VBAC.

Vaginal Birth after Ceasarean Section – VBAC.

This can be an emotive topic for some and so I want to approach discussing it by saying up front that I think most people, and I include obstetricians in this, go to work trying to do their best and I do not believe the fantasy that “all women can have a vaginal birth”.

If not having a caesarean in the first place is very important to you then prevention is better than the cure so the whole subject does start with you doing proper research into your hospital and obstetrician. There are mums groups and review websites which, while not perfect, can help.

My advice is that if you do look at the reviews then only pay attention to the ones where the doctor has been tested due to unforeseen circumstances. That’s when you see what they are made of and if the glowing review is of them being “nice” that’s less useful for a serious thing like a VBAC in my view. I’m always puzzled when I’m told by my patients that their friend was upset they had a caesarean but went to see an OB with a reputation for them in the first place. If it was that important then surely a little ground work?

In my own hospital the caesarean rate is 50% - that is made up of me being consistently the lowest of the busy OBs at 35-40% and some others being over 80%. It used to be the case that a lower caesarean rate meant a more skilled OB but this has blurred over time as caesareans have become more on demand, better to recover from and less people worry about it. In my own case if I see that a birth is going to be a warzone I offer a planned caesarean and I don’t think I or my patients have ever regretted it.

My approach is usually to go hard on a first try and if it ends as a ceasar just have another next time as they are protective of your pelvic floor and the true great recovery that folks hope for with a vaginal birth tends to be more with a second vaginal birth. After the first vaginal birth you can be quite sore and sorry but the second is usually much, much better and that’s where the assumption that a VBAC is worth it comes from IMO.

By then there is the first born zooming around so that’s why I try to give women a good swing at it first time. Some women don’t think about this and only realise this is going to be an issue when they have the toddler and sometimes feel they were talked into a caesarean for their first birth maybe by fear. By then its too late.

I still do VBACs regularly despite some OBs pulling back from them and hospitals getting more nervous. That’s because I’ve done them for years and I know that when the rules are followed they are safe especially when I did the ceasar before myself. I also know I can bring you out of any hole that you get into during the attempt. In a scar rupture that hole can be very deep.

If you are still keen the most successful VBACS go in this order.

1. Previous ceasar done by me or other fully qualified OB for breech or fetal distress in labour rather than a long labour and getting stuck.
2. You must labour spontaneously and be in good labour with a dilating cervix before having an epidural.

Get yourself to a 4-5cm dilated cervix and have that epi if you want it. Many do.

Least successful VBACs

1. Previous ceaser done in a public hospital – the scar can be weak.
2. Past your due date. Scar is thin and baby is bigger. IMO Book in a planned ceasar knowing you were prepared to give it a try but baby knew it was a bad idea and refused to come.
3. Getting to the hospital and have an epidural in very early labour (<2cm dilated) will usually stop the labour and turns it into an induction of labour with its higher failure rate and risks of uterine rupture.

Before folks use Chat CPT to criticize these opinions are generalisations from being an OB for 30 years (this year) so obviously there are exceptions that you may have heard about but that’s just my thoughts. And by the way I’m not old I just was a doctor delivering babies at age 24! The days are long but the years are short my friends.