I say this because it is not the standard care that is offered in the hospital system.

The report makes an excellent comment:

"Neither the patient nor the clinician would have to fret about whether to attempt a trial of labour or choose a repeat Cesarean if the first Caesarean had been prevented."

And this is something that is frequently over-looked. Preventing that very first caesarean. We know that a woman who had a vaginal birth with her first baby is highly unlikely to ever need a caesarean in the future. How much is being done to assist women to birth vaginally the first time around?

Interestingly, the study found that the overall risk of uterine rupture was a mere 0.2%, much lower than the oft-quoted 0.5%. This is very reassuring news.

The challenge will be to get the word out to women that continuity of care is the missing link in a successful VBAC. The National VBAC rate is a mere 15%, which means that 85% women undergo another caesarean with their subsequent children. This is mostly because VBAC is not supported. Ads with all birth options, a woman's best chance of success occurs when she chooses a care provider who is skilled at the type of birth she is after. If a woman is wanting to have a VBAC, the best chance of a successful and safe VBAC would be in the care of a private midwife.

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