I had my first daughter by emergency caesarean just over 3 years ago. I am currently expecting baby number 2 in early February next year. I live in the UK and In my area, I can choose whether to have a repeat caesarean, a hospital birth or a home birth. I am automatically classed as ‘high risk’ by the NHS, but despite this I am planning to have the baby at home.
After a caesarean section, in subsequent pregnancies there is a small risk of scar rupture during labour. The actual level of risk is about 0.2-0.5% according to the most recent studies (older studies have included medically induced labours which increases the risk). The risk of the baby dying is even smaller (about 1 in 10,000), and the overall risk of uterine rupture is no different to first pregnancies – there was no mention of this risk in my first pregnancy, but now that I have had a caesarean it is the first thing that midwives want to talk about. There are other things that can go wrong in any pregnancy but none of them are singled out to the same degree as scar rupture is for VBAC mothers, if they are even mentioned at all.
The NHS doesn’t distinguish between different levels of risk and so this slight increase is automatically classed as ‘high risk’. In my area, this means that I am not ‘allowed’ in a midwife led unit (MLU) and have to choose between the hospital labour ward or home birth. This seems rather illogical to me, to allow me to give birth at home but not in the MLU, but I was told that they do not admit so-called ‘high-risk’ women because it can affect their success rates.
Women having VBAC in hospital are usually advised to have continuous fetal monitoring (CFM) which involves having two monitors strapped to your stomach, which are attached by wires to a machine that continuously monitors uterine contractions and the baby’s heartrate. One of the early warning signs of scar rupture can be a drop in the baby’s heartrate so this monitoring aims to detect any problems early. However, it still requires a human being to check the readings, and in a busy hospital ward there is no guarantee that there will be enough midwives available to do this regularly. It also restricts movement as mothers are usually confined to the bed on their back, which is known to increase the likelihood of further intervention. In addition, it is not the only indication of a scar rupture, and on VBAC forums online there are stories from women who have experienced scar rupture where the baby’s heartrate did not drop.
Other hospital protocols for VBAC labours include having an IV or cannula placed on admission, early admission to hospital, and restrictions on the length of the first and second stages of labour. None of these protocols are based on research and there is no evidence that they improve safety for mother or baby. They do however interfere with the natural progression of labour and increase the chances of intervention. It is important to remember that none of these protocols are legally binding and if you do choose a hospital VBAC, you don’t have to go along with them if you don’t want to.
Early warning signs
As mentioned above, the most well-known indicator of a possible scar rupture is a drop in the baby’s heartrate. This can be monitored by CFM in hospital, or via intermittent monitoring using a handheld device (the same kind that is used to check the baby’s heartrate during pregnancy). There are other indicators which include a spike in the mother’s temperature, a drop in the mother’s pulse, pain in between contractions, unexplained bleeding, and the mother’s instinct that something is wrong. An attentive midwife would easily spot these signs, and in the case of a home birth would call an ambulance straight away to transfer the mother to hospital.
At the end of the day, it’s a matter of weighing up the different risks and benefits of each option: repeat CS, hospital VBAC or HBAC. Personally I would support any woman to make the choice that she feels most comfortable with, and I can understand why someone might choose any of those options – it’s a very individual thing. If you had your first baby by elective caesarean then a repeat CS might seem like the safe option, as you’ve been through it before (and also makes it easier to arrange childcare). Some people will feel safer planning a hospital VBAC, knowing that if anything does go wrong they are in a building full of doctors and medical equipment. And some people will feel more comfortable at home, where they have much more control over the environment and feel more relaxed (and you may not even need to arrange childcare!).
Myself, I am opting for a home birth after carefully considering the pros and cons of each option. From the research I have done (see below), it seems that the risk of having any intervention is lower for women planning a home birth, although I understand that if something does go wrong, there is the added delay of having to wait for an ambulance and transfer to hospital. I don’t feel like a hospital birth is the right choice for me as I have a phobia of hospitals and doctors, and fear can slow or even stop labour from progressing. In addition, during my first labour I was on CFM most of the time and I found being stuck on the bed extremely uncomfortable, and made me feel trapped and even more scared. For these reasons, I feel that my chances of success are far, far greater at home, and the benefits of being at home outweigh the risks. It also means my 3-year-old daughter can be present at the birth, which is important to us, although we will have some friends on standby to pick her up if she becomes distressed or bored, or in an emergency.
There are two books I would highly recommend, the first is Birth after Caesarean by Jenny Lesley (available from AIMS) which has a very balanced and sensitive approach to both VBAC and planned caesarean.The second is Vaginal Birth After Caesarean: The VBAC Handbook* by Helen Churchill and Wendy Savage which again discusses the pros and cons of VBAC and caesarean and has advice on maximising your chances of success if you choose to plan a VBAC.
There are a lot of resources online about VBAC and HBAC, the following are ones found particularly helpful, several of which are from midwifery publications and websites:
- Homebirthers and Hopefuls – Home Vaginal Birth After Caesarean
- Cochrane Summaries – Comparing Continuous Electronic Monitoring…with intermittent monitoring
- Midwifery Today – Homebirth After Cesarean: The Myth and the Reality
- Midwife Thinking – VBAC: making a mountain out of a molehill
- Science & Sensibility – Is Elective Repeat Cesarean Surgery Truly Safer Than Planned VBAC?
- Aims Journal – VBAC – On Whose Terms?
- Caesaran Birth and VBAC Information: Mary Cronk’s thoughts on early detection of scar problems during VBAC
- BirthChoiceUK http://www.birthchoiceuk.com/
- NICE C-section section quick reference guide http://www.nice.org.uk/nicemedia/pdf/CG013quickrefguide.pdf
*Disclosure: This is an affiliate link and I will receive compensation if you choose to buy this book after clicking on this link.