According to the Australian Institute of Health & Welfare the current caesarean section birth rate in Australia is approximately 34%. As a consequence many Australian women today are asking “If I had a caesarean, does it mean I will have a repeat caesarean next time? What are my chances next time of a successful vaginal birth?”
Well there are a number of factors to consider when answering. It is not a clear black and white answer. Any decision taken should be on an individual basis.
In terms of rates of success next time the Safer Care Victoria guidelines (2021) states that it varies between 29 to 89%.
TOLAC (Trial of Labour After Caesarean, previously known as VBAC) is contraindicated in instances where there have been 3 or more caesarean sections, a previous uterine rupture, a classical caesarean incision, or if there is now a low-lying placenta, or the baby is “lying across” as opposed to “head down”.
Caution is also advised if it has been less than 18 months since the last caesarean, or if it is suspected that the next baby is larger in size than average (as these both increase the likelihood of uterine rupture). In addition Induction of labour is associated with an increased risk of uterine rupture. The incidence of rupture during TOLAC is 0.5-3.9%.
There are a number of factors which increase the likelihood of success, such as; a reduction in BMI (Body Mass Index) between caesarean and attempting TOLAC, a maternal age of less than 30 years, a maternal BMI of less than 30, the previous caesarean not related to the arrest of labour/obstructed labour and labour happening spontaneously before 41 weeks.
TOLAC is considered for a number of reasons- as well as some woman wanting to experience the vaginal birth, there are advantages such as faster recovery, discharge from hospital, easier mobilisation, and less complications for future pregnancies. A successful TOLAC is associated with a lower risk of complications compared to an elective repeat caesarean.
However, a sizeable number of women decide on an elective repeat caesarean due to risks such as uterine rupture and the possibility of emergency caesareans. This is an issue in our smaller regional hospitals who provide “low risk births.” Many women are reluctant to travel further away to the larger maternity units and be separated from their other young children when giving birth, aiding further stress when having to consider childcare arrangements.
So how does Australia compare worldwide? Interestingly enough according to BMC Pregnancy & Childbirth, Germany had a 74% success T
OLAC rate, whilst Ireland was 66% closely followed by Italy at 64%. According to the latest figures from the Australian Institute of Health and Welfare the percentage of women having a TOLAC is a low 12%. So why the difference? One reason could be the influence of private healthcare in Australia. Looking at the figures more closely rates of successful TOLAC were astonishingly three times higher in the public hospitals compared to the private sector.
In addition given that there is a rise in the rates of freebirth and homebirth with risk factors, here in Australia, it clearly shows that women feel there is inadequate maternity care options.
As argued by the Conversation when it comes to childbirth, and whether to have a VBAC or repeat caesarean, “women need balanced, evidenced-based information and they need their choices supported”.