When’s the best time to plan for a VBAC?  Maybe before you’re pregnant!

Photo: Kelly Jordan Photography

I have long been passionate about educating women and their partners about vaginal birth after caesarean (VBAC). Many of my doula clients are hoping for a VBAC, following a less than positive previous birth experience.

Understand the birthing landscape.

The national caesarean rate in Australia is now edging towards 40%. That’s when we combine public and private hospitals together. If we were to separate them out, public hospitals do slightly better, with a rate closer to about 34%, whereas private hospitals often have a rate in excess of 60%. Some private obstetricians have c-section rates over 80%. How many women actually ask their private obstetrician what their c-section rate is, and what their VBAC success rate is? Perhaps the more salient question is why DON’T we ask them?

Our VBAC success rate in Australia is abysmal – less than 12% – meaning that nearly 90% of people will have a repeat caesarean. This is mainly because most women are successfully talked out of trying for a VBAC in the first place. Those that do attempt one, are more often than not bombarded by hospital policies and protocols that are not evidence-based and more than likely will lead to a repeat caesarean. Finding a truly VBAC supporting care provider can feel like finding a needle in a haystack.

Once you’ve had two caesareans, it is almost impossible to find a care provider who will be supportive of a future vaginal birth, despite the fact that there is good evidence to suggest that the absolute risk of a serious complication such a uterine rupture is not statistically significant between one prior c-section and two prior c-sections.

According to the Royal College of Obstetricians and Gynaecologists (RCOG) in the U.K., “A multivariate analysis of the NICHD study showed that there was no significant difference in the rates of uterine rupture in VBAC with two or more previous caesarean births (9/975, 92/10000) compared with a single previous caesarean birth (115/16 915, 68/10000). These findings concur with other observational studies, which, overall, have shown similar rates of VBAC success with two previous caesarean births (VBAC success rates of 62–75%) and single prior caesarean birth. It is notable that more than half of the women with two previous caesarean deliveries had also had a previous vaginal birth and 40% had a previous VBAC. Hence, caution should be applied when extrapolating these data to women with no previous vaginal delivery.”

It’s worth pointing out that this finding does seem to reinforce other evidence which has shown that women who have previously had a vaginal birth, or a successful VBAC are more likely to have a future VBAC.

Despite all the strong evidence that exists that has concluded that VBAC is a safe option for most people and should be routinely recommended, there are still significant barriers to success and very little evidence-based VBAC education available in Australia.

Whenever I teach a VBAC class, I’m reminded of all the things I wish people knew before they attend the class. I recently received an email from someone who was still suffering the emotional and psychological fallout from her previous birth, which resulted in an emergency c-section. It was coming up to her child’s first birthday, and with it, a tidal wave of emotions and anxiety, sadly so common for so many people. It was her email that inspired this article, and it’s my hope that this information helps even one person to process their birth trauma and find the support they need in order to heal.

There’s no expiry date on your trauma.

All too often, women’s feelings are shut down and minimised. “You’re alive, your baby is healthy – what’s there to be sad about?”

Women are also made to feel like there is time limitation on how long they are “allowed” to feel upset, disappointed, anxious or depressed. So, when that arbitrary time is up, women tend to internalise their emotions, fearful of people’s reactions if they continue to talk about their birth.

So, I am here to tell you (I will yell it from a hill top if I need to!) that there is no expiry date on your trauma! I know that you will have good days, and you will have shit days. I know that the oddest, most unexpected thing can trigger you and inside you feel like you are going to fall apart.

One of the best resources I have come across is a fabulous book called, How to Heal from a Bad Birth. I recommend it to all my clients who have experienced birth trauma.

Organise a birth debrief (even if it’s a year later).

While you might have received some basic debriefing from the hospital immediately following your caesarean, it’s likely to be a bit of a blur (especially given the fact that you were still on major pain medication post-surgery!). If you haven’t got a copy of your medical file, you can request one from the hospital. Making sense of it is another thing – especially if you are not a healthcare professional. You can request a meeting at the hospital to go through your notes, or alternatively, you can take your file to a private practitioner (often privately practicing midwives offer birth debriefing as a service). Going through the chain of events that ultimately led to the caesarean can be very helpful and somewhat healing in and of itself.

I’d also strongly recommend that you seek out a counsellor who specialises in birth trauma and birth debriefing. If you are based in Melbourne, I can highly recommend the following practitioners.

Rhea Dempsey – https://www.birthingwisdom.com.au/birthing-services/counselling/

Nisha Gill – https://feminineinstincts.com.au/trauma-healing-2/

In some situations, a perinatal psychologist is the best person to seek treatment with. People experiencing more severe symptoms may also require treatment through a perinatal psychiatrist. Talk to your midwife, obstetrician or GP if you are struggling and ask for a referral to a perinatal mental health specialist.

Check in with your partner too and make sure they’re ok. Birth trauma can absolutely affect partners too.

Make a complaint (if you feel it’s warranted).

Many women feel a great deal of anger towards their care provider or the hospital about the way they were treated emotionally, or because of the care that they received. Again – there is no time limitation on this, so don’t feel that if you didn’t lodge a complaint soon after the birth, you are unable to do so now. For many people, it takes time to process their emotions, especially given the fact that once your baby is born, you are overwhelmed with the task of caring for your child! Sometimes it’s months before you feel ready to talk about your birth or write down what happened to you.

Each hospital has a designated person that you can contact to lodge a complaint. Hospitals also have consumer advocates who can support you. In addition, there are external consumer advocacy support services such as the B.E.A.R. program at Lamaze Australia who can provide individual advocacy (at no cost) should you feel that you need someone by your side to support you and advocate for you.

Preparing for your next birth.

I feel like a bit of a broken record when I say this, but it’s just so important, so I will say it again! The two most important decisions you need to make when you are planning your next birth is WHERE and WITH WHOM are you are going to birth?

Evidence clearly shows that VBAC success is most likely to be achieved with midwife-led care from a known midwife – so continuity of care models, such as midwifery group practice (MGP) or caseload programs are ideal. If funds permit, you might like to consider hiring a private midwife. You can then opt to have a homebirth, or a hospital birth. Generally speaking, public hospitals have significantly higher VBAC success rates compared to private hospitals.

If you had a terrible experience at a public hospital and the thought of birthing there again is filling you with dread, then you can ask your GP to write you a letter requesting that you be permitted to birth at another public hospital (especially if you are out of zone and would not normally be accepted). Most women who can provide a letter from their medical care provider, stating psychological trauma as the reason they cannot birth again at their local hospital will be permitted to birth at an alternative hospital.

If you prefer to go private and hire an obstetrician, then you need to select your doctor very carefully. The reality is that obstetricians are not trained to support normal birth. That’s the area of expertise for midwives. Obstetricians are highly trained specialists who are experts in the pathology of pregnancy and birth (i.e., all the things that can go wrong). They are trained surgeons and generally-speaking, not very good and sitting in the corner quietly, patiently waiting for a baby to arrive into the world!

Of course, there are exceptions to every rule, and there are wonderful, very VBAC-supportive obstetricians out there. My advice would be – do your homework! Don’t be swayed by superficial things like fancy consulting rooms, gourmet food at the hospital, or the opportunity to spend a few nights at a 5-star hotel post-birth. These things pale in comparison compared to the elation you’ll feel when you get to birth on your terms!

Hire a doula.

Regardless of where you choose to birth next, I can highly recommend that you consider hiring a doula to support you. Doulas have proven their worth with considerable evidence demonstrating that the presence of a doula improves outcomes – including lower rates of medical pain relief, lower rates of instrumental birth, lowered caesarean rates, and lower rates of postpartum anxiety and depression.

Knowledge is power.

Finally, my last bit of advice in preparing for your next pregnancy & birth, I would highly recommend that you and your partner attend a VBAC education course – and ideally, do it early on in your pregnancy. I teach my in-person VBAC Your Way course a few times a year and also have a self-paced online version if you are located outside of metro Melbourne.  

Ooh – and final, final bit of advice (I promise!) is if you are looking for an excellent book on VBAC to read, I cannot recommend Hazel Keedle’s new book, Birth After Caesarean: Your Journey to a Better Birth highly enough. Published in 2022, Dr Keedle, who is a professor of Midwifery at Western Sydney University is widely considered to be one of Australia’s top VBAC experts. It’s a very accessible read (it’s primarily written for pregnant people, as opposed to health professionals) and it’s bang up-to-date in terms of the evidence. An excellent resource for anyone planning a VBAC!