Image via iStock. By: Hannah Dahlen , Western Sydney University and Hazel Keedle , Western Sydney University

We’ve come a long way from the first documented successful caesarean. In 1500, Jacob Nufer, a Swiss farmer who castrated pigs for a living, operated on his wife after a labour of several days involving 13 midwives. Both mother and baby not only survived but the woman went on to have five more vaginal births, with one involving twins.

These days nearly one in three pregnant women in Australia gives birth by caesarean. The most common type – lower segment caesarean section (LSCS) – involves an obstetrician making a horizontal cut along the lower part of the uterus. Sometimes, such as when the baby is very premature, the cut is made vertically through the uterus. This is known as a classical caesarean section.

Women planning their next birth after caesarean are faced with two options: they can have a repeat caesarean section when the baby is term (around 39 weeks), or they can attempt a vaginal birth after caesarean (known as a VBAC).

Risks and benefits.

The advantages of a VBAC include a greater chance of an uncomplicated birth in future pregnancies, shorter recovery time, reduced risk of blood clots, and enhanced mother-infant bonding.

Women planning their next birth after caesarean are faced with two options. (Image via iStock.)

Women who have caesarean sections stay in hospital longer and are more likely to need re-admission for complications such as infection. Other aspects of mothering may be affected, such as picking up their baby or toddler, being able to drive a car and carrying the washing.

There is also emerging evidence that caesarean sections may have longer-term effects, such as increasing susceptibility to disease.

Disadvantages of VBAC include the risk of a uterine rupture. This is when the uterine wall opens up during the labour. It can be very slight, or extreme, where the uterus completely opens up. Uterine rupture occurs in about one in 200 VBACs and can be catastrophic for both mother and baby.

In some cases, when a woman seeks to have a VBAC she may end up having a caesarean section. If an emergency caesarean is required, she is at increased risk of blood loss. (Post continues after gallery.)

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In terms of the baby’s safety, guidelines on VBAC just released by the United Kingdom’s Royal College of Obstetricians and Gynaecologists (RCOG) state that the risk of a baby dying during labour and birth is extremely low and is similar to the risk for women having their first baby.

Reversing the declining trend.

Most Australian women (84.4 per cent) have a caesarean for subsequent births after a caesarean. Only 15.5 per cent of women have a VBAC. In private hospitals, this rate is even lower, at 11 per cent. Internationally, VBAC rates vary from 45-55 per cent in Finland, Sweden and the Netherlands to 10% in the United States.

VBAC rates have declined internationally since 1999 when the American College of Obstetricians and Gynecologists (ACOG) changed its VBAC guidelines. Only facilities that had immediate access to an operating theatre, rather than “within a reasonable time frame”, were recommended to offer VBAC.

The ripple effect of this decision led to VBAC no longer being offered in many smaller hospitals and birthing centres, and the popularity of elective caesarean increased. This also impacted on countries such as Australia, where the VBAC rate was once around 60%.

Most Australian women have a caesarean for subsequent births after a caesarean. (Image via iStock.)

More recent ACOG guidelines recognise the restrictive aspect of the term “immediate access” and suggest VBACs can occur in other settings as long as logistical emergency plans are in place.

However, it’s hard to change an established culture and it will take time.

What drives women’s decisions?

We have been investigating what motivates women to chose VBAC or repeat caesarean section.

In one study, we found belief systems fell within a broader motherbirth or childbirth paradigm. On the “motherbirth” side, the mother’s physical health and emotional well-being were seen as important, in order for her to care for her baby. These women were more likely to choose a VBAC.

On the “childbirth” side, the mother put the needs of the baby above her own needs and took a more sacrificial perspective, seeing this as what a “ good mother ” would do. These women were more likely to choose a repeat caesarean section. (Post continues after gallery.)

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