VBAC vs elective Caesarean section

A question and my answer on a health matter advise website where I am a Heath Professional ‘expert contributor’.

Question to the health advise website from an anonymous person (not my patient) who I don’t know and who lives somewhere in Australia:

“I have had 2 children – the first a caesarean due to complications, and secondly a VBAC. The 2nd birth happened very quickly in the end during which time I felt paralysed and out of control, nothing like what I have seen in birthing classes. The outcome was a healthy baby and a not-too physically scarred mother, but I can still vividly recall details of the birth and things said during the time. Being in the delivery suite now (as a visitor) leaves me in tears.

VBAC vs Elective Caesarean Section - Baby Sleeping

I really want a caesarean delivery for my 3rd child (currently 28 weeks pregnant) despite knowing in my head that a natural birth would be better for the bub and my own recovery afterwards. Do I need counselling to move past the last birth experience? My obstetrician feels the last birth wasn’t particularly traumatic in his opinion, so how do I get past the fear and anxiety which I think about constantly and lose sleep over?”

My answer

It sounds like your obstetrician doesn’t understand where you are at. If you would feel more comfortable with an elective Caesareans action then I suggest you insist. You are in your right.

I had a new antenatal patient today (first visit) who had an emergency Caesarean section last pregnancy with another obstetrician. It was done for foetal distress in labour and under a general anaesthetic. She was told it was so a there was not enough time for a regional anaesthetic. It was an emotionally very traumatic experience for her.

We discussed the pros and cons of an elective Caesarean section and VBAC in detail.

I advised with a VBAC decision there is about a 40% chance of an emergency Caesarean section in labour being required for reasons such as lack of progress in labour, foetal distress in labour and rupture of the uterus in labour. The incident of rupture of the uterus in labour in studies varies is generally quoted as 1 in 200. A ruptured uterus can have considerable implications for mother and baby’s health. As well a VBAC is associated with an increased incidence of operative vaginal deliveries. That is because it is too dangerous to allow a woman to push too long in second stage labour after she has had a Caesarean section.

An elective Caesarean section is a planned event which is booked to be done before she is likely to go into labour. As such her expectation is for Caesarean section, so she knows what will be happening. There is not the fear of what happened last time – the emergency Caesarean section. This certainly is very important and means she is more likely to relax, enjoy her pregnancy and not have fear. It can be done with her awake and as a positive experience. I encourage the anaesthetic sister to lift her head so she can see her baby being born. I invite her to touch her baby immediately after delivery and later to cuddle her baby while the operation is being completed. He husband/partner is present. He is encouraged to take lots of photos and to cut the umbilical cord. As a ‘baby friendly’ Caesarean section her baby and husband stay with her and the midwife all the time she is in the operating theatre and in the recovery ward. In the recovery ward her baby is weighed and put to the breast. And she can go home when she is ready and wants. This may be as early as two or three days after her delivery. I have had patients even driving a car two weeks after a Caesarean section.

For my new antenatal patient the door is open and I said I am happy to support her in what SHE DECIDES as long as there are no contraindications.

Because of her history and the associated emotional scarring from last time I suspect she will decide on an elective Caesarean section.

But another woman who had to have an elective Caesarean section first time for a non-recurring problem is more likely to request a VBAC to experience labour and hopefully a normal delivery.

I don’t know that ‘having a natural birth means it is better for the bub and my own recovery afterwards’. Yes if all went very well. But there is the uncertainty that it may not and if it does not it is potentially much more hazardous for you and bub.

Also see VBAC – Risks and management in the Question and Answer section

Posted by Dr Gary Sykes on - Caesarean section

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