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Maternity Unit

Birth after a previous caesarean

The decision whether to plan for a vaginal birth or have another caesarean section is sometimes difficult. For most women who have had one previous caesarean section, there is no good medical evidence that one choice is ‘better’ than the other. Therefore your involvement in the decision is very important.

Here we present the information to help you to make an informed choice about the option that is best for you.

When do I need to make a decision?

It is never too early to start thinking about your preferences when planning for birth and ensuring that you get the information you need to make the right choice. An appointment will be made for you to see either a midwife or a consultant when you attend for your 20 week ultrasound scan. Before you attend the clinic we urge you to read this information and to think carefully about the issues that are most important to you regarding this decision. At this consultation we will be discussing your options for the birth of your baby. If you feel that it would help please make notes and bring these with you to the appointment. The consultation will be very much led by you and we will be discussing your thoughts and preferences to help you to move towards the decision that you feel is best for you, your baby and your family.

Usually a decision will be agreed between you and the obstetrician or midwife between 34 and 36 weeks. Once a decision is made you can still change your mind although it is better not to do this once you are in labour. If your pregnancy has been uncomplicated, you will have three options:

  • You can plan to deliver normally (also called a Vaginal Birth After Caesarean or VBAC). If you don’t go into labour naturally then labour would be induced at 42 weeks.
  • You can plan to have an elective caesarean section.
  • You can plan to deliver normally but opt for a planned caesarean section if you do not go into labour by 42 weeks rather than have your labour induced.

Planned vaginal delivery or planned caesarean section?

Whichever method you choose the risk of anything going wrong during your pregnancy or delivery is very small. However, because you have had a previous caesarean section, the risk of problems during labour or caesarean section are slightly higher than in a woman without a previous caesarean section.

There have not been any studies directly comparing planned vaginal delivery with planned caesarean section in a group of women with one previous caesarean section. However, the information available from different types of studies allows us to estimate the risks and benefits of the different options.

Vaginal birth after caesarean section (VBAC)

Vaginal delivery is the most natural way to give birth and you should not underestimate the value of this experience. 75 in every 100 women will achieve a successful VBAC after a single previous caesarean section.

After a vaginal delivery women tend to have a shorter hospital stay and return to normal activities, such as driving, more quickly. Two to three in every 100 babies have mild breathing difficulties following a vaginal delivery compared to four in every 100 babies after a planned caesarean section.

Birth needs to be in the Delivery Suite as the baby’s heartbeat needs to be monitored continuously once you are in established labour. This allows the midwives to quickly see if the baby is having any problems during your labour. This does not mean that you  are obliged to remain on the bed throughout your labour, in fact, if you do not have an epidural your midwife will encourage you to be as mobile as possible to help labour to progress.

What are the potential problems of attempting a VBAC?

Approximately 25 in every 100 women who plan a VBAC eventually require a caesarean section. Often this is because the cervix does not fully open or because the baby shows signs of stress in labour.

There is a risk that the scar on your womb could tear; this is known as scar rupture. This is uncommon affecting only two to seven in every 1,000 women attempting a vaginal birth. In fact the same problem can occur in one in every 1000 women having a planned caesarean section.

If the scar does rupture then an emergency caesarean section is necessary to deliver the baby and repair the womb. Very occasionally it is not possible to repair the tear and to control the bleeding the womb has to be removed (hysterectomy). A hysterectomy is necessary in only one in 10,000 women opting for a vaginal delivery.

Can labour be induced or augmented?

It is possible we may offer you induction of labour but this reduces the chance of a vaginal birth. When it is necessary to use prostaglandins first to open the neck of the womb (cervix) this slightly increases the risk of scar rupture. Increasing the strength, length and frequency of contractions with an oxytocin drip (augmentation) may later be necessary and once again this is a careful decision to make as it may again increase the risk of scar rupture.

All decisions whether to induce or augment labour are only be made by a senior doctor after discussion with you.

Quote from a women having a vaginal delivery after caesarean section

“I was asked to make a choice and I wanted to try for a vaginal birth this time. I think, with having a caesarean previously, I felt as if I got so far and then, the last bit, I just didn’t quite manage it, and it’s almost like you’ve been denied that, you’ve gone through all that hard work and you were denied that last pleasure. I was desperately wanting to feel that experience of having the baby delivered and brought on to my chest. It’s just not the same really when, the baby comes out of your stomach and it’s took away and washed and checked over and brought to you in a towel. It’s just not the same. I’m not some sort of masochist who enjoys going through labour but I just wanted to know what it is like to do it naturally. If I can keep it as natural as possible and try to do it myself I suppose it will give me some sense of achievement.”

Benefits of elective repeat caesarean section

  • You avoid labour altogether.
  • You can plan the birth and feel in control. 
  • Please be aware that 10 in every 100 women who choose elective caesarean section will go into labour beforehand and will be offered an emergency caesarean or will deliver vaginally.
  • You reduce the risk of scar rupture (although it does not completely remove the risk).
  • 10 in every 100 women who have an elective caesarean section will require a blood transfusion. This compares to 20 in every 100 women who plan a VBAC but require an emergency caesarean section.
  • You can still have skin to skin and feeding your baby can start as soon as you wish.

Potential problems of elective repeat caesarean section

  • Pain and difficulty moving around after the operation.
  • You may need extra help at home and will be unable to drive for six weeks after delivery (check with your insurance).
  • You will need a caesarean section in all future pregnancies.
  • Four in every 100 babies delivered by caesarean section have breathing problems that occasionally require admission to the nursery.
  • In a future pregnancy two in every 100 women have a placenta that develops under the scar inside the womb (placenta accreta). This makes it difficult to remove the placenta at caesarean section. This may result in heavy bleeding and complications including the possibility of a hysterectomy (removal of the womb).

How do other women make a choice?

Each woman makes choices based on the issues that are important to her. For some women the chance to have a vaginal birth is so important that they feel the benefits outweigh the risks. Other women may choose elective caesarean section because the uncertainty of the outcome of labour is so unsettling that they prefer to have the risks of a caesarean section.

The reasons are personal to each family, which is why we want you to have as much information as possible to help you make your own choice. Please ask questions and be sure you are happy with the answers you are given.

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