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.

Osteoarthritis is a leading cause of chronic pain and disability, affecting more than two million Australians.

Routine x-rays aren’t recommended to diagnose the condition. Instead, GPs can make a diagnosis based on symptoms and medical history.

Yet nearly half of new patients with knee osteoarthritis who visit a GP in Australia are referred for imaging. Osteoarthritis imaging costs the health system A$104.7 million each year.

Our new study shows using x-rays to diagnose knee osteoarthritis can affect how a person thinks about their knee pain – and can prompt them to consider potentially unnecessary knee replacement surgery.

What happens when you get osteoarthritis?

Osteoarthritis arises from joint changes and the joint working extra hard to repair itself. It affects the entire joint, including the bones, cartilage, ligaments and muscles.

It is most common in older adults, people with a high body weight and those with a history of knee injury.

Many people with knee osteoarthritis experience persistent pain and have difficulties with everyday activities such as walking and climbing stairs.

How is it treated?

In 2021–22, more than 53,000 Australians had knee replacement surgery for osteoarthritis.

Hospital services for osteoarthritis, primarily driven by joint replacement surgery, cost $3.7 billion in 2020–21.

While joint replacement surgery is often viewed as inevitable for osteoarthritis, it should only be considered for those with severe symptoms who have already tried appropriate non-surgical treatments. Surgery carries the risk of serious adverse events, such as blood clot or infection, and not everyone makes a full recovery.

Most people with knee osteoarthritis can manage it effectively with:

• education and self-management
• exercise and physical activity
• weight management (if necessary)
• medicines for pain relief (such as paracetamol and non-steroidal anti-inflammatory drugs).

Debunking a common misconception

A common misconception is that osteoarthritis is caused by “wear and tear”.

However, research shows the extent of structural changes seen in a joint on an x-ray does not reflect the level of pain or disability a person experiences, nor does it predict how symptoms will change.

Some people with minimal joint changes have very bad symptoms, while others with more joint changes have only mild symptoms. This is why routine x-rays aren’t recommended for diagnosing knee osteoarthritis or guiding treatment decisions.

Instead, guidelines recommend a “clinical diagnosis” based on a person’s age (being 45 years or over) and symptoms: experiencing joint pain with activity and, in the morning, having no joint-stiffness or stiffness that lasts less than 30 minutes.

Despite this, many health professionals in Australia continue to use x-rays to diagnose knee osteoarthritis. And many people with osteoarthritis still expect or want them.

What did our study investigate?

Our study aimed to find out if using x-rays to diagnose knee osteoarthritis affects a person’s beliefs about osteoarthritis management, compared to a getting a clinical diagnosis without x-rays.

We recruited 617 people from across Australia and randomly assigned them to watch one of three videos. Each video showed a hypothetical consultation with a general practitioner about knee pain.

One group received a clinical diagnosis of knee osteoarthritis based on age and symptoms, without being sent for an x-ray.

The other two groups had x-rays to determine their diagnosis (the doctor showed one group their x-ray images and not the other).

After watching their assigned video, participants completed a survey about their beliefs about osteoarthritis management.

What did we find?

People who received an x-ray-based diagnosis and were shown their x-ray images had a 36% higher perceived need for knee replacement surgery than those who received a clinical diagnosis (without x-ray).

They also believed exercise and physical activity could be more harmful to their joint, were more worried about their condition worsening, and were more fearful of movement.

Interestingly, people were slightly more satisfied with an x-ray-based diagnosis than a clinical diagnosis.

This may reflect the common misconception that osteoarthritis is caused by “wear and tear” and an assumption that the “damage” inside the joint needs to be seen to guide treatment.

What does this mean for people with osteoarthritis?

Our findings show why it’s important to avoid unnecessary x-rays when diagnosing knee osteoarthritis.

While changing clinical practice can be challenging, reducing unnecessary x-rays could help ease patient anxiety, prevent unnecessary concern about joint damage, and reduce demand for costly and potentially unnecessary joint replacement surgery.

It could also help reduce exposure to medical radiation and lower health-care costs.

Previous research in osteoarthritis, as well as back and shoulder pain, similarly shows that when health professionals focus on joint “wear and tear” it can make patients more anxious about their condition and concerned about damaging their joints.

If you have knee osteoarthritis, know that routine x-rays aren’t needed for diagnosis or to determine the best treatment for you. Getting an x-ray can make you more concerned and more open to surgery. But there are a range of non-surgical options that could reduce pain, improve mobility and are less invasive.

Belinda Lawford, Senior Research Fellow in Physiotherapy, The University of Melbourne; Kim Bennell, Professor of Physiotherapy, The University of Melbourne; Rana Hinman, Professor in Physiotherapy, The University of Melbourne, and Travis Haber, Postdoctoral Research Fellow in Physiotherapy, The University of Melbourne

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