Emotions, opinions and fears run high when it comes to birth. If we are frightened of birth in the first place, then the thought of a VBAC going wrong is terrifying. Women’s VBAC stories show that health professionals often focus on uterine rupture, damage to the baby or mother, and the risk of death. No wonder health professionals are often discouraging of VBAC! Their fears and concerns may come through in the way they present information, the way they speak about VBAC and a woman’s birth history.
Women’s fears however are even more complex. Many women have had their confidence and belief in their ability to birth shaken by the experience of labour followed by an emergency caesarean. Many women report feelings of failure and having let their baby down. They may fear another vaginal birth ending in an emergency, they may fear another frightening or dehumanising caesarean birth, and they may fear feeling like they have failed again.
The risks of VBAC include separation of the uterine scar before or during labour and a higher risk of infant mortality compared to a caesarean birth. Professor of Midwifery, Hannah Dahlen, explains that the chance of infant death from a uterine rupture is 1 in 10, 000 babies and this is equal to the chance of a death of a baby in a first pregnancy.
The risk of infant mortality in a VBAC is also equal to the chance of a perinatal death due to mid-trimester amniocentesis, or the risk of an infant death due to sudden infant death syndrome explains Catherine Spong in her review of the latest studies on VBAC risk. Other rare complications like cord prolapse or shoulder dystocia are more likely in any labour than a uterine rupture occurring during a VBAC explains Midwife and academic Rachel Reed in Birth Journeys. Yet women are frightened and discouraged out of VBACs for levels of risk that are acceptable to most people in other circumstances.
Meanwhile the risks of caesareans have been downplayed. Immediate risks of a caesarean include heavy bleeding or haemorrhage for the mother, infection in the wound and blood clots. We are only just beginning to see some of the long-term risks to mothers of repeat caesareans. With each caesarean the risks of the placental abnormalities like placenta accreta and placenta previa increase, the risks of uterine rupture increase, and the risk of internal damage to mother or baby during the surgery increase. Adhesions to the scar tissue, chronic pain, future ectopic pregnancy and hysterectomy become more likely. Risks of maternal death increase. 
We know little about the long term impact of caesarean birth on the health of a baby. We know that babies born by caesarean are more likely to have respiratory problems, and now studies are finding an increased risk of asthma, allergies and type 1 diabetes. 
Each woman needs to be aware of her unique circumstances and explore her own risks for a vaginal birth and a caesarean birth. The length of time between pregnancies, reasons for the first caesarean, and many other individual factors are relevant – but also important is a woman’s emotional wellbeing and her reasons for desiring a VBAC. It is helpful to distinguish between fears and risks. While you (or a doctor) might be very frightened of a negative outcome from a birth, the likelihood of it happening to you remains slim – but still possible. This doesn’t mean your fears are invalid or the risks are unimportant, but it does mean you have the power to do something about your fears. You have the power (and the right) to prepare yourself for the most positive birth after caesarean on your terms.
VBAC for most women after one or two caesareans
Current research supports VBAC in hospital as a safe and reasonable option for most women after one or two caesareans. This research is starting to filter into obstetric guidelines for birth after caesarean around the world. However there is still a considerable gap between guidelines and what some women are experiencing at this time. Many women still share that they are limited in their options, refused a VBAC, unable to find a supportive doctor, or unable to negotiate their care plan to give them the best chance of a successful VBAC.
I hope we will see an increase in VBAC opportunities, VBAC support and VBAC rates. We also need to see a reduction in avoidable first caesareans so that 30+% of women will not have to face the choice of VBAC or another caesarean.
 From Professor Hannah Dahlen’s presentation on VBAC at the Maternity Coalition’s Empowering Birth Stories, May 1013.
 CY Spong, In PLoS Med. 2012;9(3):e1001191. doi: 10.1371/journal.pmed.1001191. Epub 2012 Mar 13.