If you have had one previous caesarean section this leaflet is designed to help you decide the best way to give birth to your baby. The decision whether to have another caesarean section or a planned vaginal delivery is sometimes very difficult. For most women, there is no good medical evidence that one choice is better than the other. It is therefore important that you make this decision for yourself. If your pregnancy has been uncomplicated, you will have three options:

1. You can plan to deliver normally (also called a Vaginal Birth After Caesarean or VBAC). This could include going into labour naturally or having your labour induced. Three out of four women in this group will go on to have a vaginal delivery while one in four will have an emergency caesarean section.
2. You can plan to have a caesarean section (elective caesarean section)
3. 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.

Your doctor or midwife will look at your specific situation and give you an estimate of your chances of successful planned vaginal delivery. Before making a final decision please consider:

• Your thoughts about how you want to deliver your baby
• Your experience of your previous delivery
• The estimate of your chances of successful vaginal delivery
• The risks and benefits of the different options
• Your thoughts about further pregnancies

Whether you choose a planned vaginal delivery or a planned caesarean section, 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 higher that in a woman without a previous caesarean section.

There have not been any research 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 delivery is the most natural way to give birth and many women value this experience
• When planned vaginal delivery is successful women tend to have a shorter hospital stay and return to normal activities such as driving more quickly compared to women having a planned caesarean section
• There is lower risk of mild breathing difficulties in babies born after planned vaginal delivery (2-3 out of 100 babies compared to 4 out of 100 after planned caesarean section).
• The next two benefits relate to any future pregnancies you may have.

If you have a second caesarean section, your doctor will recommend that you have a planned caesarean section if you get pregnant again.

The risk of some problems in pregnancy increases the more caesarean sections you have. The most important of these are placenta previa (where the placenta covers the neck of the womb) and placenta accreta (where the placenta is unusually attached to the muscle of your womb and therefore difficult to remove after the birth of the baby). These problems may cause heavy bleeding and occasionally require a hysterectomy (removal of the womb). 1 in 1,000 women require a hysterectomy if they have had two previous caesarean sections compared to 12 in 1,000 women after five caesarean sections. This is important if you are planning to have several children.

• Higher chance of achieving the method of delivery you have planned. About 75% of women who plan a vaginal birth will actually deliver vaginally while 90% of women who plan an elective caesarean section will actually deliver by this method. (10% will go into labour before their elective caesarean is due to be performed and will deliver by emergency caesarean section or vaginally)
• Lower risk of scar rupture. This is when the scar on your womb from the previous caesarean section opens up or ‘ruptures’ (this occurs in between 2 to 7 women per 1000 women who plan to deliver vaginally and almost never in women who plan a caesarean section). In most cases of scar rupture, the baby is delivered by emergency caesarean section and there are no long-term problems. 
• Lower risk of needing blood transfusion (1 in 100 women having a planned caesarean section need a transfusion compared to 2 in 100 for those having a planned vaginal delivery) 
• Lower risk of infection in the womb (2 in 100 women having a planned caesarean section will develop a womb infection compared to 3 in 100 women having a planned vaginal delivery. These infections are easily treated with antibiotics. 
• Lower risk of problems with your baby due to the baby becoming distressed during labour, or problems that can occur when your pregnancy goes beyond your due date. Because planned caesarean sections are done at 39 weeks they avoid some of these problems.

The above benefits are because 1 in 4 women who plan a vaginal delivery actually deliver their baby by emergency caesarean section which has a higher risk of complications compared to a planned (elective) operation before labour.

If you go past your due date, we will recommend that your labour should be induced at around 42 weeks. This is because there is an increasing risk to the baby if pregnancy goes beyond 42 weeks. There are other reasons why your baby may need to be delivered early and induction of labour might be one option. 

• Most women who have a previous caesarean section and have their labour induced in the next pregnancy deliver normally without any problems. However there are some increased risks that you may want to discuss with your doctor or midwife. For women with a previous caesarean section, induction of labour further increases the risk of scar rupture (the risk is 2-3 times higher compared to women who go into labour on their own). The risk is further increased if the cervix is tightly closed and hormone pessaries are needed to soften and open the cervix. 
• Because of the additional small risks with induction, you will be given the option of an elective caesarean section if you reach 42 weeks. You will have the opportunity to discuss these two options further with a doctor or midwife before you make this choice.

When should I make up my mind about type of delivery?

It is never too early to start thinking about your preferred option for the birth of your baby. Usually, a decision will be agreed between you and your doctor or midwife before 36 weeks

Can I make this choice myself or will I have to get my doctor/midwife to agree with my decision?

This decision should be made by you. You should read this leaflet and consider the good and bad points of each method of delivery. Your doctor and midwife are there to support you in whatever choice you feel is best for you and your baby. If you feel you need extra information or support then please ask your doctor or midwife.

Can I change my mind?

Yes, you can change your mind at any time. Please let your midwife and doctor know as soon as possible if you change your mind or become uncertain about your choice so there is time to discuss any issues and plan your delivery.

What if I go into labour before the date of my planned caesarean section?

If your labour starts or your waters break, you should contact the Maternity Assessment Unit on (0191) 282 5748. If you are in the early stages of labour and still want a caesarean section, then this will be done as soon as possible.

Alternatively, if you have gone into labour yourself you may decide that you wish to continue and try for a vaginal delivery. If you are in advanced labour, it may be safer for you to have a vaginal delivery. Your doctor and midwife will discuss this with you and reach a decision.

When will a planned caesarean section be performed?

If you would like a planned caesarean section, it will be done around 39 weeks.

Further information

You can find further information about type of delivery after caesarean section on the following websites:

The Royal College of Obstetricians & Gynaecologists

http://www.rcog.org.uk/resources/Public/pdf/green_top45_birthafter.pdf

www.nice.org.uk

www.babycentre.co.uk

Birth Reflections at the RVI

If you have any thoughts or feelings about any previous experience of birth at the RVI, this is an opportunity to discuss them with a midwife. Please phone (0191) 2820212. This is an answer phone. Please leave a message and your call will be returned.