Experience of Having a Vaginal Birth after Cesarean Section in Order to Prevent Postpartum Complication Using Narrative Review

Abstract

Vaginal birth after cesarean (VBAC) is defined as a vaginal delivery by a woman who has had a previous cesarean delivery. Vaginal birth can lead to quicker post birth recovery, less operative trauma, shorter length of hospital stays, and improved feelings of wellness. It is well-known that C-section now, hysterectomy complications later. This review aims to explore the existing research on VBAC in order to prevent postpartum complication. This review commences with the exploration of women’s attitudes around VBAC, education and decision on their mode of birth. Eight main themes were: Women’s attitudes and views of VBAC; VBAC education and decision-making programs; previous VBAC; maternal morbidity and mortality; short inter-pregnancy interval; induction of labor; neonatal morbidity and mortality; and birth trauma. Evidence shows that midwives have a positive influence on VBAC rates without an increase in maternal or neonatal morbidity. Review revealed the limited comprehension and awareness regarding the factors influencing women’s decision to opt VBAC, and the viewpoints held by midwives. The recommendation is to increase the number of VBAC by emphasizing on midwifery role, continuity of care, education program, and conducting more research.

1. Introduction

Vaginal birth after cesarean (VBAC) is defined as a vaginal delivery by a woman who has had a previous cesarean delivery [1]. When women receive support to undergo a VBAC, numerous advantages arise for the women themselves, their families, and society as a whole. Opting for a vaginal birth can result in swifter post-birth recovery, reduced surgical trauma, shorter hospital stays, and enhanced overall well-being, encompassing physical and psychological aspects for women [2]. VBAC is associated with lower maternal mortality and less overall morbidity for mothers and babies [3]. It is well-known that C-section now, hysterectomy complications later. In cases where women had previously delivered through cesarean section, the likelihood of encountering surgical complications increased during hysterectomy procedures. According to a comprehensive Danish cohort study that looked back at past records, women with a history of C-section had elevated rates of reoperation within 30 days and experienced more perioperative and postoperative complications when undergoing a benign hysterectomy compared to women who had delivered vaginally [4].

This review aims to explore the existing research on VBAC to provide a background and purpose to this paper. The review encompassed a range of research methodologies, including qualitative and quantitative approaches. It begins by examining women’s attitudes and perspectives toward VBAC, along with investigating VBAC education and the decision-making process for choosing the mode of birth. The study identifies various factors that contribute to achieving a VBAC, which are further categorized into sub-themes. Furthermore, the review delves into the morbidity and mortality risks associated with cesarean sections, as well as comparative studies comparing the risks and outcomes of VBAC versus cesarean deliveries. Additionally, the review places emphasis on the outcomes of VBAC births that occur outside of hospitals, the management of VBAC within hospital settings, and the existing research on birth trauma. Within the topic of birth trauma, the review explores women’s emotional experiences related to their previous traumatic births, including some that involved cesarean sections, and also highlights the potential healing effects of a positive subsequent birth.

2. Literature review method

A search of the following databases was undertaken: CINAHL, Medline, Scopus, PubMed, and Cochrane. Papers published in the last 10 years were included to ensure key papers were identified. The study utilized specific keywords such as cesarean, VBAC, vaginal birth after cesarean, and childbirth. To maintain objectivity, opinion pieces and anecdotal articles were excluded. Additional papers were discovered by examining the reference lists of the included studies, leading to a snowball effect in the search process. A total of 45 studies were carefully reviewed and contributed to the construction of this literature review.

2.1 Women’s attitudes and views of VBAC

The literature review begins by examining and analyzing the existing research regarding women’s attitudes and perspectives toward VBAC, as it is one of the primary areas of focus for this review. While the review concentrates on the experiences of women who undergo VBAC, there is currently a lack of research that specifically addresses the experiences of this particular group. Nevertheless, there are research papers available that explore the attitudes and views of women who choose to have a VBAC.

A total of four qualitative studies and one quantitative study were identified, all of which delve into women’s attitudes and experiences regarding VBAC. Among these studies, three focused on the perceptions and experiences of women who planned to have a VBAC in a hospital setting, while one specifically explored the experiences of women who opted for a water VBAC in a midwife-led unit [5]. A common thread observed across these studies was the emphasis on informed choice, variations in postpartum recovery, and factors influencing the bonding process [6, 7, 8, 9]. The women actively attempted to minimize the medicalization of childbirth by limiting medical staff input. Opting for Water VBAC was a means of avoiding the ‘cascade of obstetric interventions [5].

Women observed variations in the manner in which healthcare providers either positively encouraged or negatively impacted their choice to pursue a VBAC. For some women, when healthcare providers presented options and actively involved them in the decision-making process, they felt a sense of trust toward their healthcare provider [9]. Other women found that the healthcare provider did not give sufficient information [5] and implied VBAC was very risky, which resulted in the women feeling bullied into following the staff recommendations and later made to feel guilty if anything was to go wrong [8]. Fenwick et al. [6] also reported the positive effect of family and friends’ attitudes toward VBAC, the effect of reflection on the previous cesarean, as well as the benefit of VBAC to the health of the baby.

Other quantitative research reflex attitude of women reports the effect of reflection on the previous cesarean as well as the benefit of VBAC to see vaginal delivery as the natural method of childbirth, and even more appealing to them is the faster recovery after a vaginal delivery as compared to CS [10].

In a qualitative study in Cyprus that adopted phenomenological study, participants described their previous experience of CS as traumatic in contrast to vaginal birth and their need of evidence-based information, guidelines of birthing options, good preparation, and personalized care [7].

In a study conducted by Dahlen and Homer [11], discussions about VBAC on international blog sites were explored. The primary theme that emerged was labeled as ‘mother birth/childbirth’. Within the ‘mother birth’ framework, women expressed the belief that a mother’s health and well-being were crucial for the well-being of the baby, and they considered the birth experience to be significant in achieving this. These women balanced their own needs with those of the baby and were more inclined to choose a VBAC. On the other hand, the ‘childbirth’ framework described women who prioritized the needs of the baby over their own and opted for what they perceived to be the less risky option, namely, elective cesarean. Other themes that emerged in line with previous research included the importance of choice, fear of giving birth, and perceptions of body failure [11].

2.2 VBAC education and decision-making programs

A total of nine studies examined in the decision-making process of women in choosing between aiming for a VBAC or opting for a repeat elective cesarean section. Among these studies, five included an educational program as part of their investigation, focusing on understanding how such programs might impact decision-making and outcomes [12, 13, 14, 15, 16]. This study explored the effect of a variety of educational programs on women’s decision making and VBAC outcomes.

The women stated that they need information about VBAC from supportive clinicians, but they also asked for information from other women with experiences of VBAC; the women prefer calm surroundings during birth and clinicians who are confident with VBAC [17, 18]. Other studies that Bako et al. conducted found differences in the way healthcare providers either positively supported or negatively influenced their decision to pursue a VBAC. Certain women discovered that by receiving counseling from healthcare providers during pregnancy, along with the implementation of public education campaigns to enable informed decision-making, they were able to develop trust in their healthcare providers. This trust will help them to take their decision [10].

Three studies explored the effect of a variety of educational programs on women’s decision-making and VBAC outcomes. These included a face-to-face education program versus a pamphlet [13], a 90 minute computer-based information resource [16], and an information program covering issues such as complications for the mother and baby compared with a decision analysis program [15]. The effectiveness of the aforementioned programs showed varying results, potentially influenced by a bias in the program content. For instance, Wang et al. [16], despite conducting a small study, observed a positive shift in attitude and increased knowledge among participants after the intervention. This resulted in an increase in the number of women planning to have a VBAC, with the count rising from six to nine and, ultimately, eight of them successfully achieving a VBAC. The program had a positive orientation toward VBAC and incorporated the personal experiences of other women who had undergone VBAC.

However, in the study done by Frost et al. that included interviews with 30 of the women from the Diamond trial, key themes were: role of decision aids in reducing decisional conflict and uncertainty during the pregnancy; impact of decision aids on knowledge and anxiety; the relationship between prior preferences, decisions, and actual outcome; and the mediating role of decision aids. It was found that some of the women’s concerns about both the decision analysis tool and the information provision for VBAC [14]. They should be relevant to their individual needs. One study found that women who scored high on motivation for vaginal birth were more likely to have a VBAC, regardless of education style [13].

2.3 Previous VBAC

According to Mercer et al. [19], women who had previously experienced a VBAC were more inclined to have a vaginal birth in subsequent pregnancies. The study revealed that for women without a prior VBAC, the rate of VBAC was 63.3%. However, if they had one previous VBAC, the rate increased to 87.6%, and for those with two or more previous VBACs, the rate further rose to 90.9% [19]. Interestingly, women who had a history of two or more VBACs also tended to have undergone multiple cesarean sections; a number of factors are associated with VBAC, including previous vaginal birth, particularly previous VBAC, being the single best predictor for VBAC and is associated with an approximately 87–90% planned VBAC rate [20, 21].

2.4 Maternal morbidity & mortality in cesarean versus planned VBAC

In this section, the literature review will focus on large multicenter studies that have investigated the disparities in maternal morbidity and mortality among women with a previous cesarean section and the various modes of birth for subsequent deliveries. These studies have highlighted specific outcomes related to maternal morbidities, such as endometritis, increased bleeding necessitating blood transfusion, and operative injuries, in the context of planned VBAC compared to elective cesarean sections [22, 23, 24, 25]. However, when examining the data that identifies the mode of birth within the planned VBAC group, it becomes evident that the heightened morbidities are primarily attributable to emergency cesarean sections. For instance, in the study by Landon et al. [24] that focused on planned VBACs resulting in cesarean sections, the rate of endometritis was 7.7% compared to 1.2% for vaginal births and 1.8% for elective cesarean sections. Similarly, the need for a blood transfusion when a VBAC was unsuccessful was 3.2%, compared to 1.2% for successful VBACs and 1.0% for elective cesarean sections [24].

Factors that increase uterine rupture rate Fear of uterine rupture is one of the key deterrents for VBAC [26]. The uterine rupture rate varies in different studies, from 0.1% to 2.7% [23, 24, 27, 28]. An Australian study found the uterine rupture rate was 0.2% [22].

Several studies have examined the factors associated with increased rates of uterine rupture in women with a history of previous cesarean sections. Two specific factors have been identified: the interval between the cesarean section and subsequent pregnancy (known as the inter-pregnancy interval) and the use of pharmacological agents to induce labor. These factors have been investigated in studies conducted by Smith et al. [29], Buhimschi et al. [30], Stamilio et al. [28], Fitzpatrick et al. [31], Stock et al. [32], and Palatnik and Grobman [33].

A systematic review study by Wu et al. [34] that included 94 studies found the most factors affecting the success of VBAC were diabetes, hypertensive disorders complicating pregnancy, Bishop score, labor induction, macrosomia, age, obesity, previous vaginal birth, and the indications for the previous CS. The midwife should take into her consideration these factors to increase success of VBAC. Also, a complete obstetric history is important for a safe VBAC [35].

2.5 Short inter-pregnancy interval

Stamilio et al. [28] conducted a study focusing on the influence of short pregnancy intervals. The findings indicate that women with a short inter-pregnancy period, defined as the time between the birth of one child and the conception of the next pregnancy, have a higher rate of uterine rupture at 2.7% compared to a rate of 0.9% for women with an interval of more than 6 months. However, the rate of successful VBAC did not differ significantly, remaining at 77%. One study that focused on the reported cases of women who had experienced a uterine rupture found rupture rates increased with a short inter-pregnancy interval of less than 12 months and where induction/augmentation occurred [31]. Royal College of Obstetricians and Gynecologists [36] guidelines state a period of less than 18 months since the previous cesarean is a contraindication to VBAC.

2.6 Induction of labor

Studies have looked at the impact of using pharmaceutical techniques for induction or augmentation of labor (IOL) on the incidence rate of uterine rupture in women trying a VBAC. The highest rate of uterine rupture tends to occur following a multi-pharmacological use of prostaglandin gel and oxytocin [29, 30, 32, 33]. Alternatives to pharmacological IOL have been explored in a study on serial membrane sweeping [37]. With 108 participants in the sweeping group and 105 in the control group, the sample size was small. There was no difference in the primary outcomes of labor induction or the frequency of repeat cesarean deliveries, and there were no uterine ruptures during the treatment, which involved either weekly membrane sweeping or weekly vaginal inspections [37]. A recent study [38] has reported no differences in VBAC success rates or neonatal and maternal outcomes for women who had one or more prior cesareans and used pharmacological induction of labor techniques.

Women who had continuity of care (CoC) with a midwife were more likely to feel in control of their decision-making and believe their healthcare provider supported their decision to have a VBAC, according to the Australian VBAC survey by Keedle et al. [39]. Women who underwent CoC with a midwife were more likely to be active during labor, to experience submersion in water, and to give delivery in an upright position.

2.7 Neonatal morbidity and mortality

The large studies that compared the outcomes of VBAC verses elective cesarean also included neonatal morbidity and mortality [22, 24]. One study found an increase in the rate of antepartum stillbirth in the planned VBAC cohort (0.6%) compared with the elective cesarean group (0.2%) [22]. The authors did identify that these numbers included babies with known congenital malformations and women experiencing fetal death in utero who were encouraged to have a VBAC rather than a cesarean. Neonatals born via vaginal birth after cesarean (VBAC) require less oxygen resuscitation and are less likely to be admitted to neonatal intensive care units (NICU), according to research from Gilbert et al. [23] and Kamath et al. [40]. These infants showed an increase in neonatal infection and a modest rise in transitory tachypnea [23, 40].

The size of the hospital has been found to be a contributing factor to the risk of neonatal death resulting from uterine rupture [29]. Of 107 uterine ruptures in the study by Smith et al. [29], 17 were neonatal deaths of which 13 occurred in hospitals that have <3000 births per annum, 15 in women with no previous vaginal birth, and five associated with the use of prostaglandin as an induction method [29]. In contrast to full uterine ruptures, which resulted in 13.6% more infant deaths than partial uterine ruptures, the partial uterine rupture had no neonatal deaths, according to a study [26]. It is important to highlighted that Keedle et al. [39] emphasized that both qualitative and quantitative studies have shown that having midwifery care can have a positive influence on VBAC rates without an increase in maternal or neonatal morbidity.

2.8 Birth trauma

Many studies on VBAC focus on physical consequences such uterine rupture or surgical trauma with little attention paid to the psychological problems these various birthing methods cause. Birth trauma can result from the emotions that women feel during and after giving birth, not necessarily from the physical mode of delivery. Feelings such as vulnerability, fear, out of control, ignored and abandoned, and anxiety seem to be linked to birth trauma [41, 42]. Traumatic birth has been found to impact on women for many years and can have an impact on lifelong self-esteem and willingness to seek healthcare [43].

Elmir et al. [42] did a review of the literature on birth trauma and found that partner relationships as well as maternal–infant connections may be impacted. Women should have access to counseling and debriefing, according to Elmir et al. who also argue that further study is needed to determine the efficacy of these therapies. Women who give birth via main cesarean may feel any or all of these emotions, and they may or may not have thought about these problems prior to being pregnant again.

In a survey of 59 women who had previously undergone a cesarean section, it was discovered that the previous birth experience was frequently characterized as traumatic and was, on average, scored as scoring 3 out of 10 on a Likert scale, with 1 denoting severe trauma and 10 denoting no trauma [44]. Five themes emerged from the open-ended questions about prior birth experiences, according to the researchers. These themes related to the women’s perceived feelings of failure, their sense of control loss, how they were treated by their healthcare providers, their labor and cesarean experiences, and the distress of giving birth apart from their child [44].

The answers after these births were noticeably more positive, with an average rating of 9/10 on the Likert scale. Twenty-nine of the 59 women in this study went on to have a VBAC. The two themes that arose from these encounters were whether or not the women felt in control and how supported they felt [44]. Participants were sourced through a consumer organization called Birthrites, which uses its website to encourage women who want to undergo vaginal birth after cesarean delivery both domestically and overseas. As these women intentionally viewed the website, the authors are aware that this cohort of women is not a representative sample of women who have had cesareans or VBACs. Given the popularity and use of forums and support groups on the internet and in social media, it would be fascinating to replicate this study [44].

The advantages of an after-birth service where women could meet with a midwife consultant on a needs-basis to explore the woman’s traumatic birth narrative and to be able to make plans for the next birth were highlighted by a small UK qualitative study that examined women’s experiences of a positive birth following a traumatic birth [45]. Five of the study’s 14 women (5/14) underwent a cesarean section for their first delivery. Many of these women did not use the service until after their subsequent pregnancies [45]. Women who later had a healthy birth showed sentiments of accomplishment and pride and regarded it as a calming experience; the authors refer to this as a “redemptive birth”. This study included two women choosing to have an elective cesarean [45].

3. Summary and conclusions

The eight main themes that concluded in this review were: Women’s attitudes and views of VBAC; VBAC education and decision-making programs; previous VBAC; maternal morbidity and mortality in cesarean versus planned VBAC; short inter-pregnancy interval; induction of labor; neonatal morbidity and mortality; and birth trauma.

This review has explored the current issues surrounding VBAC, from the risks of uterine rupture and maternal and neonatal morbidity and mortality to the women’s attitudes, views, and experiences. The safety of VBAC has also been explored. Evidence showed that midwife has a positive influence on VBAC rates without an increase in maternal or neonatal morbidity.

Through this literature research, it has been demonstrated that there is a dearth of understanding and knowledge on the factors that might influence a woman’s decision to have a VBAC and the views of the midwives who support this choice, so more research is needed to cover this topic deeply. The recommendation drawn from this review is toward increasing the number of VBAC by emphasizing on the midwifery role, continuity of care, personalized care, education program, and conducting more research.