VBAC or repeat C-section?

What you should know before making the call

Andrea Natale, of Stevensville, Ont., and Heather Waller of Kingston, Ont., have never met. Nonetheless, the two women have a lot in common. Both strongly believe vaginal birth is ideal for babies and moms. Both had their first labours induced (Natale was overdue, and Waller had pre-eclampsia), and both ultimately delivered their first babies by Caesarean section when the procedure didn’t go as planned.

However, when it came time during their second pregnancies to decide between vaginal birth after Caesarean (VBAC) or repeat C-section, the two women made different decisions. For Natale, who opted for an elective C-section, the clinching factor was the 20-month spacing between her two births: Evidence suggests that such close spacing may increase the odds of uterine rupture. Waller, whose second pregnancy was complication-free, was determined to aim for a vaginal birth. At 41½ weeks, she got her wish: After going into labour on her own, she pushed out a nine pound, three ounce baby.

Despite the fact that their second babies arrived via different routes, Waller and Natale are both content with their choices. “I felt empowered by my decision, even though it was one I didn’t want to make,” says Natale. “My recovery after my first was horrendous because I had gone through hours of labour and pushing, then the C-section. The second time around, I was grateful to only have to recover from the surgery — it was definitely easier.”

And while Waller had mentally prepared herself to deal with a second C-section if necessary, she’s delighted she didn’t have to. “My recovery was a breeze — I had a shower right off the table,” she says. “I felt like a million dollars. And I was able to breastfeed this guy,” she adds, something she wasn’t able to do after her first birth.

If your first baby was born by C-section and you’re now expecting your second, you have a decision to make: Would you prefer to book a repeat Caesarean, or try for a vaginal birth instead? Thanks to modern medicine, the odds of something going seriously wrong during either scenario are very small. But before you opt for one path or the other, you need to know the pros and cons of each.
VBAC Benefits/C-section Risks

Let’s start with the reasons you might decide to try for a VBAC. The medical bottom line is that a successful vaginal birth is the safest route for both mom and baby. And most women who attempt a VBAC — roughly 75 percent — do succeed. (See “Assessing Your Odds” on factors that affect your personal likelihood of success.)

However, it’s often the non-life-and-death considerations that lead women to attempt a VBAC. Recovery from a vaginal birth is typically much quicker than after a Caesarean (which, after all, is major abdominal surgery) and, consequently, simple things like getting out of bed and holding the baby to nurse are typically easier and less painful.

That’s important when you already have a toddler needing your attention. And some women have a deep desire to experience a vaginal birth, which may help make bonding and breastfeeding go more smoothly and, frankly, can be an extraordinarily empowering experience. “Above and beyond the practical benefits of VBAC, everyone here is committed to the idea that there’s something valuable about normal physiologic birth,” notes Dale Steele, the obstetrician lead at the Best Birth Clinic at BC Women’s Hospital in Vancouver.

The medical advantages of VBAC primarily have to do with avoiding the risks of C-section. First of all, because there’s no cut, there’s no chance the incision will become infected, which happens to 2½ to six percent of women who undergo C-sections, says Jon Barrett, a spokesperson for the Society of Obstetricians and Gynaecologists of Canada, and chief of maternal-fetal medicine at Sunnybrook Health Sciences Centre in Toronto.

C-section also carries higher risks of problems, such as blood loss, operative injury, anaesthesia-related complications and deep vein thrombosis (a potentially dangerous blood clot that forms inside a blood vessel). It’s also much more common for the tissues of the uterine lining to become infected after a C-section than following a vaginal birth. And while the chance of dying during a C-section is tiny (less than one in 3,000), the odds of that happening during a vaginal birth are even more remote. In short, “Caesarean has a higher risk than vaginal birth,” says Barrett. And if you plan on expanding your family further, some of that risk carries forward: A repeat C-section increases the risk of stillbirth and problems with the placenta in future pregnancies.

For the baby, the advantages of a successful VBAC include a lower likelihood of breathing problems (these are usually temporary, but may require a short stay in the NICU). And C-section may possibly increase the odds of immune-related problems, such as allergies and asthma, and possibly even type 1 diabetes, later in life. (It’s thought that early exposure to antibiotics, which are routinely given during C-section, or lack of contact with the beneficial bacteria normally found in the birth canal may increase the incidence of such immune system malfunctions.)

VBAC Risks/C-section Benefits

So much for the benefits — what about the risks? A VBAC attempt (a.k.a. a trial of labour) does carry some risks over and above those of regular labour. In a small number of cases, contractions can cause the uterus to tear, usually along the scar. This necessitates an emergency C-section, which is slightly riskier than the scheduled variety. For a woman who goes into spontaneous labour after one low transverse C-section (the most common type), the odds of this happening are about one in 200, according to Andrew Kotaska, clinical director of obstetrics and gynaecology at Stanton Territorial Hospital in Yellowknife. Mind you, in a modern obstetrical unit, the risk of something truly dire happening is much lower than that. “If you rupture, the risk of a bad outcome for your baby in a large Canadian maternity hospital is about one in 10,” Kotaska explains. That means that the chance of a baby suffering brain damage or death during a trial of labour is approximately one in 2,000, though some doctors, like Barrett, place that number slightly higher, at one in 1,200. To put those statistics in perspective, the SIDS rate is about one in 2,000 live births.

To minimize the risk, many caregivers recommend only trying a VBAC in a hospital that has anaesthetists and surgeons available around the clock. Other safety measures include frequent or continuous monitoring, and abandoning the attempt if labour doesn’t progress despite adequate contractions.

What about an elective C-section? Does it carry benefits that aren’t outlined above? On the plus side, some women who’ve already had a Caesarean feel more confident about a repeat operation because they already know what to expect. They may also, understandably, want to avoid a repeat performance of a long, gruelling labour that ultimately ended in a C-section.

Ideally, you and your caregiver should be able to weigh both your individual risks and your personal chances of success. You’ll also want to take into account other factors (for example, whether you plan on having more children) before making your decision. “Part of the counselling that we do is to say that you’re either a good candidate, or not such a good candidate,” says Steele. But either way, as long as you understand what’s involved, the choice is yours. “We hope to empower women to inform themselves and make a choice for their best possible birth.”

VBAC resources

vbac.com

childbirthconnection.org

powertopush.ca (Click on Info for Professionals, then Patient Information and Forms)

sogc.org

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