Wednesday, June 29, 2011

Births after Caesarean

Is spontaneous natural labour and birth a realistic option?

The answer, in each case, depends on decisions made during the pregnancy and as the labour progresses.

Most midwives, and many doctors, would encourage women to give birth vaginally. Unless there is a specific and valid reason to avoid vaginal birth, there is no safer way for mother and baby than spontaneous, natural, unmedicated vaginal birth.

A pregnant woman who intends to give birth spontaneously, naturally, whether or not she has had previous Caesarean births, has significant decisions to make as her pregnancy progresses. Each decision is in effect a fork in the road, guiding and determining the subsequent course of the journey.

Here are a few key decision points:
Decision Point #1: Model of care and primary care provider
Decision Point #2: Onset of labor
Decision Point #3: Progress in labour
Decision Point #4: Giving birth
Decision Point #5: Third stage/ baby's transition

The woman who is able to make the decision consistently to continue in a normal physiological pattern of activity, and avoid medical 'help' in its many forms, is the person most likely to achieve vbac.

The woman who simply assumes that the hospital/service/doctor/midwife has the skill and capacity to support her desire for vbac may be disappointed. There is huge variation in the rates of attempting and achieving vbac in maternity services.  (The images below are not very clear - you can download them in .pdf files from the Vic Health Department publications site.)

In Victoria the Health Department have a very useful system of reporting Performance Indicators for public maternity hospitals. The hospitals are named, and rates given for the various indicators. For links to these publications click here, and go to Victorian Maternity Services Performance Indicators complete set for 2008-09 August 2010.
[Quoting from p17]
MAT 4. Vaginal births after primary caesarean section
Clinical significance
Nearly one third of all babies in Victoria are born by caesarean section. While many of these procedures are necessary and improve outcomes for women and babies, they also can prolong recovery from the birth, increase the small risk of serious morbidity after the birth, increase the risk of major complications in subsequent pregnancies, particularly problems with placentation, and require additional resources. Reducing the number of avoidable caesarean sections minimises these
problems. There are two main strategies for achieving this: preventing a woman’s first caesarean section; and encouraging women who have had a prior caesarean section to attempt a subsequent vaginal birth (VBAC) and supporting them to achieve it.
Observations on the data
 (see images Mat4a and Mat4b)
Thirty-seven hospitals each had at least five women give birth whose only prior birth was by caesarean section. The rate of attempted VBAC for these women ranged from zero to 68 per cent.
Twenty-two hospitals had a least five of these women plan a VBAC for their second birth.
The range of achieved VBAC at these hospitals was 40 per cent to 86 per cent.
At least 50 per cent of women who planned a VBAC achieved a VBAC at 18 of the 22 hospitals; at least 60 per cent achieved VBAC at 13 hospitals.
Over time, the rate of women who plan a VBAC has remained steady at 30 per cent. However, there is wide variation in the rate of women planning a VBAC across hospitals. This may be a reflection of clinician practice variation and warrants further investigation.
There is an encouraging upward trend in the proportion of women planning VBAC who achieve VBAC.

Midwives who practise privately, or independently, are ideally situated to work with women who plan vbac.   The midwife and the woman are able to achieve a model of care that is personal and centred on the woman.  The midwife as primary carer is able to move with the woman as she makes each decision. The woman who is able to make the decision consistently to continue in a normal physiological pattern of activity, and avoid medical 'help' in its many forms, is the person most likely to achieve vbac. The midwife who has a professional partnership with the woman planning vbac will provide information and advice with the aim of protecting the wellbeing and safety of mother and child.

To download an INFOSHEET on Births after Caesarean, click here.
For the Homebirth Australia Facebook page Save HBAC in Australia, go to


Anonymous said...

if only 30% of women plan a VBAC and half of them are successful that is just a grand total of 15% success rate for VBAC. That doesn't seem like good odds espcially since 70% actually have another section with no labour and 15% have another section after some labour.

Joy Johnston said...

Thankyou for this comment 'Anonymous'.

Readers need to understand that statistics are presented in different ways, so that useful comparisons can be made. The numerator and denominator in any equation are very important.

In the tables shown here the first (Mat 4a) looks at the women in public hospitals in Victoria who planned vbac for the birth immediately following a primary (first) C/S [numerator] compared with all women who gave birth following a primary C/S [denominator]. The satewide rate is around 30%. As you point out, this means that 70% have elective repeat Caesarean surgery.

The second figure (Mat 4b) uses as the denominator those who actually planed vbac. Figure 4b shows that there was a better than even chance that if a woman planned vbac, she would have achieved a vaginal birth in a Victorian public hospital. It also shows that if that woman was in certain hospitals, she had a high chance (70% +) of achieving vbac if she planned to do so.