Can I have a VBAC after 2 C Sections?
If you've had 2 or more previous caesareans births and you are pregnant again you might be wondering if you can have a vaginal birth this time. Is it a lot more risky?
Well the very simple answer is YES! Yes you can. its your choice to make as to how your baby is born.
You don't need permission to use your vagina!
I know, it sounds pretty ridiculous to put it that way. But really you don't need permission to use your body as you want.
If you go read the NICE guidelines you'll find that they support you to choose a vaginal birth up to after 4 previous caesareans. And i'd warrant a guess they only say 4 because they have no data beyond that rather then a VBA5C suddenly becoming a big risk.
You can read the full NICE guideline for VBAC here but this is the part you'll want to make reference to:
Not only should your care providers support your choice, but it clearly states that for most people a vaginal birth is as safe as repeat surgery. For you, your baby & any future babies.
Thats reassuring isn't it! However what I see time and time again is that health care providers either assume you will be booking another CS, and maybe just book it for you (!!) or they are very very reluctant to support your choice (even though, as we have seen its not considered any more risky then a regular VBAC) and is clearly stated as a valid choice in the guidelines the drs are meant to follow.
Why are some doctors so hesitant?
Well its safe to say that many doctors won't have supported many, or maybe any VBA2C. Not a huge amount of people are having 3+ babies and of them even less will have had 2 caesareans, and of them majority of people will choose a repeat CS. So as our group of brave VBA2C families get smaller so do the drs who have supported it.
A drs role is to help in emergencies, high risk situations and all those "not quite normal" times. As a result they do not see regular boring, uneventful (beautiful) births all to often, these are the births they are not needed at nor called too.
They are very familiar with cesareans - but offering care around something they are not used to can feel risky for them. It is often easier and more controllable to suggest a repeat cesarean for you.
So is a VBA2C more risky?
The main risk associated with a VBAC is uterine rupture - this is where the uterus can partially or completely reopen during labour and is an obstetric emergency. As with most things there's a spectrum of how bad it can be. You can have a more severe rupture (know as catastrophic) and also ones that are not as severe. A catastrophic rupture can result in death for the baby or the mum. I know that sounds really concerning, so it's really important to understand how often this actually happens.
After one C section the risk is accepted to be 1:200, which is 0.5% (this is for all ruptures including the less severe ones. Of those that do rupture, 6% will be catastrophic, so a very tiny amount of those having a VBAC)
After 2 Caesareans the risk is higher, usually quoted around 1-1.5% (So you still have over 98% chance of not having a rupture.) Yes the risk is higher but the risk is still very small.
With any VBAC the risk of rupture increases with the use of synthetic oxytocin ("the drip") which is typically used in the induction process or to speed up your labour. The is due to the fact its puts a larger amount of strain on the uterus through forced & stronger contractions - and the body can't regulate itself. Generally the risk is believed to double. Some trusts will support an induction and others won't.
If you had a scar rupture it can also lead to needing a hysterectomy and further surgery, however, a hysterectomy is also be a risk of having caesarean (0.5% however this figure includes those with known complications. Read the study here)
Knowing the risks and carefully considering them in your specific circumstances is really important.
Is another Caesarean safer?
No, if your only "risk" factor is previous C sections than having a VBAC isn't considered any more risky than a repeat surgery (as shown in the guidelines). Its also really important to know that whilst the risk of a uterine rupture is almost totally removed with a planned C Section - you are increasing your risk of other things which might be lower in a vaginal birth. Maternal deaths are higher with a Caesarean (although this is still a very very small risk) The risk of a haemorrhage is always higher in surgery as well 5-10% reference here. There are also risks for the baby, more Caesarean babies require a NICU admission, often due to needing some support with their breathing.
Its also important to consider the future - each surgery that's performed increases the risk of some placenta abnormalities in future pregnancies - previa (covering the cervix) accreta (invasive growth into uterus & tissues or pelvic organs) and also a general build up of adhesions and scar tissue. These risks do increase with each pregnancy.
What else do I need to think about?
When you are considering "can I have a VBAC after 2 C Sections" it's really important to think about what YOU want. What feels important to you as a parent about your birth experience. Do you plan to have more babies after this one? What is your support network like for postpartum if you are recovering from surgery? How do you want to feel when you look back in 3, 5, 10 years? How do you want to feel when you meet your baby? Will you have regrets or doubts from choosing one way or another?
Choosing to have a VBA2C is a totally valid choice and well supported by evidence and policy, however as we discussed previously your care team may be less supportive so it can be helpful to know:
-you always have the right to decline to see an unsupportive care provider again
-ask for second opinions, and don't be afraid to state you are aware of your rights and your choice is clearly supported by policy & evidence.
-You don't have to see consultants, though your care path way will automatically sign you to see them it is your right to decline the care if it doesn't feel right for you.
-you cannot be coerced into surgery that you do not want if you are of sound mind. You can still be very polite in these interactions
-You can decide if you will accept an induction or not, again you cannot be forced to have one.
-You can go past 40 weeks! Many care providers will tell you yes have a VBAC but it has to be before 40 weeks. This is not evidence based, or supportive. The choice as ever is always yours.
Can I have a VBAC after 2 C sections?
Well the short answer is yes, but as we've seen there is lots of things to consider. You will be offered appointments with a consultant to discuss your plans, however they may not always be supportive, or offer unbiased information.
It can be really helpful to have the support of a doula, offering you emotional support, helping you to find the evidence around your options, and also to weigh this up in your specific situation. After all we are all so different and have different values, needs and desires.
If exploring your options for a VBA2C is feeling a little overwhelming I'd love to support you through this time. I have a variety of options from stand alone chats, to my fully virtual VBAC doula support, to in person birth doula care in the Bristol area.
And don’t forget to check out my VBAC library - its all my favourite VBAC related resources helpfully pulled together.