Going natural after a caesarean

Back in the day

Edward Craigin, an American doctor in the early 1900s said, “Once a caesarean, always a caesarean.”

This may have been true back in the days when fewer than 2% of births were by caesarean and these were life saving emergency operations using methods that were primitive compared to techniques that have been perfected these days.

More women are giving birth by caesar today

More women are giving birth by caesar today, either by choice or due to circumstances that threaten complications. The private medical sector in South Africa is no exception with a c-section rate of 65% compared to 10 – 20% in government hospitals.

In a recent study, women who had given birth by caesarean were asked what type of birth they would prefer in future. 89% percent were in favour of a natural birth.

Having a VBAC

A successful vaginal birth after a caesarean is called a VBAC. Before birth and during labour the procedure is known as TOLAC (trial of labour after a caesarean). Should there be any problems that necessitates another caesarean birth, it’s called AVBAC or attempted vaginal birth after caesarean.

Controversial topic

All this terminology can only mean that for women who want to have a natural birth after a caesar, it’s a hot topic that’s currently debated by midwives, obstetricians, gynaecologists, government health departments, tertiary academic hospitals and even lawyers.

The big question is: how safe is it to have natural birth after all 3 muscular layers of the womb have been weakened by an incision?

Midwife Henny de Beer conducted research into VBACs and found that 50 – 80% of TOLAC labours could result in successful VBACs. Yet in countries like the US, repeat caesarean sections have become standard (92% in 2006). Because many private medical institutions in South Africa don’t support TOLAC, women who would like to have this type of birth, may have a hard time finding a doctor to support them.

Why do women opt for natural birth after a c-section?

According to research cited by Henny in her own research, natural birth nurtures a woman’s “maternal instincts” making her feel in control of her body because she is involved with making decisions about her body and the way she will give birth.

The bond between the woman in labour and her midwife helps her to feel less inhibited and more relaxed, empowering her to work through the natural progress of labour.

Women who are already anxious about anticipated problems or negative memories of a previous delivery need to trust and have confidence in their midwives. Recovery after birth (both physically and psychologically) can be easier than after an emergency c-section.

Women who have not had a successful VBAC

Women who have not had a successful VBAC with their previous pregnancies are not advised to make a second attempt.

There are circumstances when a TOLAC is not negotiable such as when there is:

• A history of previous uterine corrective surgery
• When her previous caesarean was a “classical” cut (the cut shows from just under the belly button but heals well, since it’s easier for the stomach muscles to re-attach and repair themselves)
• When the baby’s head is too big for the pelvis (or her pelvis is too small)
• When there are maternal problems such as pre-eclampsia
• Baby is at risk. 
• An abnormal placenta presentation
• Second birth is less than 24 months after the first
• Caesar scar shows signs of weakness
• If this type of birth puts mom and/or baby’s life at risk in any way.

Factors that weaken a caesarean scar

• Obesity (more than 135kg)
• A pregnancy that continues after the due date
• Induced labour
• An ultrasound assessment of the scar indicating an abnormally thin lower uterine segment
• Women who have had more than 1 previous caesarean section
• A multiple pregnancy
• Women who are older than 35 years
• Breech presentation.

Doctors opinions

When doctors were asked why they were not in favour of VBACs, 99% were genuinely concerned about uterine rupture – yet research has shown that this risk is less than 1% (0.24% to 0.98% compared to 0.12% to 0.49% chance of uterine rupture in a first time natural labour).

Factors that improve the chances of having a successful VBAC

• Having had at least 1 previous vaginal birth, (this decreases the risk of uterine rupture by 60%)
• Delivering the baby before term.

Of note is the history of her previous caesarean birth – were there any complications such as wound infection, and what method was used to stitch the womb after the operation? One research study showed that single-layer closure increased the incidence of rupture by 8 times.

Guidelines when you are considering a VBAC

TOLAC is within the scope of practice for a South African midwife as long as she is experienced and competent. Her patients should be seen by a medical practitioner at least once during the pregnancy and the doctor would be consulted should a problem arise either during pregnancy or at the time of delivery.

Careful monitoring during labour is essential to prevent complications should there be any deviations from the norm. Accurate diagnosis and prompt intervention can save lives.

Midwives (and doctors) are very selective when deciding whether a women “qualifies” for a VBAC or not because an unsuccessful TOLAC could be devastating for some women – especially if she has never had a vaginal birth.

Guidelines to selective criteria

1. Age – she must be younger than 35 years.
2. Parity – the number of children she has given birth to.
3. Gravity – the number of times she has been pregnant (this must not exceed 4).
4. The interval between her present and previous pregnancy must be at least 24 months.
5. Reasons for previous c-section may recur ruling out the possibility of a VBAC.
6. Labour must progress normally so that the woman gives birth within 12 hours.

Having a vaginal birth after a previous caesar is not a simple procedure. Circumstances have to be ideal (the birthing unit must have emergency theatre and staff back-up). The team includes a midwife with a medical practitioner, paediatrician and anaesthetist on stand-by.

Many women who want natural birth may be disappointed to learn that either she does not qualify for a VBAC or her medical practitioner or birthing facility is not in a position to accommodate her, so check first.