VBAC (Vaginal Birth After Caesarean)

Why is there so much interest in VBACs now?

From a national point of view, repeat caesarean births account for a significant portion of the overall caesarean rate and there has been a lot of focus in recent years on how we need to get our national rates lower. Historically, VBAC rates have fluctuated as obstetric practice has changed over the years from being pro-VBAC to a preference for repeat caesareans. Focus is back on increasing the VBAC rates now. VBAC is a safe option for most women and success rates for those who attempt a VBAC are high, generally reported to be about 70%. The reason(s) for the first caesarean is a factor that influences the rate of VBAC success and the level of caregiver support for planning a VBAC. There are many personal reasons why a woman might prefer a vaginal birth over a repeat caesarean:

• Easier recovery after birth
• Better able to care for older children
• Vaginal birth option is healthier for both mother and baby (lower morbidity)
• Wanting to experience a vaginal birth
• High likelihood of success

What printed information does my local unit give about VBAC?

Units typically have a range of leaflets available. Some units provide an information booklet or magazine instead. We asked if information on VBAC was available and 11 units said yes.

What services and supports are available antenatally for women hoping to have a VBAC?

Not all units answered this question. Answers included giving information and support, leaflets, providing special clinics (only 2 units) or discussions at antenatal clinics. Five units mentioned special VBAC antenatal classes. Some specified consultant involvement in planning care.

Are there separate antenatal classes for women hoping to have a VBAC?

Specialised classes for women hoping for a vaginal birth after caesarean (VBAC) are only offered in 3 out of 19 units – typically the larger maternity hospitals. One unit said that they would be included in the refresher classes. Another specified a VBAC clinic facilitated by a midwife. Some units were hoping to provide these classes when funding allowed, so please check locally for an update. If they are still not available, you could write to the director of midwifery because demand will be taken into account when planning services.

I’m aiming to have a VBAC (vaginal birth after a caesarean). What is my local unit's policy?

This varies from unit to unit with several units stating that it's encouraged and others stating that it's decided on an individual basis based on discussions between the woman and a consultant obstetrician. Labour starting spontaneously is preferred, with some units mentioning cautious approaches to inducing labour – often limited to artificially releasing the waters (ARM – artificial rupture of membranes) or very careful use of the Syntocinon drip. Five units specified the use of continuous monitoring. See the FAQ below on rates, but VBAC attempt rates vary widely from unit to unit so it appears that women in some units receive more encouragement and support than women in other units.

I’m aiming for a VBAC (vaginal birth after caesarean). What are the implications for labour and birth?

Not all units answered this question and those that did gave varied responses. Several stated that plans would be discussed in advance and some specified obstetrician-led care. Labour starting spontaneously is preferred, with one unit mentioning cautious approaches to inducing labour or the use of the Syntocinon drip in spontaneous labour. Six units specified the use of continuous monitoring. One unit mentioned their specialised antenatal classes for women planning a VBAC.

I’m hoping to have a VBA2C (vaginal birth after 2 caesareans). What is my local unit's policy?

The national clinical guidelines on delivery after previous caesarean section (CS) issued in 2011 states, ‘It is normal practice to advise women with two or more previous CS to have a repeat elective CS at term….’ But also, ‘In individual circumstances where a woman strongly desires a trial of labour after two previous CS, it may be considered.’ The policy in most units is to have a planned caesarean birth, with one unit saying ‘the majority’ would have a repeat caesarean. Only two units indicated that there would be discussions about options. We asked how many women had had VBA2Cs, but most units couldn’t give us that information. CUMH stated their rate was ‘less than 1%’ and UHG had 1 unplanned VBA2C. These figures are from 2014 & 2015. Rates may be higher now as more women are educating themselves about the possibility of VBA2C.

How many women have VBACs in my local maternity unit?

Some of the units couldn’t provide us with any figures at all and others could only give some of the data we asked for. The process of compiling this guide has highlighted and raised concerns about differences in data recording and reporting abilities in the 19 maternity units and 2 midwifery-led units in Ireland. Hopefully, the roll-out of the new Maternal & Newborn Clinical Management System will standardise data recording in future years and will enable better reporting.

There are lots of different ways of calculating VBAC figures. One way is to look at the number of VBACs as a percentage out of all the births in the maternity unit. This results in low figures, typically less than 5%. This figure runs between about 2.2% and 4.4% for the 11 units that could give us this information for 2014.

The next way to look at the rate is to find out what percentage of women who had one prior caesarean ended up giving birth vaginally. This figure runs between about 15% to 39% for the 9 units that could give us this information for 2014. This is an important figure as it gives the best indication of the unit’s VBAC rate.

The next way of calculating the VBAC rate is often quoted as VBAC success rate. It is the percentage of women who attempt a VBAC and get one. The success rate is high in Ireland in keeping with internationally quoted levels, running between about 53% and 75% for the 10 units that could provide this information. Most values are above 65% which is very encouraging for those aiming for a VBAC.

A very interesting figure, though, is the percentage of women with one prior caesarean who attempted a VBAC – in other words who laboured (either spontaneously or by induction of labour) or had what’s known as a ‘trial of labour’. In some units this is significantly lower than in other units. The rates range from 29% to 57%. In units with attempt rates of only 30%, are women being given the information, support and encouragement they need from their caregivers to have the confidence to attempt a VBAC? Should we applaud VBAC success rates of 70% in units where the attempt rate is only 30%? Given that there are concerns about how to safely induce labour in a woman attempting a VBAC, we also asked for the split between spontaneous labours and induced labours. The split varies from unit to unit with some units having very low levels of induced trials of labour and other units with about 10% of mothers with one prior caesarean having their labours induced.

Given the nationwide rise in caesarean births in recent years, what strategies are in place to reduce the numbers of caesarean births in my maternity unit?

The units responded with a range of answers including promotion of VBAC (vaginal birth after caesarean). Other strategies reported are close auditing of Caesarean births, use of fetal blood sampling, consultant input, delaying induction to 42 weeks where possible, education of women, external cephalic version to turn breech babies, and use of upright positions & birthing aids to help labour progress.