Vbac 3rd pregnancy advice

[oregano666]

my first was a natural labour at 39+1 - waters broke at 11pm at 39 weeks and DD was born 10.30am at 39+1

second was footling breach so planned section at 39 weeks - 3.5 years after first birth

pregnant with 3rd now, there will be 22 months between births. One consultant had aggressively recommended a section due to risks with the scar tissue separating. Second consultant and community midwife see no current issues with a vbac if things stay how they are now as no high risk factors

ive got another appointment with the consultant booked in for 34 weeks, the midwife has said this is to review the scar itself and see if vbac will be possible (I’ve no idea how they check this or if it’s just a general discussion so any advice on this appointment would be helpful)

Luckily I recovered well both from the natural birth and the section so currently have no preferences and need some advice

of course worst case scenario is trying for a vbac and ending up with an emergency section, as I know the recovery will be far worse than a planned section

I've had advices to have a section booked in for 40 weeks and see if I go naturally before hand as it’s easier to cancel a section than book one late

I’ve also had advice saying as it’s my third and I’ve had a natural labour before i am more likely to be successful with a vbac

I have no idea what is for the best, in an ideal world I’d go into labour naturally and it would all be as simple as it can but the thought of being induced or ending up with an emergency section gives me the fear!

does anyone have any advice or have been in a similar situation? It seems most threads are about vbac after multiple sections, or sections due to failure to progress and I just can’t get my head round what would work out best

thank you for reading!

Where do you live? Very strange not to offer a vbac. I had a vbac 20 months after my caesarean. RCOG vaginal birth after caesarean guideline below https://www.rcog.org.uk/media/kpkjwd5h/gtg_45.pdf

Thank you for responding, im in the north west, one consultant (and midwife) has said it’s fine for vbac but the first really advised against - I’ve really pushed for vbac so far when it’s been discussed

I’m just not sure if having an initial spontaneous birth and the section being due to breech rather than failure to progress make any difference with a vbac or not

This document clearly states that a ‘short inter-delivery interval’ is <12 months. It then states that’s not a risk for rupture 🤷‍♀️ the only risk is for preterm birth. But you’re past 12 months interval anyway.

the doc states that a short interval potentially increases the risk (along with a bunch of other things). However a 'recent' study has shown it may not be that clear....but ...the evidence level is only 3....and the 'recent' retrospective study was published in 2013 (this greentop guide is 10 yrs old), so there may be more useful data that a consultant could quote (not my specialty so I don't know). You can't really read snippets of these docs in isolation - they make much more sense when you read the whole thing and understand the way levels of evidence and strength of recommendations work. Having a scar is a risk factor for having a uterine rupture...whether the interval between deliveries is strongly predictive seems a little unclear.

I appreciate the majority risk is 12 month between births but that’s not really my concern.

I'm asking does the initial spontaneous labour (my first) and the section (my second) being required for breech presentation only, make it more likely to have another reasonably straightforward spontaneous natural labour?

I know it’s asking the unknown really, I’m just thinking with the extra checks during labour due to risk of rupture and I’d like to avoid an emergency section even if the best way to do that is to have a planned section

i hope that makes sense

I had two spontaneous vaginal births. I met with the consultant during my second pregnancy (high risk) and he said that the best predictor for how labour will go, is the previous labour. His advice would indicate to me (not a medical professional) that your previous spontaneous vaginal birth is a good sign that you are capable of doing that again. I don’t think your previous section will impact your chances because it was only required due to baby being breach.

simply considering previous deliveries, IIRC, the strongest predictor of a successful vbac is a previous successful vbac (so obvs not relevant to you), but having had a vaginal delivery at all is better than not having had a vaginal delivery (all other risk factors being equal though). The problem with childbirth though is that you only ever know it's going to go smoothly after it did go smoothly. Even though the chance of a rupture is low, the chance of a catastrophic outcome is relatively high if it does happen.

Part of the reason perhaps for varying levels of enthusiasm for VBACs amongst staff is that people will have seen the full range of different outcomes and you don't need to have seen to many of the 'dramatic' ones to become more cautious. That said though, it's entirely the woman's choice, not that of the staff, and each woman will have a different threshold of acceptable risk. Although the chance of rupture is low, staff will see more of them than patients ever hear about (I anaesthetised for one last week) and we're only human - it does make you a bit twitchy for a while - perhaps that's why consultant 1 was a bit less enthusiastic. Hopefully the next consultant can put things into the context of your exact history/current pregnancy so that it's easier to make a decision.

can't edit that last comment to add that uterine ruptures are uncommon. For the rest of the attempted VBACs that don't go to plan, it's more likely to be a 'failure to progress'/less dramatic scenario... still would result in an unplanned trip to theatre, but not all unplanned sections/trials are mad, crashing rushes - more often than not it's a spinal anaesthetic (or epidural if there's one in and working well), with birth partner present, music, photos and all that nice sort of stuff.

I’ve had an emcs and an unplanned VBAC as I did actually have a elcs booked but changed my mind in labour.
In your situation I would happily try a VBAC. I was hooked up to the monitor constantly through labour which was fine.
I wouldn’t have any sort or induction having had a cs.
There is a risk of the scar rupturing at any time but pregnancy and labour do increase the risk. I preferred the recovery from the VBAC.

Before I ended up with praevia for DC3 the obstetrician was happy to allow me to attempt VBAC after two EMCS due to malrotated head positions (laboured fully and dilated to 10cm, just got stuck pushing). They were going to check my pelvis dimensions I believe, but weren't worried about the scar. There would have been 23 months between DC2 and DC3 if that had happened. In your case with a previous vaginal birth without issues and then a ELCS I shouldn't see why they wouldn't be willing to let you try.

Ultimately you have the final day. I'm in northwest. I had same as you. Water went but long natural delivery with first. Second was breech at 41 weeks so elective section. Waited 6 years decided to do vbac. Waters went at 38 weeks. Went in for checks and sent home to wait for labour to progress. Mines an extreme outcome unfortunately I had a placental abruption and my daughter didn't survive. It was a catalogue of errors and like I say the extreme. Has I have been kept in rather than sent home it wouldn't have happened I suspect I would have had an earlier section. I then had 4 and 5 by section. The recovery was fine after all 4 sections. Think after the first I'm slightly numb. X

@vitalityvixthank you, that was my thoughts too in that the section being due to breach makes a difference to say a failure to progress but I wanted to check I wasn’t wrong to think that!

@Greybeardythat makes sense regarding the varying responses I’ve had, it makes sense anyone consultant or otherwise would be more cautious if they had seen bad outcomes.

@Autumn1990yes I agree, I’m not sure if they’d offer induction but I think I’d rather a planned section than an induction given the risks, it’s one thing taking a small risk when it’s spontaneous labour but I think ‘forcing’ it doesn’t seem the best idea and wouldn’t be something I’d look to do

@Choconuttolatathank you for your insight I do appreciate it

@TheQuirkyPombearI'm so sorry this happened to you and your daughter, it goes to show as pp said even if the chance is small, if it does happen the outcome is likely to be horrific. I think this is why I’m so torn and thinking maybe a planned section would be a better idea than taking even the smallest of risks

thank you all for helping me see it’s not an easy decision and it’s ok to go back and forth on what should happen. Hopefully the next consultant appointment will make the decision easier and who knows the choice might taken out my hands anyway!