Risks of VBAC

[HappyAsEyeAm]

I had an EMCS with DD, 4 years or so ago. Back to back baby, chin up, failure to progress, foetal distress ... you know the drill! I am 34 weeks pg.

I am beng encouraged to have a VBAC this time, and although the midwives are saying that the consultant will take my views into account when I meet with him/her next month, I know that I will be further encouraged to go for a VBAC as long as the baby isn't so late that I would have to be induced.

My problem is that I am having great difficulty trying to get information from my midwife as to the risks of VBAC for mother and baby. She is pushing the advantages of a VBAC eg shorter recovery time, no need for unnecessary surgery and risk of infection etc, but I can't get any other information out of them at all. I can't seem to get any infromation out of them as to the risks of a VBAC for mum and baby.

I asked what the risks to the mum were of a VBAC and I was told that beyond the risk of uteriune rupture, there were no risks at all, and she said that she didn't know what I was talking about. No mention of incontinence issues, prolapse, tearing etc. I was made to feel that I would be mad to opt for a c-section But I feel that I need to know more about the pros and cons of a VBAC in order to try and come to my own view before I see the consultant.

Having had an EMCS last time, I am well aware of the pros and cons of a c-section, and these were emphasised.

I do know though that if I opt for a VBAC, I am going to refuse a forceps delivery.

Can anyone tell me about the advantages and risks involved in VBAC please?

www.rcog.org.uk/womens-health/clinical-guidance/birth-after-previous-caesarean-information-you

Here you go ... this lists the advantages first but goes on to the disadvantages. Good luck.

Hi

Can you talk to your consultant or one of their team? I got really good non-biased advice from them. From what I gather there is no right answer - both have risk - albeit different. It's hard weighing up the pros and cons - but I really wanted to experience a natural childbirth so I went for a VBAC.

There is some more research out on the BBC today www.bbc.co.uk/news/health-17353803
which adds to the confusion but I think the advice from Dr Beckett sums it up well: " Choosing a vaginal birth or a Caesarean section carries different risks and benefits but overall either choice is safe with only very small risks".

Hiya, there is a book which is very useful called Caesarean Birth: A positive approach to preparation and recovery by Leigh East (2011). there is some info about VBAC in there in Chapter 4, p.41-45. The risks of each are outlines and the book generally gives good overall context.

My second baby is due in just under 6 weeks and I'm considering ELCS due to a back problem that developed during the delivery of my daughter in 2009. Although my request for ELCS is being supported, I've had to jump through hoops and been heavily informed of the risks of CS. Apparently, it's only benefit is te knowledge of the date that baby will arrive!

Which, from what I've informed myself from extant literature and research on te subject, isn't cometely true!

Best of luck you you :) x

I had an EMCS in 2009 for fetal distress and a VBAC in December 2011. I found the following articles helpful in researching VBAC during my pregnancy:

New England Journal of Medicine

NEJM 2

As CheeringBell said, there are risks (and benefits) of both options. I agonized over the decision but ultimately opted to try for a VBAC as I had a boisterous toddler at home who was quite likely to inadvertently hit me in the stomach, being unable to drive would make life difficult and although I had had a good recovery from my c-section I was worried my luck may not hold out. I was also worried about potential issues (e.g. placenta previa / accreta) for future pregnancies and the possibility (however remote) that another c-section could limit the number of children we could have.

My VBAC delivery was straightforward and a positive experience in general, although I have had some residual issues with the episiotomy performed (scar tissue not healing).

With regard to your comment on refusing a forceps delivery - I was / am petrified of forceps and discussed this possibility with my consultant at around 35 weeks - while he was sympathetic to my reasons he made it quite clear that there are situations where forceps are the only option (baby too far down the birth canal to safely perform a section).

The difficult part of making a decision between VBAC and ELCS is that there are no guarantees - you could have an easy VBAC or ELCS or there could be complications. Unfortunately you won't know until you have it - which was what I found hard about the whole process, being a bit of a control freak !

It is worth noting that I was put under no pressure to have either ELCS or VBAC - decision was entirely my own (am not in UK). My consultant did say that if I went into the VBAC anxious it would not be a good start, so you should be - on balance anyway (I was not 100% committed myself) - comfortable with the approach being taken. If you feel like you really don't want one, I would fight for an ELCS.

I used the RCOG guidelines to get my elcs last month.

My emcs in 2010 was a result of premature induction + pre-eclampsia. Anyway, he was in the same position as your first... So I guess he wasn't coming out.

During my elcs last month it transpired that this boy too was back to back, chin up and actually wedged in - it was a fight to get him out via section and I'm still sporting a very bruised abdomen 5 weeks on. My mw told me there was no way he'd have come out vbac.

So, does your baby feel back to back and in the same position as last time?

The NICE caesarean guideline also has info in the birth after caesarean section part. Overall, the risks for VBAC are a bit higher than repeat c-section and NICE has said women should have a choice.

You are more likely to avoid an emergency c-section during labour if you have had a previous vaginal birth.

Actually, that's a good link from BBCcheering bell It says:

Risk of womb rupture after a previous section - 0.21% in women trying for a natural labour and 0.03% in women having a planned C-section

The risk of the baby dying was 1 in 6,000 in women trying for a natural labour after a previous section, compared with 1 in 18,000 for women having a planned C-section after a previous section

Other factors that raised the risk of womb rupture were two or more previous C-sections, a C-section less than 12 months previously and induction of labour

So basically, I guess if head is ruling heart it definitely points to repeat c/s but if you are dead set on experiencing vaginal birth then the risks aren't that huge.

Having had both, I actually would rate my c/s a better experience than the natural birth but people do have different views so it is very personal Hope it goes well for you anyway.

Thanks so much for such informative responses and links.

I don't feel that I need/want to experience a vaginal birth - one of the things that my previous delivery taught me was that there was so much more to being a mummy that delivering naturally, and I am not at all bothered about trying to experience a natural delivery.

neitehr do I think that we'll have another baby after this (but I also said that after my first, and here I am pg again!), as I'm 36 and very happy with my lot. But who knows how things turn out.

I am indecisive at the best of times, and when pg it seems to get worse, and I know that this is noe asy decision and risks have to be balanced. Its just so hard!

I think I will buy the c-section book. Having a book always makes me feel better!

Lunarlyte is right, there is quite a lot of information in the book conparing VBAC and repeat CS. Thank you for the mention. www.csections.org/

3/4 VBACs are successful (in the sense you don't go on to require another caesarean), which of course means a quarter do require a CS and now in an 'emergency' situation. However these figures do not include reference to the possible morbidities associated with vaginal birth. Your midwife was right in the sense that scar rupture is the primary risk associated with VBAC and those risks are incredibly small (though fractionally higher than with a repeat CS). However your midwife is also assuming that the other concerns you describe are 'normal risks' associated with vaginal birth and therefore implies you should not factor them into your decision making process. You are absolutely doing the right thing trying to inform yourself before making the decision.

In addition to the VBAC section in the book there is an entire appendix (pg 141-163) providing research based comparison of vaginal birth and caesarean section benefits and risks.

You might find some bits in this article helpful too www.moormums.co.uk/pregnancy/pregnancy-tips/considering-a-vbac-vaginal-birth-after-caesarean/

Good luck.

And this post too... www.csections.org/?p=147

I went for a VBAC with DC2, as I was advised it was the safest option. I was allowed to labour far too long and ended up in intensive care with a uterine rupture and my poor DC was asphyxiated and transferred to a specialist hospital with suspected brain damage. (He is fine, thank God). I ended up having an emergency section anyway.
If you do go for a VBAC I would make sure that if your labour failed to progress then you would be offered a section in the first instance- I asked for one and was refused.

Well, the biggest risk is uterine rupture which can result in all kinds of things from a hysterectomy, to PPH, to a brain damaged baby to the need for ICU admission.

As for the recovery, you have no guarantees with either option. The midwife you spoke to seems to be assuming you'll have an uncomplicated VBAC and hence a shorter recovery. If you end up with severe tearing or an operative VB, your recovery may well be long anyway. Also keep in mind that you may still end up with an EMCS, which is usually harder to recover from than a planned CS, because you haven't been in labour for hours with the latter.

This may help you-

www.nejm.org/doi/full/10.1056/NEJM200107053450101

The broad conclusion : "For women with one prior cesarean delivery, the risk of uterine rupture is higher among those whose labor is induced than among those with repeated cesarean delivery without labor. Labor induced with a prostaglandin confers the highest risk."

They also give statistics on how uterine rupture is least common with planned CS, followed by EMCS, followed by spontaneous VB and the riskiest is an induced VBAC.

"Uterine rupture occurred at a rate of 1.6 per 1000 among women with repeated cesarean delivery without labor (11 women), 5.2 per 1000 among women with spontaneous onset of labor (56 women), 7.7 per 1000 among women whose labor was induced without prostaglandins (15 women), and 24.5 per 1000 among women with prostaglandin-induced labor (9 women). As compared with the risk in women with repeated cesarean delivery without labor, uterine rupture was more likely among women with spontaneous onset of labor (relative risk, 3.3; 95 percent confidence interval, 1.8 to 6.0), induction of labor without prostaglandins (relative risk, 4.9; 95 percent confidence interval, 2.4 to 9.7), and induction with prostaglandins (relative risk, 15.6; 95 percent confidence interval, 8.1 to 30.0)."

It's your choice ultimately, don't let anyone pressure you either way.