If you have had a caesarean section in a previous pregnancy, this information will enable you to consider your options and help you make choices about the birth of your next child. Most women who have had a caesarean section before could give birth vaginally next time. At Maidstone and Tunbridge Wells NHS Trust we aim to support you with having a vaginal birth, sometimes called VBAC (Vaginal birth after caesarean). However there are a number of issues for you to consider and the information below may help answer any questions you have.

Please discuss any of the subjects raised here with your midwife, consultant obstetrician or consultant midwife.

Why did I have a caesarean section last time? Will I need to have another one?

It can be helpful to talk with a midwife or doctor about why you had your previous caesarean section. Most reasons for having a caesarean section are unlikely to recur and the chances of having a successful VBAC for women who choose this option should be around 72-76%, depending on why you had a caesarean before.

Occasionally you might need a caesarean for a different reason altogether. If this is your second baby then your chances of having another caesarean are roughly the same as they were the first time you were pregnant.

In some rare circumstances (eg extreme prematurity or fibroids in the lower uterus), the incision of your previous caesarean may have been made vertically rather than from side to side. This is not as strong when healed and has an approximate 7% chance of rupturing if you go into labour. In these circumstances we would therefore strongly recommend that you avoid attempting VBAC and choose a repeat caesarean.

Will it make a difference if I’ve had any babies vaginally before?

If you have had any vaginal births before then it makes it even more likely that you could give birth vaginally this time (87-90%).

What are the advantages to having a VBAC?

Safety:
A vaginal birth has always been safer for the mother than a caesarean section (whether planned or as an emergency). Deaths following elective caesarean section are twice as likely as with vaginal birth and are 12 times greater with an emergency caesarean section, though the risk is still very small.

Reduced risk of complications
There is more risk of complications during a caesarean such as infections and blood clots (thrombosis).

Attempting a VBAC reduces the risk of the baby developing breathing problems at birth to 2-3% compared to 3-4% with caesarean birth.

Recovery time
If you have a vaginal birth you may recover much more quickly than if you have a caesarean. (A caesarean section will mean that you have an abdominal wound which causes increased pain and limits your mobility. A shorter and easier recovery means that you may also be better able to care for your other child or children following a vaginal birth.

Breastfeeding
If you have a vaginal birth you are more likely to breast feed successfully and ‘bonding’ with your baby is reported by women to be easier.

Self-esteem
Many women find giving birth vaginally very satisfying and fulfilling and have commented that giving birth vaginally made a difference to their self-esteem.

What are the risks of VBAC?

There is a small chance that your old caesarean scar could open, causing a problem for you and your baby. Research suggests that this is only likely to happen to about one in 150 women who have had a caesarean before.

If your scar opens, there is a very small risk of damage to your baby (1 in 1-2,000) or even your baby dying (a risk of about one in 3-5000). However, if your labour is monitored carefully and a caesarean is done promptly if problems arise, then almost all babies will be fine. Your midwife will observe you carefully in labour, to ensure that any signs of your scar opening are detected at an early stage, which should avoid serious problems for your baby.

A planned VBAC also carries a slightly increased risk of requiring a blood transfusion after the birth, but this is only about 1%.

What if I go past my due date?

If your pregnancy continues beyond your due date you will be seen in the antenatal clinic to discuss the available options with your consultant team. This is because an induction of labour increases the risk of your old scar opening by 2-3 times.

Is there anything I can do to increase my chances of a vaginal birth?

Support
Good support in labour is one of the most important factors in helping women have a normal birth. Having lots of encouragement to get through labour and feeling well cared for is known to help women cope with the pain of labour. It may also affect the length of labour and what sort of birth you have (although there are other factors that influence your labour too). You may find it helpful to have another birth supporter, as well as your partner, with you.

Mobility
Being able to move freely and adopt different positions is also likely to help keep your labour normal. Women often find movement a helpful way of coping with pain and being upright will help get your baby’s head into a good position and encourage it to descend into your pelvis.

When to come into hospital
Many women come into hospital very early in labour. This is not necessary and may increase the likelihood of your labour being considered slow.

For most women we recommend waiting until the contractions are in a regular pattern coming every five minutes and lasting for a whole minute.

Of course there are some situations when you would be advised to come to hospital before this point, if you have bleeding or your waters break, if you have severe abdominal pain that is not related to your contractions or have any worries about your baby.

Pain relief options
A wide range of options for pain relief are available such as entonox (gas and air), an injection of pethidine, an epidural, and the use of breathing, relaxation and massage.

Please ask your midwife to discuss the advantages and disadvantages of these options with you.

Are there any differences in how I am cared for in labour?

Electronic monitoring
We strongly recommend that once you are in established labour (with strong, frequent and regular contractions) that your baby’s heart rate is monitored continuously with an electronic monitor (CTG). This will help us to detect any changes in your baby’s heart rate that could be related to problems with your scar.

Continuous electronic monitoring can restrict your ability to move about freely and adopt different positions in labour, however it is often still possible to perform the monitoring with you sitting in a chair or standing close to the monitor.

Intravenous cannula
We recommend that you have a cannula in a vein in your forearm so that if you should need a caesarean it is easy to attach a ‘drip’ (intravenous infusion). (A cannula is a very fine plastic tube that is inserted with a needle that is then re-moved). Any blood tests can be done at the same time.

Progress of labour
In order to minimise the likelihood of problems with your scar in labour we would expect you to make good progress once in established labour. Excessively slow progress may indicate that a problem is developing.

In some circumstances we can give you a drug called syntocinon to help speed up your labour. This can increase the risk of your scar opening by about 2-3 times, so the medical staff would discuss this with you prior to it starting.

Can I have a water birth and/or a home birth?

There is no evidence on the safety of home birth or water birth for women who have had a caesarean before, although it is widely known that both are safe for women with straightforward pregnancies.

At home or in water, monitoring of the baby’s heart rate is undertaken intermittently with a handheld device, as it is not possible to monitor the baby’s heart rate continuously.

While there is no evidence to suggest that this is less effective at detecting problems with the baby’s heart rate, it may not be possible to pick up problems as quickly as with continuous electronic monitoring. An abnormal CTG recording is the most consistent finding if there is a problem with the old scar opening and this sign is present in 55-87% of these events.

Home birth could also potentially mean a delay should the need for a caesarean arise due to problems with your scar. It is strongly recommended that women who have had a caesarean before have a hospital birth, where there are facilities for an immediate caesarean section should it be necessary.

If you do decide to have a home birth or labour in water, we would, of course, still care for you.

Is VBAC possible after two previous caesarean sections?

Research indicates that there is no difference in the rates of the scar opening in VBAC with two or more previous caesarean births, compared with a single previous caesarean birth. There is, however a small risk in the incidence of needing a blood transfusion if there have been more than one previous caesarean (3.2% compared to 1.6%) and a hysterectomy 60/10,000 compared to 20/10,000).

It is important that you are aware of this if you choose this option.

What are the advantages and disadvantages of having an elective caesarean?

Advantages:
Planning an elective caesarean section can mean that you are able to avoid the uncertainly of whether you will need a caesarean in labour. Some women who have had a very difficult experience with their previous birth may feel that planning a caesarean gives a greater sense of being in control.

Disadvantages:
An elective caesarean can occasionally result in breathing difficulties for your baby as the process of labour helps prepare babies for breathing once they are born. In order to make this less likely we recommend that an elective caesarean is done when you are 39 weeks pregnant so that your baby’s lungs are more mature.

Having another caesarean can make problems with your placenta more likely in a future pregnancy – for example – ectopic pregnancy, placenta praevia (low lying placenta) and placental acreta where the placenta is adherent (sticks) to the uterine scar. The latter becomes more of a risk with repeated caesarean sections and, although rare, is the commonest cause for a hysterectomy to be performed in childbirth.

Research shows that women who have caesareans tend to have longer gaps between children and are more likely to have fewer children, although the reason for this is not known.

Some women choose an elective caesarean to avoid the pain of labour, but of course they will have an abdominal wound with more pain and a slower recovery instead.

What happens if I choose an elective caesarean?

We recommend that your caesarean is booked for when you are 39 weeks pregnant (unless there is a clinical reason to do it earlier).

You will be given a patient information leaflet on elective caesarean section which explains in details all the risks, benefits and alternatives, as well as exactly what will happen during the procedure.

Occasionally your caesarean can be delayed due to an unexpectedly high workload on the labour ward. You will be informed if this is the case.

What can help me decide?

Your decision about whether to plan to go into labour or have an elective caesarean section will be influenced by a number of factors:

  • The reason why you had a caesarean before.
  • How you feel about having had a caesarean before and the prospect of having another.
  • How you feel about the advantages and possible risks of both VBAC and Caesarean section.
  • Any new clinical factors that arise in this pregnancy.
    Type of previous uterine scar

We recommend that the majority of women with a previous caesarean should consider a VBAC, but recognise that for some women this may not be their choice. Please talk about this with your midwife or doctor and give yourself time to decide what is best for you. Our main objective is for you to have a healthy baby and feel satisfied with your birth experience and we aim to support you with whatever choice you make.

Further information

www.aims.org.uk – Association for Improvements in Maternity Services (AIMS) actively supports women and health professionals who recognise that, for the majority of women birth, is a normal rather than medical event.

www.nct.org.uk – The National Childbirth Trust (NCT). Antenatal education and postnatal support.

www.infochoice.org/ – Informed Choice Leaflets: information Leaflets on a range of subjects including VBAC, positions in labour, coping with pain, fetal monitoring, breech birth and many more.