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What are my choices for birth after a Caesarean delivery?

More than one in five births in the UK are currently by Caesarean section (a surgical operation where a cut is made in your abdomen and your baby is delivered through that cut). Sometimes you may have had more than one Caesarean birth.

If you have had one or more Caesarean deliveries, you may be thinking about how to give birth next time. Whether you choose to have a vaginal birth or a Caesarean delivery in a future pregnancy, either choice is safe with different risks and benefits. Overall, both are safe choices with only very small risks. In considering your choices, your obstetrician will ask you about your medical history and about your previous pregnancies. They will want to know about:

• The reason you had the Caesarean delivery and what happened – was it an emergency?
• The type of cut that was made in your uterus (womb)
• How you felt about your previous birth. Do you have any concerns?
• Whether your current pregnancy has been straightforward or have there been any problems or complications?

You and your obstetrician or midwife will consider your chance of a successful vaginal birth, your personal wishes and future fertility plans when making a decision about vaginal birth or Caesarean delivery.

What is an elective repeat Caesarean delivery?

An elective caesarean means a planned Caesarean. The date is usually planned in advance at your hospital antenatal visit.

The Caesarean delivery usually happens in the seven days before your due date, unless there is a reason why you or your baby need an earlier delivery.

What is VBAC?

VBAC stands for ‘vaginal birth after Caesarean’. It is the term used when giving birth vaginally, after a Caesarean delivery in the past. Vaginal birth includes birth assisted by forceps or ventouse.

What are the advantages of a successful VBAC?

The advantages of a successful VBAC include:

• A vaginal birth (which might include an assisted birth).
• A greater chance of an uncomplicated birth in future pregnancies.
• A shorter recovery and a shorter stay in hospital.
• Less abdominal pain after birth.
• Not having surgery.

When is VBAC likely to be successful?

If you have had one caesarean section before, and subsequently have a straight forward pregnancy and go into labour there is a 90% chance that you will give birth vaginally.

If you have had two previous caesarean sections you can give birth again by caesarean section, however, should you go into labour, your chance of a successful vaginal birth is slightly less (between 70 and 75%).

What are my chances of a successful VBAC?

A number of factors (risk factors) make the chance of a successful vaginal birthless likely. These are when you:

• Have never given birth vaginally.
• Need to be induced.
• Did not make progress in labour and needed a Caesarean delivery (usually owing to the position of the baby).
• Are overweight – a body mass index (BMI) over 30 at booking.

What are the disadvantages of VBAC?

The disadvantages of VBAC include:

Emergency Caesarean delivery
There is a chance you will need to have an emergency Caesarean delivery during your labour. This happens in 25 out of 100 people who are giving birth after a previous caesarean section (25%). This is only slightly higher than if you were labouring for the first time, when the chance of an emergency Caesarean delivery is 20 in 100 people (20%). The usual reasons for an emergency Caesarean delivery are labour slowing or if there is a concern for the well-being of the baby.

Blood transfusion and infection in the uterus
Those choosing VBAC have a 1 in 100 (1%) higher chance of needing a blood transfusion or having an infection in the uterus compared with those who choose a planned Caesarean delivery.

Scar weakening or scar rupture
There is a chance that the scar on your uterus will weaken and open. If the scar opens completely (scar rupture) this may have serious consequences for you and your baby. This occurs only in two to eight people in 1000 (about 0.5%). Being induced increases the chance of this happening. If there are signs of these complications, your baby will be delivered by emergency Caesarean delivery.

Risks to your baby
The risk of your baby dying or being brain damaged if you undergo VBAC is very small (two in 1000 or 0.2%). This is no higher than if you were labouring for the first time, but it is higher than if you have an elective repeat Caesarean delivery (one in 1000 or 0.1%). However, this has to be balanced against the risks to you if you have a Caesarean delivery (see below). These disadvantages are more likely where a VBAC is attempted but unsuccessful.

When is VBAC not advisable?

There are very few occasions when VBAC is not advisable and repeat Caesarean delivery is a safer choice. These are when:

• You have had three or more previous Caesarean deliveries.
• The uterus has ruptured during a previous labour.
• You have a high uterine incision (classical Caesarean).
• You have other pregnancy complications that require a Caesarean delivery.

What are the advantages of elective repeat Caesarean delivery?

The advantages of elective repeat Caesarean delivery include:

• Virtually no risk of uterine scar rupture.
• It avoids the risks of labour and particularly the risk of possible brain damage or stillbirth from lack of oxygen during labour (one in 1000 or 0.1%).
• Knowledge of the date of delivery. However, since caesarean delivery is usually planned for the 39th week of your pregnancy, there is a chance that you may go into labour before the date of your caesarean section, as there is a 1 in 10 (10%) chance you may go into labour before your Caesarean date. The planned date may on occasion need to be changed to ensure safe running of surgical lists.

What are the disadvantages of elective repeat Caesarean delivery?

The disadvantages of elective repeat Caesarean delivery include:

A longer and possibly more difficult operation
A repeat Caesarean delivery usually takes longer than the first operation because of scar tissue. Scar tissue may also make the operation more difficult and can result in damage to the bowel or bladder. There is a risk of baby’s skin being cut at the time of the Caesarean section. This occurs in about 2% of cases but usually heals without further harm.

Chance of a blood clot (thrombosis)
A blood clot that occurs in the lung is called a pulmonary embolus. A pulmonary embolus can be life threatening (death occurs in less than one in 1000 caesarean deliveries).

There is a longer recovery period
You may need extra help at home and will be unable to drive for about six weeks after delivery (check with your insurance company).

Breathing problems for your baby
Breathing problems are quite common after Caesarean delivery and usually do not last long. Occasionally, your baby will need to go to the neonatal unit. Between three to four in 100 babies (3-4%) born by planned Caesarean delivery have breathing problems compared with two to three in 100 (2-3%) following VBAC. Waiting until the week before the due date minimises this problem.

A need for elective caesarean delivery in future pregnancies
More scar tissue occurs with each Caesarean delivery. This increases the possibility of the placenta growing into the scar making it difficult to remove at Caesarean (placenta accreta or percreta). This can result in bleeding and may require a hysterectomy. All serious risks increase with every Caesarean delivery you have.

What happens if I go into labour when I’m planning VBAC?

You will be advised to deliver in hospital so that an emergency Caesarean delivery can be carried out if necessary.

Contact the hospital as soon as you think you have gone into labour or if your waters break. Once you are in labour, you and your baby’s heartbeat should be monitored continuously. You can have an epidural if you choose.

What happens if I do not go into labour when planning a VBAC?

If labour does not start by 41 weeks, different options will be discussed with you by your obstetrician. These are:

• Continue to wait for labour.
• Induction of labour. This increases the risk of scar weakening and lowers the chance of a successful VBAC.
• Repeat elective Caesarean delivery. You may choose to aim for VBAC if you labour spontaneously but opt for a repeat elective Caesarean delivery rather than induction of labour.

What happens if I have an elective Caesarean planned and I go into labour?

Telephone the hospital to let them know what is happening. It is likely that an emergency Caesarean will be performed once labour is confirmed. If labour is very advanced, or if the labour is early (before 37 weeks), then VBAC may be more suitable. Your obstetrician will discuss this with you.