VBAC

Wish to have a natural vaginal birth after my previous caesarian, hence did some read-up on this. I am now pondering the decision to engage a doula...

Some info extract from the web:

BabyCentre:

What is VBAC?

VBAC (pronounced vee-back) stands for "vaginal birth after caesarean section". It's the term used when a woman who has had a caesarean gives birth to her next baby vaginally. For most of the twentieth century, many doctors tended to hold the view "Once a caesarean, always a caesarean". But research now suggests that having a VBAC may be safer than previously thought. One of the main reasons for avoiding VBAC has traditionally been the risk of uterine rupture, but studies show that this risk is no higher than eight in 1,000. If you had a caesarean for your last baby you can elect to have a repeat caesarean with your next baby, or you may want to go for a vaginal delivery, or you may simply be undecided. Guidelines recommend women should be supported if they wish to have a vaginal delivery after a previous caesarian section, provided they are clearly informed about all the pros and cons.

Advantages of VBAC :

Many of the advantages of VBAC are the same as those of a vaginal birth compared to a caesarean. Following a normal delivery, you are less likely to:
• need further surgery
• be admitted to an intensive care unit
• need a hysterectomy
• have a blood clot
• have a placenta praevia in future pregnancies
• suffer injury to your bladder
• need a blood transfusion.
• Your baby is also less likely to have breathing difficulties following a vaginal delivery.
• You'll take less time to recover than from a caesarean, so your hospital stay will be shorter.
• It may take a little longer to conceive next time following a caesarean.
• If you felt disappointed that your last baby was born by caesarean, it may give you a sense of achievement to be able to have your next baby vaginally.

Disadvantages of VBAC :

These are generally the same as those experienced by mothers who have had previous vaginal deliveries and may include:
• Perineal pain and/or stitches following the birth.
• More chance of stress incontinence in the first three months after birth (although not in the long term).
• Increased chance of your womb "dropping" (prolapse) in later years.

Some disadvantages are specific to VBAC:
• In very rare cases, the uterus may rupture, which could put you and your baby at risk
• Psychologically, you may feel that you cannot risk having a failed VBAC attempt.

What is uterine rupture?

If you're considering a VBAC, someone will almost certainly mention the words uterine rupture at some point. This is when the scar on your uterus gives way, usually during labour, although it can happen during pregnancy, or during a caesarean operation, too. It's possible for your scar to gape slightly - what's known as a dehiscence - during pregnancy but this is unlikely to cause any problems for you or your baby. Uterine rupture, on the other hand, can be life-threatening for both mother and baby. However, it's also very rare: studies show that the rate of uterine rupture in women giving birth vaginally following one previous caesarean section is 0.09 to 0.8 per cent. It's so rare, in fact, that a 2004 study published in the British Medical Journal calculated that doctors would have to perform 370 repeat caesareans just to prevent one uterine rupture.

Your risk of uterine rupture increases if:
• You have a vertical, or classical, scar, but it's much more usual to have a horizontal scar now.
• You are given prostaglandin to induce labour - the risk of rupture is about eight per 1,000 ordinarily, but 24 per 1,000 if prostaglandin is used.

What are my chances of achieving a VBAC?

This partly depends on why you previously needed a caesarean and on how your pregnancy is progressing this time around. If you needed a caesarean for a problem that is on-going, such as a small pelvis, then you may well need to have a caesarean again. However, if you had a caesarean because of something particular to your last pregnancy - for example, if your baby was breech or you had a low-lying placenta - then you stand a good chance of having a vaginal birth this time. Although figures vary, research suggests that at least half of women attempting a VBAC achieve a normal delivery.

Your chances of having a successful VBAC are higher if:
• You have delivered at least one baby vaginally in the past
• Your last caesarean was for a breech baby.

VBAC rates are lower if you:
• Previously had a caesarean because of a small pelvis
• Have already had more than one caesarean
• Have oxytocin to induce labour.

What is a trial of labour (TOL)?

Trial of labour (TOL) is the jargon used by doctors to describe labour after a previous caesarean. This rather negative term highlights the fact that it is considered uncertain whether the labour will be successful. Because of this uncertainty, you and your baby will be closely monitored during labour so that any problems can be spotted early on. A maternity unit offering VBAC should offer electronic fetal heart monitoring and be fully equipped to perform an emergency CS immediately. It should also have access to blood transfusion services.

Key messages :
• If you wish to have a VBAC, your doctor should support you, but you should also be fully informed about the pros and cons, and take your obstetric history into account
• VBAC carries a small risk of uterine rupture - in about eight cases in 1,000.


ParentingWeekly:

Vaginal Birth After Cesarean (VBAC):

For many years, the medical community believed that once a woman had given birth via a cesarean section that any additional babies she has must also be born via c-section. In fact, safe and successful vaginal deliveries are possible after a c-section, giving women the option to experience the childbirth process if they wish.

Experts estimate that 60 to 85 percent of women who had cesareans the first time around are able to have a normal labor and deliver vaginally their second, third or subsequent baby without incidence. Successful VBAC rates are higher for those women with non-recurring causes (such as a breech presentation with the first baby, but the favorable head-down position with the second) and those who have previously delivered vaginally.

There are many reasons a woman might choose to deliver a baby vaginally after a cesarean. Some women feel a sense of accomplishment with a vaginal birth, others have a medical condition which makes a repeat c-section riskier, while others do not want to repeat the lengthy and often painful recovery process associated with a c-section. Cesarean is also considered major surgery and, as such, is not without risks to mother and child, such as hemorrhage, infection and venous thromboembolism, and may place future pregnancies at increased risk for placenta previa, placenta accreta, uterine rupture, and peripartum hysterectomy. In addition, the process of labor and delivery helps prepare your baby for life outside the womb by helping him or her to expel much of the mucus and fluid from his lungs. There is also a decreased incidence of surgery-related fetal injuries (lacerations, broken bones) with a VBAC.

The type of uterine incision (which may differ from your abdominal incision) you received during your previous c-section will largely determine whether or not you will be able to attempt a VBAC. If you had a low transverse incision (horizontal, across the lower part of the uterus), there is an excellent chance you can deliver vaginally without incidence. However, if you had a classic incision (vertical, down the middle of your uterus), your obstetrician may not allow you to attempt a VBAC because this type dramatically increases your chances of uterine rupture.

Uterine rupture is the most common problem associated with VBAC; however, it happens very rarely – in approximately 1 to 2 percent of VBACs. Your doctor will be able to assess your risk and advise whether VBAC is an option for you.

While the ACOG considers oxytocin use during VBAC acceptable, induction of labor, regardless of the method used, is increasingly recognized as a risk factor for uterine rupture, according to the AAFP. Recent VBAC studies have shown three to five times more ruptures among induced mothers compared with those having spontaneous onset of labor, and the AAFP recommends prostaglandins and oxytocin (Pitocin) be used with great caution during VBAC.

Positive Factors (increased likelihood of successful VBAC):
– less than 40 years old
- Prior vaginal delivery (particularly prior successful VBAC)
- Favorable cervical factors
- Labor begins spontaneously
- Non-recurrent indication that was present for prior cesarean delivery

Negative Factors (decreased likelihood of successful VBAC):
- Increased number of prior cesarean deliveries
- Gestational age – baby is less than 40 weeks
- Birth weight – baby weighs less than 4,000 g (8.8 pounds)
- Labor must be induced or augmented

If you decide to attempt a VBAC and you wish to use pain medication, such as an epidural or narcotics, you should discuss this with your obstetrician well before your due date. Pain relief medications can be used with a VBAC; however, it's important to use them wisely. Epidurals can slow labor and may increase your chance of needing another c-section. However, some studies indicate that if you delay an epidural until you are dilated at least 5 centimeters, your chances of having a cesarean delivery drop dramatically. Narcotics can lessen your anxiety and help relax you and, while they do not increase your chances of having a cesarean, they do affect your physical mobility and may affect your baby because they enter your bloodstream and therefore can cross the placenta.

There are plenty of ways you can help ensure you and your baby are safe during a VBAC delivery. Consider taking a childbirth refresher course to brush up on breathing and relaxation techniques that will help you labor efficiently and reduce stress on your body, or hire a doula to help coach you through labor. And during labor, let your doctor know immediately if you feel any unusual abdominal pain or tenderness.

The best way to prepare for your VBAC is to educate yourself and your partner about the benefits as well as the risks, and what you can expect. Read everything you can on the subject, ask plenty of questions of your doctor or midwife, and talk to other mothers who have experienced a VBAC, as well as those who have never had a cesarean.