VBAC, natural birth after a caesarean section: when is it possible?

VBAC stands for Vaginal Birth After Cesarean. In Italy, unfortunately, the baby of one in three women is born by caesarean section and not by natural childbirth. Certainly not the fault of women! According to the WHO, World Health Organization, only 10-12% of babies should be born by caesarean section, in the sense that only 10-12% of all deliveries would actually require this “wonderful rescue operation”, as Michel Odent defines it, caesarean section.

Unfortunately, the ability to recognize what is natural has been lost and therefore there is fear, and more use is made of medicalization. Fear that something serious will happen to the mother and the child, fear of saying “in my opinion they can do it” because a complaint is always lurking around the corner, and fear because we are no longer used to seeing how wonderful birth is when it happens undisturbed.

The timing of labor has been placed in strict tables without taking into account everything that can affect the delicate balance of hormones that regulate birth. Over time, medicalization, the use of more and more cards, books, precise times, lack of observation have made us forget some things that require unlearned practice and some doctors rather than risk children and mothers prefer to choose a path that they know well.

The risks of caesarean section

Caesarean section is not a different type of birth to give birth to a child, it is a real surgical operation with which babies are born accompanied by all the risks that there are for all other operations plus those that add up for future pregnancies.

Compared to a natural birth there are greater risks of bleeding, risks of uterine atony (the uterus that does not contract). Other complications related to the operation are the risk of pulmonary embolism, greater morbidity (more chance that the woman will get sick, need transfusions, infections), risk that during the operation important organs such as the bladder will be damaged, and a greater risk of mortality (2 to 10 times greater).

For the child the risks include increased risk of breathing problems and often have a lower APGAR score.

There are also greater difficulties with breastfeeding due to the causes of the cesarean, the difficulties in moving and therefore in being able to look after one’s baby, greater pain after childbirth, distance from the baby.

One or more caesarean sections for a new pregnancy can lead to abnormalities in the site of placentation, or the placenta could rest on the wound making it difficult to detach and being the wound low a placenta previa or very low could form, this especially when there are more repeated caesarean sections.

The operations lead to the formation of scars and the formation of scar tissue that can create adhesions or filaments of scar tissue that joins the internal organs that would lead to complications during subsequent operations or ectopic pregnancies. Adhesions are not always present but more operations can increase the likelihood of them forming.

The VBAC

The most feared complication when thinking of a natural birth after a caesarean is the rupture of the uterus at the level of the scar. This is because the point where the cuts and subsequent sutures were made is very fragile and could not bear the contractions if it has not had the opportunity to heal well or if the stimulation of the contractions are caused by synthetic oxytocin or prostaglandins (with induced or piloted birth) which for this reason are not recommended. Recent studies have shown that
and are therefore comparable values. It has been noted that the more time passes between the caesarean section and the subsequent pregnancy, the more the possibility of a rupture of the uterus decreases:

• Under 12 months there is a 4.8% chance
• Between 13 and 24 months it drops to 2.7%
• Between 25 and 36 months it drops again to 0.9%
• After 36 months it drops to 0.2%

If you wait about 2 years between the cesarean and the next pregnancy the body will have good time to recover and will cope better with labor and after the first baby it will be easier to manage together with the new born!

It is precisely because of the rupture of the uterus that natural childbirth has always been feared after a caesarean section and that doctors advised against natural childbirth. The latest studies and in particular the latest Italian guidelines (created after sifting through a series of studies from around the world choosing from the most reliable ones), admit women who have had two and I mean TWO caesarean sections to the labor test!! This is precisely because studies have shown that uterine rupture, in a uterus that has had time to heal, is similar to that of a uterus that has never been caesarean.

Trial of labor… unfortunately it is called as follows: TOL ” Trial of Labor ” and not real labor as in my opinion it should be faced, a normal labor that can encounter complications that any low-risk woman can experience. About 3 out of 4 women who try to deliver their babies naturally succeed perfectly! Equalizing in percentages, 75% succeed with their VBAC versus about 73% of women who do not pre-caesarean. Obviously the percentages vary a lot between north, center and south.

Hospital care is based on guidelines that have been drafted based on selected articles. In Italy they did not also include the article that considered natural childbirth in women with 3 or more caesareans, and therefore . There are facilities or private midwives who feel competent and safe of women and assist them despite having had more than 2 caesareans and there are many testimonies proving that everything went well.

Women who have had a previous rupture of the uterus, those who for other operations on the uterus have had a longitudinal incision (not the classic “bikini” cut) are excluded from the labor test, and deliveries that require the induction of labor.

A very important thing is to be informed. There are many gynecologists, midwives and hospitals who, despite the guidelines and EBMs (evidence-based medicine, scientific studies) confirming that it is healthier and less risky to have a natural birth than another caesarean section, will tell you that it is better another CT. They will tell you that a natural birth is too risky, or other arguments that can confuse you.

Childbirth assistance in a VBAC

Another thing to point out in the case of VBAC is this: witnessing a labor and birth of a woman who has had a previous cesarean section is different than witnessing a normal birth: there are signs that there may or may not be, there is so much fear , perhaps it is not known that the body takes on a slower rhythm because it knows it is not in one piece and in order not to damage itself it “goes slower” and therefore the labor could last a little longer or the contractions be lighter or more spaced out . Unfortunately, to those who do not know how the labor of a pre-caesarean woman behaves, these behaviors could seem anomalous and could lead them to make the decision for a new caesarean.

Of course, if during pregnancy there are conditions that require a caesarean section, such as pathologies that require an urgent caesarean section or an abnormal presentation of the baby, or the contractions do not arise spontaneously beyond the term of the pregnancy at 42 weeks, unfortunately the woman will have to deliver your baby by caesarean section.

VBAC does not heal from a previous CT scan

which still strengthens the woman. In this case, healing must take place in other ways: with discussions in self-help groups, chats with a psychologist, and everything you need to process your experience and maybe get to be reborn as mothers and women before facing a new pregnancy. This is because you could face another caesarean section or discover that even with a beautiful natural birth that void has remained unfilled. So creating a support network that is given by family members, friends, midwives, gynecologists, psychologists, but also by other women known online who may have lived a similar experience, brings women a lot of strength and determination in dealing with the choice of natural childbirth, in this society that unfortunately is not yet very open to the most natural and least risky choice when possible.