A vaginal birth after caesarean (known as a VBAC) is when a woman who has had a caesarean has a vaginal birth down the track.

In Australia, about 12% of women have a vaginal birth for a subsequent baby after a caesarean. A VBAC is much more common in some other countries, including in several Scandinavian ones, where 45-55% of women have one.

So what’s involved? What are the risks? And who’s most likely to give birth vaginally the next time round?

What happens? What are the risks?

When a woman chooses a VBAC she is cared for much like she would during a planned vaginal birth.

However, an induction of labour is avoided as much as possible, due to the slightly increased risk of the caesarean scar opening up (known as uterine rupture). This is because the medication used in inductions can stimulate strong contractions that put a greater strain on the scar.

In fact, one of the main reasons women may be recommended to have a repeat caesarean over a vaginal birth is due to an increased chance of her caesarean scar rupturing.

This is when layers of the uterus (womb) separate and an emergency caesarean is needed to deliver the baby and repair the uterus.

Uterine rupture is rare. It occurs in about 0.2-0.7% of women with a history of a previous caesarean. A uterine rupture can also happen without a previous caesarean, but this is even rarer.

However, uterine rupture is a medical emergency. A large European study found 13% of babies died after a uterine rupture and 10% of women needed to have their uterus removed.

The risk of uterine rupture increases if women have what’s known as complicated or classical caesarean scars, and for women who have had more than two previous caesareans.

Most care providers recommend you avoid getting pregnant again for around 12 months after a caesarean, to allow full healing of the scar and to reduce the risk of the scar rupturing.

National guidelines recommend women attempt a VBAC in hospital in case emergency care is needed after uterine rupture.

During a VBAC, recommendations are for closer monitoring of the baby’s heart rate and vigilance for abnormal pain that could indicate a rupture is happening.

If labour is not progressing, a caesarean would then usually be advised.

Why avoid multiple caesareans?

There are also risks with repeat caesareans. These include slower recovery, increased risks of the placenta growing abnormally in subsequent pregnancies (placenta accreta), or low in front of the cervix (placenta praevia), and being readmitted to hospital for infection.

Women reported birth trauma and post-traumatic stress more commonly after a caesarean than a vaginal birth, especially if the caesarean was not planned.

Women who had a traumatic caesarean or disrespectful care in their previous birth may choose a VBAC to prevent re-traumatisation and to try to regain control over their birth.

We looked at what happened to women

The most common reason for a caesarean section in Australia is a repeat caesarean. Our new research looked at what this means for VBAC.

We analysed data about 172,000 low-risk women who gave birth for the first time in New South Wales between 2001 and 2016.

We found women who had an initial spontaneous vaginal birth had a 91.3% chance of having subsequent vaginal births. However, if they had a caesarean, their probability of having a VBAC was 4.6% after an elective caesarean and 9% after an emergency one.

We also confirmed what national data and previous studies have shown – there are lower VBAC rates (meaning higher rates of repeat caesareans) in private hospitals compared to public hospitals.

We found the probability of subsequent elective caesarean births was higher in private hospitals (84.9%) compared to public hospitals (76.9%).

Our study did not specifically address why this might be the case. However, we know that in private hospitals women access private obstetric care and experience higher caesarean rates overall.

What increases the chance of success?

When women plan a VBAC there is a 60-80% chance of having a vaginal birth in the next birth.

The success rates are higher for women who are younger, have a lower body mass index, have had a previous vaginal birth, give birth in a home-like environment or with midwife-led care.

For instance, an Australian study found women who accessed continuity of care with a midwife were more likely to have a successful VBAC compared to having no continuity of care and seeing different care providers each time.

An Australian national survey we conducted found having continuity of care with a midwife when planning a VBAC can increase women’s sense of control and confidence, increase their chance to be upright and active in labour and result in a better relationship with their health-care provider.

Why is this important?

With the rise of caesareans globally, including in Australia, it is more important than ever to value vaginal birth and support women to have a VBAC if this is what they choose.

Our research is also a reminder that how a woman gives birth the first time greatly influences how she gives birth after that. For too many women, this can lead to multiple caesareans, not all of them needed.

Hannah Dahlen, Professor of Midwifery, Associate Dean Research and HDR, Midwifery Discipline Leader, Western Sydney University; Hazel Keedle, Senior Lecturer of Midwifery, Western Sydney University, and Lilian Peters, Adjunct Research Fellow, Western Sydney University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

“Childhood” and “dementia” are two words we wish we didn’t have to use together. But sadly, around 1,400 Australian children and young people live with currently untreatable childhood dementia.

Broadly speaking, childhood dementia is caused by any one of more than 100 rare genetic disorders. Although the causes differ from dementia acquired later in life, the progressive nature of the illness is the same.

Half of infants and children diagnosed with childhood dementia will not reach their tenth birthday, and most will die before turning 18.

Yet this devastating condition has lacked awareness, and importantly, the research attention needed to work towards treatments and a cure.

More about the causes

Most types of childhood dementia are caused by mutations (or mistakes) in our DNA. These mistakes lead to a range of rare genetic disorders, which in turn cause childhood dementia.

Two-thirds of childhood dementia disorders are caused by “inborn errors of metabolism”. This means the metabolic pathways involved in the breakdown of carbohydrates, lipids, fatty acids and proteins in the body fail.

As a result, nerve pathways fail to function, neurons (nerve cells that send messages around the body) die, and progressive cognitive decline occurs.

What happens to children with childhood dementia?

Most children initially appear unaffected. But after a period of apparently normal development, children with childhood dementia progressively lose all previously acquired skills and abilities, such as talking, walking, learning, remembering and reasoning.

Childhood dementia also leads to significant changes in behaviour, such as aggression and hyperactivity. Severe sleep disturbance is common and vision and hearing can also be affected. Many children have seizures.

The age when symptoms start can vary, depending partly on the particular genetic disorder causing the dementia, but the average is around two years old. The symptoms are caused by significant, progressive brain damage.

Are there any treatments available?

Childhood dementia treatments currently under evaluation or approved are for a very limited number of disorders, and are only available in some parts of the world. These include gene replacement, gene-modified cell therapy and protein or enzyme replacement therapy. Enzyme replacement therapy is available in Australia for one form of childhood dementia. These therapies attempt to “fix” the problems causing the disease, and have shown promising results.

Other experimental therapies include ones that target faulty protein production or reduce inflammation in the brain.

Research attention is lacking

Death rates for Australian children with cancer nearly halved between 1997 and 2017 thanks to research that has enabled the development of multiple treatments. But over recent decades, nothing has changed for children with dementia.

In 2017–2023, research for childhood cancer received over four times more funding per patient compared to funding for childhood dementia. This is despite childhood dementia causing a similar number of deaths each year as childhood cancer.

The success for childhood cancer sufferers in recent decades demonstrates how adequately funding medical research can lead to improvements in patient outcomes.

Another bottleneck for childhood dementia patients in Australia is the lack of access to clinical trials. An analysis published in March this year showed that in December 2023, only two clinical trials were recruiting patients with childhood dementia in Australia.

Worldwide however, 54 trials were recruiting, meaning Australian patients and their families are left watching patients in other parts of the world receive potentially lifesaving treatments, with no recourse themselves.

That said, we’ve seen a slowing in the establishment of clinical trials for childhood dementia across the world in recent years.

In addition, we know from consultation with families that current care and support systems are not meeting the needs of children with dementia and their families.

New research

Recently, we were awarded new funding for our research on childhood dementia. This will help us continue and expand studies that seek to develop lifesaving treatments.

More broadly, we need to see increased funding in Australia and around the world for research to develop and translate treatments for the broad spectrum of childhood dementia conditions.

Dr Kristina Elvidge, head of research at the Childhood Dementia Initiative, and Megan Maack, director and CEO, contributed to this article.

Kim Hemsley, Head, Childhood Dementia Research Group, Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University; Nicholas Smith, Head, Paediatric Neurodegenerative Diseases Research Group, University of Adelaide, and Siti Mubarokah, Research Associate, Childhood Dementia Research Group, Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University

This article is republished from The Conversation under a Creative Commons license. Read the original article.