Link: Thinking about VBAC
Considering Your Options
For Women with History of Caesarean Section
What are the Risks of a TOL?
The most serious risk is uterine rupture which happens in 0.1% to 1.5% of TOL. A uterine rupture means that the first caesarean scar opens during labour. Uterine rupture can result in death or serious brain injury to the baby and serious haemorrhage for mothers. Although this complication is very rare, a uterine rupture is a serious emergency and an immediate caesarean is needed if it occurs. For this reason, we recommend that women planning TOL or VBAC plan a hospital birth.
Some women have a higher risk of uterine rupture. Women whose due date is within 2 years of their caesarean have an increased chance of rupture.
Women who have a trial of labour which ends in a caesarean section after labouring have a higher rate of complications than women who planned a caesarean from the start. These complications can include fever, need for blood transfusion, and infection.
What are the Risks of ERCS?
Most women who have an ERCS will have an uncomplicated surgery. Women still have a higher risk of some problems compared to a vaginal birth. These include:
Placental problems in future pregnancies
Longer hospital stays
Babies born by caesarean section have more chance of having breathing problems at birth because of increased fluid in their lungs.
Midwifery Care for Women who have had a Caesarean?
The College of Midwives requires us to discuss amongst the care team every woman who has had a caesarean section. The community standard in Guelph is for us to also offer and arrange a consultation with an obstetrician towards the end of pregnancy. We are required by our College to arrange an obstetrical consult for any woman with a history of more than one caesarean surgery or if the incision was a classical or T type in addition to other reasons. Midwives will make every effort to get a copy of the surgery record to aid in decision making around TOL.
What would Midwives do Differently during a Labour after Caesarean?
Fetal Heart Rate Monitoring
The first sign of a uterine rupture is usually an abnormal fetal heart rate pattern. The SOGC recommends continuous electronic fetal monitoring for women planning TOL and VBAC.
The AOM recommends using an intermittent auscultation protocol for high risk pregnancies or continuous electronic fetal monitoring. The AOM recommends using continuous monitoring if there are abnormalities in the labour. Electronic Fetal monitors are only available in the hospital.
Progress of Labour
Research tells us that an abnormally slow labour may be related to uterine rupture. Midwives monitor closely for signs of a prolonged labour, and would consult an obstetrician as outlined in our College of Midwives guidelines.
Pain Relief in Labour
Some would argue that women planning VBAC should not have epidural because it may mask the pain that can accompany a uterine rupture and delay diagnosis of the problem. It is also worth considering that an epidural may slow labour progress and slow progress is a specific concern for women planning VBAC. Others would say that an epidural means that an emergency caesarean could happen more quickly if it is needed. There is no research evidence that shows that women should not choose the pain relief options that are right for them.
Induction of Labour
The best situation for women wanting VBAC is for labour to start naturally. Women who need induction of labour for any reason, and who are planning VBAC would have a consultation with an obstetrician to review the options available to them. Depending on the specific details of your history, an obstetrician may not recommend the medications usually used for induction because of the increased risks of uterine rupture. Women who need or want induction should discuss their options during an obstetrical consultation.
Homebirth and VBAC
As a group we recognize the benefits of homebirth for low risk pregnancies. Although many VBAC labours are uncomplicated, they are not low risk. As a group we also recognize that being at home can increase the time required to access emergency care. Weather, distance from hospital and closest hospital all affect the availability of an emergency caesarean section. The SOGC recommends hospital birth for women planning VBAC. The CMO guidelines clearly indicate that midwives offer choice of birthplace to our clients. As a practice, based on our experience and training, we strongly recommend planning for hospital birth.
IV in Labour
Neither the AOM nor the SOGC recommends an IV in a normal spontaneous labour after caesarean. Starting an IV is one of the first steps that would be taken in an abnormal labour, and is available to you at any time if you request it.
Some Final Thoughts
As midwives we strive to protect and support normal birth. Deciding about a TOL or ERCS can be difficult for families. It is important for you to know that we will support your informed choices. Additional information is available to you at any time. Please talk to your midwives about any questions or concerns you have.
Once you have considered these factors, talk with your midwives about your choices for your birth. We will review and have you sign our plan of care for women with a history of caesarean section.
Link: Information Booklet