Choosing VBAC

In Australia, one in four babies are born by caesarean section every year. The World Health Organisation (WHO) recommends a caesarean section rate of 10-15% (1+2). For many women and babies, caesarean is a lifesaving operation. Some find upon the arrival of a baby, that the mode of birth matters less than the safe arrival of a little one. It may only be later, weeks or months after the birth of a child, or even in a subsequent pregnancy, that a woman reflects on her past birth experience and discovers she harbours feelings of disappointment, perhaps even guilt about the way her baby entered the world. For future births after caesarean, most women can expect to birth normally. A VBAC (Vaginal Birth After Caesarean) after a lower uterine section caesarean, in the absence of medical complications associated with this pregnancy, is the safer choice for most women (2). The decision of whether to have a vaginal birth after caesarean (VBAC) or a repeat caesarean, should be made by the woman together with her family and care providers. Women should be supported and nurtured in their decisions throughout their pregnancy towards a positive outcome for both mother and baby.

The only way that VBAC differs from other labours is the small increased risk of uterine rupture - about 0.4% (one in 250). The risk of uterine rupture prior to elective repeat caesarean section is 0.2% ⁽³⁾.

To put this into perspective, the probability of requiring a caesarean section for other obstetric emergencies (not related to the other caesarean section), ie acute fetal distress, cord prolapse or antepartum haemorrhage, is up to 30 times higher ⁽⁴⁾.

So, what can you do to become more informed about your choices for birth after caesarean?

1. READ research, birth stories, newsletters and books. The Birthrites website www.birthrites.org has many relevant links, a suggested reading list, "Caesarean Birth…Making Informed Choices" information booklet which can be downloaded for free, and the Birthing Beautifully magazine. 2. SUPPORTIVE FRIENDS – talk to and meet with other women who are planning or have had a vbac (see www.birthrites.org for a list of support groups and contacts). 3. SUPPORTIVE BIRTH TEAM. Don't be shy to interview your doctor or midwife before you enlist them on your team. Some questions you may ask them: - what are your views on vbac? - what is your caesarean rate? - do you have a time limit on labour? - how long after the due date are you prepared to wait before intervening? - the type of fetal monitoring? - can I eat and drink during labour? - will I need an IV cannula? - will I be able to have an epidural if I choose one? - can I have an active birth? Remember you can change caregivers. Experienced birth helpers/doulas are a huge support: if you don't think you'll need them you don't have to call them, but it's best to be prepared.

4. COMMUNICATE. Let every one in your birth team know 'what' and 'how' you want things, don't presume they already know. Writing a birthplan (for a vaginal birth and c/s) is a good way of stating your choices and initiating discussion of any compromises, if they need to be made.

5. GET PHYSICAL. Exercise, swim, walk, stretch, do yoga, whatever you enjoy and aim for it daily. Practise optimal fetal positioning (see our article from last month on techniques for achieving optimal fetal positioning.). Eat a well-balanced healthy diet. Labour can be hard physical work; you need to feel ready for it.

6. UNDERSTAND. Study normal birth. Do you really believe your baby will come out your vagina? Get your medical records and learn about your last birth. Plan and practice for an active birth. Do vbac preparation classes. Visualise giving birth vaginally. Get the pink kit and learn hypnobirthing (vbac preparation hypnotherapy CD by Maggie Howells is available through Birthrites and is a beautiful resource in facing fears and preparing for a new birth).

7. DON'T HIDE. Face your fears. Find positive information to help reassure youself. Write or draw your birth story, perhaps talk to a counsellor. Keep a journal of this pregnancy. Talk to a variety of other women who have been there before you.

8. ADD SOME BALANCE. Don't focus solely on the birth. Enjoy your pregnancy. Delight in your baby. Don't forget your partner and the other children. Organise support for after the birth, whether you have another caesarean or not (see planning a positive caesarean on the Birthrites website).

Remember birth is rarely perfect, but it's worth trying. Giving your best for you and your baby is good enough. This is not a pass or fail event.

REFERENCES:
1. Australia's mothers and babies 2000. AIHW National Perinnatal Statistics Unit, Sydney, 2003.
2. www.who.int/reproductive_health/publications/MSM_94_14/MSM_94_14_chapter3.en.html. 23/08/2004.
3. Mozurkewich EL and Hutton EK. "Elective Caesarean delivery versus trial of labour: a meta-analysis of the litereature from 1989 to 1999." Am J Obstet Gynecol 2000;183:1187-97.
4. Enkin M et al. "A guide to effective care in pregnancy and childbirth" 2000. Oxford University Press.

This article was kindly provided by Birthrites: Healing After Caesarean Inc. For more information, view their website at www.birthrites.org.