Maternity care experts now believe that a vaginal birth after c-section (VBAC) is a safe option for most women and their babies.
But what about women who've had two or more c-sections who want a vaginal birth?
Women wishing to try a vaginal birth after two c-sections are generally ‘not allowed', or are advised that there's a greater risk of complications, and less likelihood of success.
They might even be made to feel that choosing a VBAC is dangerous or irresponsible.
However, a review of available evidence shows a different story.
The success rate for women who attempted a VBAC after 2 c-sections was found to exceed 71%, while the uterine rupture rate was around 1.3%. The risk of complications was similar to those of a repeat c-section.
A 2010 study compared risks and success rates from a group of over 25,000 women who had prior c-sections and were attempting a VBAC. The women who had three or more prior c-sections had similar rates of success and complications as those with one prior c-section, and as those born by elective repeat c-section.
Another study confirms the risk of uterine rupture is no greater in women who have multiple c-sections, and shows the overall risk of any complications is very small.
Benefits of VBAC After Multiple C-Section
The benefits of VBAC are the same for women, regardless of how many c-sections they've had.
A vaginal birth after c-section:
- Reduces the risk associated with c-section surgery (infection, blood loss etc)
- Has a shorter recovery time than a c-section
- Gives women a greater sense of satisfaction with their birth experience
- Reduces the baby’s risk of breathing issues that require admission to NICU
- Means your baby has chosen his or her birth date, based on when he or she was ready
Women who try for a VBAC only to require a c-section often report feeling a greater sense of control and empowerment, because they were able to make informed decisions about their birth experience. They felt they did everything they could, and surgery was truly needed.
Is VBAC After Multiple C-Section A Good Choice for Me?
When discussing whether a VBAC is a good option for you, bear in mind that many doctors may be reluctant to consider vaginal birth after multiple c-section. Choosing a supportive maternity care provider is key to ensuring you are making an informed decision about your baby’s birth.
Your chances of success for VBAC is rated higher if:
- Your previous c-section scar is from a low transverse incision (side to side incision in the lower part of your uterus).
- You've had a previous c-section for a reason that is unlikely to be repeated (breech position, diagnosis of failure to progress, placenta previa etc).
- You have already had one vaginal birth before or after your last c-section
- You and your baby have no medical complications
- Your labour begins spontaneously (without being induced)
- Your baby is in a good position (head down and facing forwards or anterior)
- Labouring freely without constraint on movement
Most hospitals require constant monitoring of the baby in case of distress, which is a sign of possible uterine rupture. Continuous fetal monitoring (CFM – where there are belts strapped around your belly) means you are restricted in movement during labour, which can lead to labour slowing down and stalling. There has been no reliable evidence to show (CFM) improves VBAC outcomes.
The Cochrane review of continuous electronic fetal monitoring found that it is not more effective at picking up distress in babies than intermittent monitoring. The review also showed that CFM increases the number of unnecessary c-sections carried out, which can reduce that chance of a successful VBAC.
Some hospital criteria for VBAC focus on baby’s size and the body weight of the mother. There is currently no evidence to show a large baby requires a c-section, unless during labour complications arise, such as true cephalopelvic disproportion (when the baby’s head is too large to fit through the pelvis).
Women with a BMI of over 30 (obese) are usually told they cannot try for a VBAC because they are more likely to have medical complications during pregnancy and more likely to go past estimated due dates. While obesity during pregnancy increases the chances of c-section, it also increases the risk of C-section complications, such as wound infections. You should discuss your health and particular situation with your doctor if your BMI is 30 or over, to determine if VBAC is the best choice for you.
Why Not A Repeat C-Section?
Women who've had multiple previous c-sections may be advised by their doctor to schedule a repeat c-section for future pregnancies. It's important to understand that a decision to have a repeat c-section should not be taken lightly. Each subsequent surgery becomes even riskier than the previous one.
You are at greater risk of serious complications such as:
- Severe blood loss (postpartum haemorrhage)
- Injury to the mother's organs and to baby during surgery
- Blood clots, and bowel obstruction (due to scarring and adhesions from the surgery)
- Ongoing infections and pelvic pain
- Ongoing issues for future pregnancies due to your uterine scar causing problems with the placenta.
Tips For A Successful VBAC
Being informed about all the risks and benefits of VBAC, as well as repeat c-section (in relation to your own individual health and situation), is key. Choose a care provider who is supportive of VBAC, and make sure you know how they feel about VBACs after multiple c-sections.
If you are planning a VBAC after multiple c-section, there is no guarantee you will avoid another c-section. But there is a great deal you can do to increase your chances of a successful VBAC. Most importantly, do your research and be as informed as possible during pregnancy, so that there are no surprises.
Choose your caregiver carefully, making sure they support and encourage VBAC as well as value your role as the decision maker in your care. Your care provider should be positive about vaginal birth and available to discuss your options for care and answer your questions. It's a good idea to review the reasons for your previous c-sections, to understand how you might improve your chances for a successful vaginal birth.
Consider hiring a doula to provide emotional and educational support during pregnancy as well as 1:1 support during labour.
Evidence shows that high risk women who have support during labour from doulas have better birth outcomes.