Looking for help/facts about risks vs benefits of VBAC

[Yogamummy23]

Hello,
I know there are some very knowledgeable people on here including mums who’ve been there and medical professionals so I’m after some insight.

I am 23 weeks preg with number 2 and have a very strong desire for a natural birth this time. I’m not quite sure where it comes from but perhaps I have some deeply buried trauma from my emcs but I am just desperate to avoid it again! My appointment with a consultant to discuss vbac is not for several weeks but my midwife has dropped a few hints that they don’t altogether love vbacs. She has said things like ‘now we won’t want you to go overdue so we will recommend inductions at 40 weeks’ etc.

For background, my first birth went roughly like this: straightforward low risk pregnancy, wanted birth centre water birth etc etc, baby wasn’t forthcoming and I never started spontaneous labour, induced by oxytocin drip at 42 weeks, laboured for 13 hours, got to pushing but she still wasn’t budging, tried assisted delivery, failed so had a c section.

It was all extremely rushed and although I was extremely grateful for my beautiful healthy baby I just felt like it was all taken out of my hands a bit. I would like more control this time.

I guess I’m asking for any reassurance of your own vbac stories. Or anyone who knows about the real risks so I don’t feel rail roaded into being induced before I’m ready as I know they so often end in emcs. I just really want this birth to be a more positive experience.

Thanks

Hello I had a VBAC although it was more than 10 years ago now. My first birth was EMCS after problems with baby's position at pushing stage and attempt to use ventouse to turn failed. Labour followed very similar pattern with second baby and was prepped for another EMCS but tried forceps first and all went well. I know some people would be concerned about use of forceps but I did not feel rushed at any point and was very well looked after. Recovery from second birth was much quicker, even with episiotomy. I'm not sure how I would have felt if I'd had another EMCS but was definitely glad to be able to try VB. Good luck, I hope all goes well.

@thedevilsavocado thank you for sharing your experience. I would imagine the recover is much quicker and especially with a toddler this time who won’t understand I would like to be on my feet again as quick as I can!

Can I ask if you went into labour spontaneously and on time? I’m worried that they will want to induce at 40 weeks on the dot!

Hi I went into labour spontaneously on the day I was going to be induced. I was one week over my due date so was given a bit of time!

Ask your m/w if your hospital runs a vbac clinic.

I was automatically referred and found it invaluable. A specialist m/w went through my notes, discussed the reasons for the emcs the first time, what contributed, and whether those factors were likely to happen in a second birth.

She then went through the risks, and the protocols in that particular hospital - it varies whether they allow induction, epidural, trial of labour etc. She discussed how to make a birth plan and write in at what point I wanted to go straight to Cs- for example only if spontaneous labour, if I’d been labouring more than x hours, or not progressing at a certain rate.

I was sent away for 4 weeks with a pile of literature - proper referenced stuff, not basic pamphlets, stats, risks, benefits, outcomes.

I had a second appointment at 36 weeks where I was asked for my decision.

@bluebluezoo thanks I will ask about that. I am after more factual risks. What I don’t want is to be pushed for induction at 40 weeks because of the risk of rupture when that risk is actually tiny. But I don’t actually know any of those risks at the moment so I’m keen to find out.

My close friend was advised to go for a VBAC with second baby. She had a previous scar rupture and placental abruption, we nearly lost her and baby suffered a hypoxic brain injury. To suffer both is very rare but these things have to happen to someone, unfortunately it was her and her child.

I had an unplanned vbac

Emcs with first child after failure to progress. Spontaneous Labour at 39 weeks.
Did a huge amount of vbac research for no2. Hadn't decided on whether to have 2 or 3 kids at that point so was concerned that three csections would be high risk.
Had a review of first Labour notes at the hospital and several appointments with consultants/registrars afterwards.

Was told induction would create risk of the old scar rupturing (forget the technical term), so no inductions allowed. Dd1 was 2yrs old at this point.
Vbac heavily encouraged.
Multiple c sections not considered high risk until you get to 4-5 of them. Then consultant would oversee.
Discovered my first labour had been back to back which I had never been told and also a number of references in my notes to narrow access / hips / etc.
Opted for elcs on the basis that it sounded medically likely it would reoccur.

Spontaneous Labour at 37 weeks with DD2 and a forceps birth. Strong suspicion that if she'd been any later it would have been a repeat experience. Emergencies ahead of me in theatre all day apparently...

Recovery time was much longer for me. 16 weeks before I could walk more than a few hundred yards. Wish I'd had my planned elcs.

Everyone's experience is different. You'll have plenty of people who've had picture postcard vbacs. Get all the info you can and then make a call on the risks for you. I went with the devil I knew and it still didn't work out that way

These are the questions I prepared for my meetings based on research

VBAC

1. Pain management during VBAC - are my pain mgmt. options more limited due to link between pain in scar area and rupture, or is monitoring a sufficient indicator should I require an epidural?
2. Among women who attempt a trial of labor after prior cesarean delivery, what is the vaginal delivery rate and the factors that influence it?
3. What are the short- and long-term benefits and harms to the mother of attempting a VBAC after prior cesarean versus elective repeat cesarean delivery, and what factors influence benefits and harms?
4. What are the short- and long-term benefits and harms to the baby of maternal attempt at a VBAC after prior cesarean versus elective repeat cesarean delivery, and what factors influence benefits and harms?
5. What are the non-medical factors that influence the patterns and utilization of VBAC after prior cesarean delivery?
6. Is continuous monitoring mandatory and if it is, or I prefer to have it, are their facilities to be monitored in a birthing pool at this hospital?
7. http://www.childbirth.org/section/VBAC.htmll_
8. Should I plan for early hospitalisation - ie if waters break or contractions start naturally to allow for monitoring. What is the general practise in this hospital?

ELCS

1. Who will be my surgeon? Can I request the same surgeon as I had before? Are trainee surgeons allowed to carry out ELCS's? Presumably not allowed to carry out EMCS's?

10. What are the risks of repeat caesarians? What would be an optimum number of children to stop at in order to statistically avoid a high risk pregnancy eg: placenta previa, or post op complications eg: hysterectomy

1. My first CS was entirely complication free but what are the key maternal risks I should be aware of with an ELCS and at what rate do the incidences of these types of injuries rise with multiple caesarians. eg bowel injury, ICU admissions, post-operative ventilator use, cystotomy and more.

1. What are the key risks to the infant I should be aware of with an ELCS?

1. Under what circumstances are forceps used during a CS and am I at higher risk of this use as part of an ELCS if the baby has/has not descended?

1. Will my post op recovery period be longer with a second CS? Internally due to repeat surgery or shorter due to fewer drugs, lack of labour etc

1. Will the incision be in the same spot or will I have two scars?

1. If I go into spontaneous labour, and there is no medical reason not to try for a VBAC, what are the decision criteria for recommending I progress to a CS? My BP or Fetal distress is an obvious one, is there a time period after which Failure to Progress status is conferred?

Gawd you know so much. I had an emergency Caesarian with DS1, bit traumatic (more for DH, one minute I was in labour next minute, hand up my wotsit and knocked out cold. Woke up with a baby 1 hour later, then 4 days in hospital). I still do not know what really happened. Asked for Caesarian for second one just because I didn't really want to go through labour THEN have a Caesarian but went into labour one day before date. On arrival at hospital they gave me an epidural just in case (amazing, so little pain). Had a normal delivery. So bloody smooth and textbook and EVERYONE afterwards told me how wonderful I was for having a VBAC. It was great!

I had a VBAC 10 years ago (previous c-section for twins and 2 VB before that). I was unequivocally told I had to have one as there was no medical reason to have another c-section and I was quite anxious, with all the scare stories I’d read about scar rupture beforehand, especially as DC4 was measuring very big. He was 9lb 7oz in the end with a big head!

I was induced at 40 +1 at my request due to my anxiety. It actually turned out to be my best birthing experience. I requested a water birth which was refused, but they agreed to minimal interference during labour so I was able to move around a lot, not stuck on the bed strapped to the monitor, and managed on gas and air. I got hypnobirthing CDs (can probably download them to your phone nowadays!) which massively helped. I started listening to them from about 6 months and I was surprisingly calm when it came to it which I credit them with and highly recommend.

Last one from me

I don't know if this helps. I dithered about VBAC and ELCS, saw three different registrars [consultants kept failing to show up] after having an EMCS for failure to progress. Eventually I contacted a consultant obstetrician and got the following response:

Questions from me.
It's been indicated already to me by a registrar that notes from the first delivery re narrow pelvis/difficulty ascertaining dilation etc put my chances of a successful VBAC at 50:50 rather than 75%. My mind is nearly made up therefore to stick with the devil I know given those odds, rather than risk all the complications that a normal delivery brings or a repeat performance. I understand though that a failure to progress would be declared a lot earlier this time around if applicable.

My key concern is this - I am in my late 30's, while it is unlikely that we will go for a third child the risks of a 3rd C/S plus the recommended 2yr break between sections would pretty much rule it out entirely if I have a C/S now. A successful VBAC would possibly leave the option open if I were mad enough.
So the question is this - is a scheduled ELCS likely to result in less uterine damage (lower risk 3rd section) than an EMCS carried out on a contracting uterus for failure to progress? Or is it entirely irrelevant generally speaking? I appreciate that's entirely subject to the latter being a repeat scenario of my first C/S - no foetal or maternal distress and you have not seen my notes so I am asking for a theoretical response but I would appreciate your opinion.

Answers

1. I would disagree your odds are 50%. If your next child was facing right way next time then your odds would be closer to 70/75% if you labour spontaneously. No one will know that until you labour so even if she was OP (back to back) before labour they often turn once labour starts. As doctors we are terrible at diagnosing narrow pelvises etc so I would ignore that comment. it is subjective and not helpful.
2. You are correct. if you laboured again you would be given usually upto 4 hours. if you hadn't progressed then usually a section would be done so no long delays like people often have with the first because of the risk of scar rupture (approx 1 in 250 but I believe its rarer than this because we tend to bail out early).
3. I wouldn't blame you for wanting an elective section. A first delivery like that is traumatic but the odds for a successful vaginal delivery would still be in your favour should you chose to wait and see.
4. No one will ever tell you 1/2/3/4/5 sections is safe but the reality is every day I operate on women with 1/2/3 and often 4 sections. They can be difficult (from my point of view) but the risk of a serious complication or bad outcome is very low. I would say less than 1% in women with 2/3 sections so to have upto 3 sections first of all is very common nowadays and generally quite safe.
5. a section is a section is a section so elective or emergency/ urgent would have no real difference from altering risks of a subsequent 3rd section. Emergency sections do carry with them increased blood loss etc but overall still I would say would are generally very safe.

6 Similarly the 2 year wait is an ideal and we see it broken the whole time without consequence. Section or no section if you ask doctors will probably say even if you have a vaginal delivery for number 2 you probably should wait but again we really don't know that ideal time. 6 months for sure but probably 1 year is ideal before trying again regardless of what the mode of delivery for number 2 is. I don't think a 2 year wait is based on very scientific evidence so I would be happy with 1. So overall I would reassure you, whatever you opt for is safe and I would opt for whatever you're comfortable doing. If a vaginal delivery is important to you then go for it. Odds of success are still in your favour. if the worry of a vaginal delivery is killing you then opt for elective section. Either option is generally the majority of the time very safe and an excellant outcome is what I would expect either way.

I'd recommend joining the Mat Expo facebook group / full of professionals who support woman led birthing choices !

@shortsaint

Gawd you know so much. I had an emergency Caesarian with DS1, bit traumatic (more for DH, one minute I was in labour next minute, hand up my wotsit and knocked out cold. Woke up with a baby 1 hour later, then 4 days in hospital). I still do not know what really happened. Asked for Caesarian for second one just because I didn't really want to go through labour THEN have a Caesarian but went into labour one day before date. On arrival at hospital they gave me an epidural just in case (amazing, so little pain). Had a normal delivery. So bloody smooth and textbook and EVERYONE afterwards told me how wonderful I was for having a VBAC. It was great!

Sounds ace 😉. You can overthink these things and still not get what you planned for !! 😂😂

I found the RCOG guidelines very useful for making this decision www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/pi-birth-options-after-previous-caesarean-section.pdf

Thank you everyone for your helpful and detailed responses! It has made me think hat maybe the midwife is not quite right and I will wait to speak to the consultant about what they recommend . She has been talking about inductions etc which I see now is not usually recommended. Good to hear that it’s possible to have a more active labour as I was stuck to the bed last time due to being on induction drip . I just feel really anxious about it but I know it’s not always within the realms of control!!!

I found the following helpful: www.rcog.org.uk/globalassets/documents/guidelines/gtg_45.pdf

It's the rcog green top guide about VBAC. I also found more detailed risk information in papers on the site (based on age and previous birth experience) which helped confirm my decision for me.

I had EMCS with my first and was very very fortunate to have a successful and complication free Vbac with my second. I had a midwife consultation prior to deciding to try for vbac, which helped massively as I had not understood properly at the time the real reason for the emcs, as far as I knew it was general “failure to progress” but in fact it was explained in the consultation it was much more to do with the angle (back to back) and size (11 days overdue) of DS1. The midwife therefore was able to advise that if neither of these issues repeated (they did not), I did not go overdue, and remained otherwise low risk, there was no reason I could not have a successful vaginal labour as I actually hadn’t “failed to progress” but was 9.5 cm dilated prior to the emcs. For me a vaginal birth was an infinitely easier experience and much easier recovery. He was 2 days early, smaller, in a good position, and it all went basically brilliantly. This is only my experience and the risks of induction / rupture etc are obviously there, but just to share.

Never had a Csection but my friend and sister both had successful VBACs. Sis had after 1 CS- she was very determined and after a very long drawn out labour, had her VBAC.

Friend's was slightly more comical. She had 2 CSections, both times baby had gone into distress and she was determined to have a VBAC 3rd time round. She went for private second opinions, spoke to lots of different consultants, etc etc and all agreed it was safe for her to try.

She went into hospital on a day when the unit was fairly quiet and there were quite a few midwives on the unit. All of them were keeping tabs on her- every time the door opened with someone going in/out (midwife/her partner) they asked "how many cm? How's it going? and then they would all take bets- is she going to do it or not?" anyway after a long drawn out labour, she finally gave birth vaginally and there were whoops and cheers from the midwives outside!!