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VBAC (Vaginal Birth after Caesarean)
What does a VBAC (vaginal birth after caesar) entail, is it safe, and what do the experts say?



Sr Burgie Ireland investigates

Edward Craigin, an American doctor in the early 1900s said, “Once a caesarean, always a caesarean.”                                                                                    

This may have been true back in the days when fewer than two percent of births were by caesarean and                                                                                  

these were life saving emergency operations using methods that were primitive compared to techniques                                                                                    

that have been perfected these days.

More women are giving birth by caesar today, either by choice or due to circumstances that threaten                                                                                   complications. The private medical sector in South Africa is no exception with a c-section rate of 65 percent                                                                          

compared to 10 – 20 percent in government hospitals. In a recent study, women who had given birth by                                                                            

caesarean were asked what type of birth they would prefer in future. Eighty-nine percent were in favour of a                                                                            

natural birth.



A successful vaginal birth after a caesarean is called a VBAC. Before birth and during labour the procedure                                                                                  

is known as TOLAC (trial of labour after a caesarean). Should there be any problems that necessitates                                                                                

another caesarean birth, it’s called a VBAC or attempted vaginal birth after caesarean.

All this terminology can only mean that for women who want to have a natural birth after a caesar, it’s a hot                                                                                

topic that’s currently debated by midwives, obstetricians, gynaecologists, government health departments,                                                                              

tertiary academic hospitals and even lawyers. The big question is: how safe is it to have natural birth after                                                                                    

all three muscular layers of the womb have been weakened by an incision?



Midwife Henny de Beer conducted research into VBACs and found that 50 – 80 percent of TOLAC labours could result in successful VBACs. Yet in countries like the US, repeat caesarean sections have become standard (92 percent in 2006). Because many private medical institutions in South Africa don’t support TOLAC, women who would like to have this type of birth, may have a hard time finding a doctor to support them.



Why do women opt for natural birth after a c-section?

According to research cited by Henny in her own research, natural birth nurtures a woman’s “maternal instincts” making her feel in control of her body because she is involved with making decisions about her body and the way she will give birth. The bond between the woman in labour and her midwife helps her to feel less inhibited and more relaxed, empowering her to work through the natural progress of labour. Women who are already anxious about anticipated problems or negative memories of a previous delivery need to trust and have confidence in their midwives. Recovery after birth (both physically and psychologically) can be easier than after an emergency c-section.

Women who have not had a successful VBAC with their previous pregnancies are not advised to make a second attempt. There are circumstances when a TOLAC is not negotiable such as when there is a history of previous uterine corrective surgery, when her previous caesarean was a “classical” cut (the cut shows from just under the belly button but heals well, since it’s easier for the stomach muscles to re-attach and repair themselves), when the baby’s head is too big for the pelvis (or her pelvis is too small), when there are maternal problems such as pre-eclampsia or the baby is at risk. Neither will a VBAC be attempted if there is an abnormal placenta presentation, if the second birth is less than 24 months after the first, if her caesar scar shows signs of weakness or if this type of birth puts mom and/or baby’s life at risk in any way.

Factors that weaken a caesarean scar includes obesity (more than 135kg), a pregnancy that continues after the due date, induced labour, an ultrasound assessment of the scar indicating an abnormally thin lower uterine segment, women who have had more than one previous caesarean section, a multiple pregnancy, women who are older than 35 years and a breech presentation.



When doctors were asked why they were not in favour of VBACs, 99 percent were genuinely concerned about uterine rupture – yet research has shown that this risk is less than one percent (0.24 percent to 0.98 percent compared to 0.12 percent to 0.49 percent chance of uterine rupture in a first time natural labour). Factors that improve circumstances to have a natural birth after a caesarean include having had at least one previous vaginal birth, (this decreases the risk of uterine rupture by 60 percent) and delivering the baby before term. Of note is the history of her previous caesarean birth – were there any complications such as wound infection, and what method was used to stitch the womb after the operation? One research study showed that single-layer closure increased the incidence of rupture by eight times.



Guidelines when you are considering a VBAC

TOLAC is within the scope of practice for a South African midwife as long as she is experienced and competent. Her patients should be seen by a medical practitioner at least once during the pregnancy and the doctor would be consulted should a problem arise either during pregnancy or at the time of delivery. Careful monitoring during labour is essential to prevent complications should there be any deviations from the norm. Accurate diagnosis and prompt intervention can save lives. Midwives (and doctors) are very selective when deciding whether a women “qualifies” for a VBAC or not because an unsuccessful TOLAC could be devastating for some women – especially if she has never had a vaginal birth.



Guidelines to selective criteria

  • Age – she must be younger than 35 years.

  • Parity – the number of children she has given birth to.

  • Gravity – the number of times she has been pregnant (this must not exceed four).

  • The interval between her present and previous pregnancy must be at least 24 months.

  • Reasons for previous c-section may recur ruling out the possibility of a VBAC.

  • Labour must progress normally so that the woman gives birth within 12 hours.

Having a vaginal birth after a previous caesar is not a simple procedure. Circumstances have to be ideal (the birthing unit must have emergency theatre and staff back-up). The team includes a midwife with a medical practitioner, paediatrician and anaesthetist on stand-by. Many women who want natural birth may be disappointed to learn that either she does not qualify for a VBAC or her medical practitioner or birthing facility is not in a position to accommodate her, so check first.

A special thank you to midwife Henny de Beer for her extensive research and literature study: “Maternal and neonatal outcomes of women who attempted a vaginal birth after caesarean section” (M.Cur 2009) that was used to compile this article.



Very useful information can be found through the following links:

www.vbac.com/chapter38.html

​www.vbac.com/index.html​​

www.vbac.com/handouts.html

www.ican-online.org/

www.vbacfacts.com

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