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Vaginal birth after caesarean (VBAC) is not simply vaginal birth

Updated: Sep 29, 2022

In a rush? Click here to jump to my three top tips for planning a VBAC


Of course, physiologically speaking, this is not true. From a physiological perspective, the only variation between a VBAC and a vaginal birth without a prior caesarean is an increased risk of uterine rupture thanks to a scar on the uterus. The absolute risk of uterine rupture in a VBAC birth is still extremely low (studies show on average around 0.5% or 1 in 200 women).


But when we look at VBAC emotionally, socially and politically - it is not simply vaginal birth.


Like so much in maternity care, the reasons are several and multifaceted - lack of evidence-based guidelines, long standing cultural beliefs about safety of birth, prior birth trauma, unsupportive systems… You get the idea.


As it stands in Australia, we only see about 18% of women across the country having VBACs. That figure comes from the Mothers and Babies Report which unfortunately doesn’t take into consideration what kind of birth mothers have planned, only what birth eventuated. Therefore, there will be some women who planned a VBAC but ended up with a repeat caesarean (for any manner of reasons) that aren’t included in that 18%, but we know that around 70-80% of women planning VBACs do have vaginal births which means there are still a huge number of those 82% repeat caesareans who never sought a VBAC.


If VBAC was just another vaginal birth, we would have higher VBAC rates. Hear me out.


I’m not talking about higher rates of so-called ‘successful’ VBAC, but higher rates of women planning VBAC.


The main reason VBAC is not just another birth is the same reason so many are not planning one – the cultural belief that a repeat caesarean is a safer option. And this belief permeates not only our general society, but also our maternal health care system. It turns up in many forms from sayings like “once a caesarean, always a caesarean” (a belief I had when I had my first baby after hearing it from my family members!) to care providers insisting on all kinds of interventions from growth scans, to constant fetal monitoring, to restricting access to water immersion in order to ‘allow’ women to even attempt their VBAC.


This cultural belief leaves women fighting for their right to use their body for a process it is created for right from the outset. And it leaves a whole bunch more wishing they could give it a go, but being afraid to even suggest it and accepting another surgery instead.


The other big reason VBAC is different is that women who are planning VBACs have frequently (though not always) had a traumatic experience in their first birth. For them, feeling safe enough to allow the hormonal processes needed for birth to happen will be a much harder job because their minds will associate the circumstances of birth with danger and initiate the flight/fight response detrimental to the birth process.



So what does this mean for women who are planning a VBAC?


Honestly, much of the time, it means they are going to be wading through a whole of BS and spending a lot of time and energy sifting through information to determine what is accurate, what is relevant, and what is important to their specific to their journey. There is a lot of fear and a LOT of misinformation (both intentional and unintentional) out there.


If you’re a woman currently pregnant or trying to conceive and thinking about a VBAC, here’s a great starting point for information and resources that can help you on your way. You can also download my quick reference resource sheet for free here!



SUPPORT

One of the big struggles when thinking about a VBAC is dealing with a lot of negativity and fear, from both care providers and people around you. This is where finding the right support can be a huge benefit. For some, it might just be finding a good online group of like-minded women, while others might need more personally focused support throughout their pregnancy and birth. Some great places you can look for support include:


Social Media:

VBAC Australia Support Facebook Group**

VBAC Homebirth Support Facebook Group


Stories:

VBAC Birth Stories Podcast

Australian Birth Stories Podcast

The VBAC Link Podcast


Personal:

Hire a doula

VBAC Mentor Lizzie Carroll

HBAC Mentor Ashley Winning

My NBAC Mentoring Program - learn more here or get in touch!


**FAIR WARNING: There is another Facebook group parading to be an evidence based VBAC support group which is, frankly, anything but. The group I have linked above is a genuine support group for VBAC without fear mongering that was set up by Lizzie Carroll and has grown to include thousands of women. If you want actual evidence-based information and true support for planning a VBAC, I’d scroll on if you see the other group pop up as recommended or find yourself in there and questioning everything you read.


EVIDENCE AND INFORMATION

As I touched on above, one of the biggest struggles women often face when planning a VBAC is getting actual evidence-based information and recommendations from their care providers. The risks are often blown far out of proportion – for example, uterine rupture during VBAC attempts happens less frequently than placental abruption or cord prolapse in all pregnancy, and yet rupture remains the primary focus of a care provider looking after a VBAC woman in most cases - and the alternatives frequently undiscussed. Here are some places you can go to find research and evidence where you need it.


Social Media:

@birthstats_nsw

@coreandfloorrestore

@melaniethemidwife (facebook and insta, plus has a podcast coming soon)

My instagram page! @thenbacguide


Websites and Blogs:


Podcasts:

(both of these podcasts are all amazing listening for information and evidence on all kinds of pregnancy, birth and postpartum related topics as well – for example, the gestational diabetes episodes from The Midwives’ Cauldron are well worth listening to.)


MENTAL PREPARATION

Another of the challenges that women planning a VBAC are mental hurdles – from fear surrounding birth (particularly in relation to uterine rupture which there is disproportionate discussion about in a VBAC pregnancy), to nagging doubts about their bodies ability to birth, to traumatic memories of their prior birth experiences. This is so common for VBAC women and is good to address early to avoid any mental blocks that might inhibit labour.


Birth debriefs can be a useful starting place. I have a write up on birth debriefs and some people offering them in my blog on birth trauma here.


Other things you can try include: counselling (ideally with someone familiar with birth trauma, also discussed in the blog linked above), reiki therapy, or hypnotherapy.


In addition to the more emotional prep, I also suggest that educational preparation is really important. Independent education programs such as Hypnobirthing and Calmbirth separate themselves from hospital guidelines and policies to ensure that you are receiving unbiased and evidence-based information, and can help you learn some ideas for building a birth plan, and techniques dealing with pain, and making informed decisions. All of these skills can help you feel mentally and emotionally ready for birth.



PHYSICAL PREPARATION

A lot of women (including myself) have asked over the years what they can do to physically prepare for a VBAC. If I’m honest with myself, what I really wanted to know was what preparation I can do to prevent a uterine rupture. Unfortunately, we don’t have any evidence to suggest that there is any kind of physical preparation you can do to strengthen your scar or reduce your likelihood of a rupture.


That doesn’t mean, however, that there is no physical preparation you can do leading up to a VBAC – there is lots you can do to make sure your body is in the best possible condition for growing and birthing a baby.


Firstly, you can do scar massage over your caesarean scar as soon as you feel comfortable after the incision is fully healed. You can start doing this even years after caesarean. Here is a great demonstration from B at Core and Floor Restore which details how to do this. Scar massage helps to mobilise and stretch the scar tissue which can mean more comfortable pregnancy and reduce tight adhesions keeping your baby from getting into an optimal position for labour and birth.


Other that looking after your scar, regular pregnancy massage and bodywork (such as chiropractic and osteopathy) can help to keep your body well aligned and relaxed to allow further for ideal positioning of your baby.


Regular exercise and a nutritious diet is also always beneficial for optimal health and wellbeing.


MY THREE TOP VBAC TIPS:


1. CARE PROVIDER

Choose your care provider carefully. Interview them and listen for red flags in their answers. The last thing you need is to be 36 weeks pregnant and have your care provider suddenly start talking about booking in a caesarean date for 39 weeks “just in case” (known as the “bait and switch”).


2. DEBRIEF YOUR BIRTH BAGGAGE

Your VBAC may well be the healing birth you are looking for, but I would implore you to work through and properly debrief your previous birth experiences as part of your mental preparation for your VBAC and not to rely on your upcoming birth to heal you.


3. EDUCATION

Independent birth education, particularly programs that explore birth physiology and the hormonal processes involved in birth, is one of the best ways to prepare yourself for a VBAC. Learning about what is happening in your body in labour and how best to support that physiology is one of the best gifts you can give yourself.



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