1 in 3 women in Australia having a caesarean birth in 2019. Of these women who go onto have another baby, not everyone will want (or need) another caesarean.

But is a VBAC really safe? Can you go onto have a vaginal birth after caesarean? There a number of myths around VBACs that make it seem like it is not a safe option, or that you don’t have choices when planning you next birth after caesarean. Let’s look at 5 of the biggest myths surrounding VBACs.

VBAC Myth 1

Once a caesarean, always a caesarean.

Once a caesarean does not always mean you must have a caesarean in the future. While it was a commonly held belief in the past, and continues to pervade our conscious today, it’s simply not true.

The National Institue for Health and Care Excellence (NICE), Royal College of Obstetricians and Gynaecologists (RCOG), American College of Obstetricians and Gynaecologists (ACOG) and the National Institutes for Health (NIH) all agree ‘that planned VBAC is a clinically safe choice for the majority of women with a single previous lower segment caesarean delivery’.

So where did this myth come from? When placed in its proper context, the myth isn’t so much of a myth. It comes from the early 1900s when Edward Cragin¹ predicted that women who attempted a VBAC were more likely to need a repeat caesarean when their labour would not progress even after days of active labour. For some background, rickets and deformed pelvises were common, synthetic oxytocin (to help speed up labour) didn’t yet exist and surgery looked very different to what it does today.

Fortunately, we have come a long way in 100 years. The way caesareans are performed has become safer – with low-transverse uterine incisions being more common (a ‘classical’ uterine scar can be contraindicated for caesarean birth). So the old maxim ‘once a caesarean, always a caesarean’ no longer holds true.

There are some circumstances where another caesarean may be recommended (and indeed the safer option) such as pregnancy complications including placental issues, previous uterine rupture or classical caesarean scar. This doesn’t mean that all previous caesarean births indicate a future caesarean.

VBAC Myth 2

The risk of uterine rupture is ‘large’

So is the risk of uterine rupture large?

 

Compared to the risk of uterine rupture in ERCS, then yes, it is larger for a planned VBAC (this is the relative risk – the risk is greater/lesser relative to something else).  However when speaking to your care provider about the risks of uterine rupture (or anything else for that matter), and you hear that the risk is ‘large’, ask for the rest of the sentence – relative to what?

Or better yet, ask for the absolute risk. The absolute risk is the actual number associated with the risk (ie 1 in 200). Is the absolute risk of uterine rupture large? That depends entirely on your definition of large and your comfort levels with the risk. If you consider a risk of 1 in 200, then that’s what you need to take into consideration.

We also need to look at the consequences of uterine rupture should it occur.

In the 21 studies reviewed by Guise et al  – where there was a uterine rupture, there were no accounts of maternal death (death of the birthing mother). Also, ‘about 5 % of symptomatic uterine ruptures were associated with perinatal mortality (death of the baby) and 13% with hysterectomy.

So, if that 1 in 200 uterine rupture did occur, 95% of babies would survive.

Guise et al also commented that it would ‘take 370 elective repeat caesareans to prevent one symptomatic uterine rupture due to trial of labour’.

 

VBAC Myth 3

There are no risks with a repeat caesarean

These are the precise words said to me during a GP appointment with my third baby (my second VBAC).

It is entirely incorrect. Both VBAC and ERCS have risks. There is no entirely ‘safe’ option – birth can never be 100% risk free.

Let’s look at some of the risks of having a repeat caesarean – major abdominal surgery.

According to QLD Health Guidelines, maternal mortality (death of birthing mother) is 0.13 per 1000 compared to .04 per 1000 with a VBAC.

Compared to a caesarean birth, a vaginal birth is associated with

• Shorter hospital stays and recovery times (which is an important consideration when you already have a child/children at home)
• less risk of deep vein thrombosis
• enhanced mother-baby bonding and more successful breastfeeding rates
• less risk of infection
• less risk of hysterectomy (1.7 per 1000 vs 3.1 per 1000 for ERCS)

ERCS and future pregnancies

There are also risks of repeat caesareans on future pregnancies and births. If you are planning on having more children, it is important that you have discussions around this with your caregiver.

Repeat caesareans can increase the risk of difficulties falling pregnant and can also increase the risk of pregnancy complications such as placenta previa and placenta accreta.

Placent previa is where your placenta lies low and partially or completely covers your cervix. Placenta accreta occurs when the placenta grows too deeply in the uterine wall and part or all of the placenta remains attached after birth. This can cause severe blood loss and may require a hysterectomy.

The risk of placenta previa and placenta accreta increases with each caesarean (all numbers below are per 1000 women)

Number of caesareans	Risk of placenta previa	Risk of placenta accreta
After two caesareans	11 – 23	2 – 9
After three caesareans	18 – 37	8 – 17

As always, it is important to look at the big picture of the risks and benefits of both VBAC and repeat caesarean and make the best decision for yourself and your baby.

VBAC Myth 4

You can’t be induced if you are having a VBAC

Have a previous caesarean does not mean that your only options are spontaneous labour or repeat caesarean. There is the option of being induced (assuming no other contraindications).

There are risks of being induced regardless of whether a planned VBAC or no previous caesarean. The main reason we hear for avoiding induction is again related to uterine rupture.

Being induced or having your labour augmented (speed up) does increase your risk of uterine rupture. According to Ophir et al ‘Not all induction agents have the same magnitude of increased risk of uterine rupture, and there have been only a small number of randomized controlled trials of labor induction in women with previous cesarean delivery’.  They found  that of the chemical induction methods, uterine rupture occurs with synthetic oxytocin at 1.1%, and 6% with Misoprostol (according to King Edward Memorial Hospital guidelines, prostaglandins are not licensed in Australia for use in women with a uterine scar and synthetic oxytocin may be used with caution).

Being induced also decreases the chances of having a successful VBAC compared to going into spontaneous labour.

Like everything, you need to assess the risks and benefits of being induced vs having a repeat ceasarean before labour or during labour.

VBAC Myth 5

Your only care option is with an obstetrician

Again – myth. While there are some hospitals that may not support a VBAC (and some that you would have a difficult journey with if you did plan on birthing there), obstetrician led care is not your only option.

Here in WA (where I am) we have the Community Midwife Program (CMP) which offers birthing in a hospital but with continuity of care with a known midwife.

Some independant midwives may offer support for VBAC home births, others may have hospital rights (again, meaning you have continuity of care with a midwife and then birth in a hospital where you have access to emergency caesarean care should it be needed).

It is important to do your research and know all of your options when it comes to options of where, and how, to birth your baby. You need to find someone who is truly supportive of your VBAC – and not just tolerant.

Speak to your GP, join your local VBAC support group, research your local government websites and start making calls. Find someone who you connect with, then ask them loads of questions to ensure that you start creating your ultimate VBAC team.

To get you started on your journey, download my free guide ‘5 questions you need to ask your VBAC care provider’.

1Ugwumadu A. Does the maxim “once a Caesarean, always a Caesarean” still hold true?. PLoS Med. 2005;2(9):e305. doi:10.1371/journal.pmed.0020305

Kate Vivian is a self-professed pregnancy and birth geek who is finally learning to embrace the chaos of having 3 kids. It was the birth and ‘bringing baby home’ experience of her first baby, and the overwhelming guilt that went with it,  and the two incredible VBAC births that followed, that led her to start Bright Mums – and create a world where Mums matter.

A Certified Hypnobirthing Australia Practitioner, childbirth educator and postpartum doula, Kate works with Mums-to-be not only supporting them through pregnancy, and birth but also teaching them to honour themselves at a time when the world is telling them their baby is the most important thing.

With almost 2 decades in adult education, Kate has the ability to create a safe space, a non-judgey space. A place where Mums can relax and feel supported regardless of what their journey looks like.

A keen traveller in a former (pre-kids) life, Kate dreams of the day her kids are big enough to take skiing and they can completely show her up while she is busy falling down mountains.

You can find out more about Kate here