Introduction
For women who have previously had a caesarean birth, the decision how to give birth in the next pregnancy can sometimes be difficult. Some women may prefer to have another caesarean birth., while others may prefer to give birth vaginally. The midwives and doctors involved in your care will be able to give you advice and information based on your previous pregnancy/delivery experience and medical history. They would also discuss with you the benefits and risks of both ways of giving birth to your baby. They will support you and help you come to a decision that you feel is right for you. It may also be helpful if you have a relative/ friend in similar situation You may hear the term VBAC (pronounced vee- back) mentioned – this refers to Vaginal Birth After Caesarean.
What are the advantages of VBAC?
Usually giving birth vaginally is associated with:
- A shorter stay in hospital (this may be important if you have children at home)
- A shorter physical recovery for you.
- A quicker return to normal activities due to less pain and discomfort Lower risk of complication with caesarean: bleeding and needing a blood transfusion, infection and developing a blood clot in your leg or lung (thrombosis) after birth.Lower chance of the baby having breathing problems or of the baby needing to be admitted to the Special Care Baby Unit (SCBU). This is because during the natural birth process, babies clear the fluid in their lungs.Higher chance of skin-to-skin contact with your baby immediately after birth and increased chance of successful breastfeeding.Lesser chance of placental problems in future pregnancies such as low-lying placenta or a placenta that gets stuck to the uterine scar, which could lead to life threatening bleed and removal of the womb (very uncommon).
- Very likely to achieve a straightforward vaginal birth in future pregnancies
What are the advantages of a repeat caesarean section?
- Being able to know in advance when the baby will be delivered – elective caesarean sections are normally carried out at 39 weeks. However, 1 in 10 women go into labour before their caesarean day and if it happens to you, you could choose to try vaginal birth or a caesarean section. This plan would be made with your doctor before you reach term.
- No risk of vaginal tears and painful stitches afterwards
- Less risk of prolapse of the womb, bladder or rectum and lower risk of incontinence problems in later life.
- Less risk of scar rupture (1 in 1000) as this risk is mostly associated with labour following Caesarean section and uterine surgery (e.g., removal of uterine fibroids).
What are the potential problems of attempting a VBAC?
- Some women who plan a VBAC will need an unplanned caesarean section. Usually this is unplanned but not an emergency, for example if labour is progressing more slowly than we believe is optimal. Sometimes it may be an emergency because the baby is becoming distressed. The chance of this happening for a VBAC is similar to the chance for a woman having her first baby.
- There is a very small chance that the scar on the uterus will start to open. This is called scar dehiscence or rupture. Risk of rupture of the scar being 1 in 200 for women attempting VBAC, when compared to women who choose planned caesarean (1 in 1000).
- We monitor women having a VBAC very carefully. You will have 1:1 care from a midwife during labour and we recommend you give birth in hospital so that doctors can also be involved in your care. If the scar does show signs of opening, it would be necessary to carry out an emergency caesarean section to deliver your baby quickly and repair your uterus.
- In the very unlikely event that the scar on the uterus opens during labour, the baby may become starved of oxygen, this could rarely lead to disability or even death of the baby. This could happen to about 10 babies in 10,000 women attempting VBAC. The risk is lower in women having a repeat caesarean section – about 1 in 10,000.
- A scar rupture may mean sometimes, it is not possible to repair the uterus and a hysterectomy may be needed (removal of the womb). This happens to 3 in 10,000 women (0.03%) so it is very uncommon.
What are the potential problems of a repeat caesarean section?
- Any operation will cause scarring; a caesarean section is no different. Repeat caesarean section may be more difficult because of this scarring and this can increase the risk of damage to other organs like the bowel and the bladder. It may also make the operation longer which can increase post-operative pain, bleeding and the chances of infection.
- Increased pain and difficulty moving around after the operation may make it difficult for you to look after your baby and other children at home; you may require extra help. It may also not be possible for you to drive for 4 – 6 weeks after the operation – please check with your car insurance company.
- Sometimes the baby can have breathing difficulties after a caesarean birth, around 4-5%. This is caused by failure to clear the fluid from the baby’s lungs that would normally occur during a vaginal birth. This usually does not last long but could sometimes mean admission into the Special Care Baby Unit.
- Women who give birth by caesarean section, especially before labour has started, are more likely to have a delay in their breastmilk coming in and may have less chance of breastfeeding successfully compared with women who give birth vaginally.
- Once a woman has had more than one caesarean section, then we would usually offer you a repeat caesarean section for your future births. Repeating caesarean sections can increase the chances of the risks previously mentioned- bleeding, infection, blood clots in leg/lungs, scar rupture, placenta stuck to the caesarean scar needing hysterectomy.
What are my chances of a successful VBAC?
After one caesarean section, about three out of four women with a straightforward pregnancy who go into labour naturally give birth vaginally.
Several factors make a successful vaginal birth more likely, including:
- previous vaginal birth, particularly if you have had previous successful VBAC; if you have had a vaginal birth, either before or after your caesarean section, about 8–9 out of 10 women can have another vaginal birth
- your labour starting naturally
- your body mass index (BMI) at booking being less than 30.
When is a VBAC not advisable?
VBAC is normally an option for most women but it is not advisable when:
- you have had three or more previous caesarean deliveries
- your uterus has ruptured during a previous labour
- your previous caesarean section was ‘classical,’ i.e. where the incision involved the upper part of the uterus
- you have other pregnancy complications that require a planned caesarean section.
What happens if I do not go into labour when planning a VBAC?
If labour does not start by 41 completed weeks, your obstetrician will discuss your birth options again with you. These may include:
- continue to wait for labour to start naturally
- induction of labour; this can increase the risk of scar rupture and lowers the chance of a successful VBAC
- Planned caesarean section.
Can labour be induced if I have had a caesarean section before?
Induction of labour can be offered for all the usual reasons, following discussion of the risks and benefits with your consultant, to enable you to make a fully informed decision. However, the risk of uterine rupture increases with induced labour compared to a labour which starts spontaneously. The risk is still low but is around three times higher than when labour starts by itself (80 in 10,000 women if labour is induced by breaking the waters and using a hormone drip and increases to 240 in 10,000 women if vaginal Prostaglandin gel is used). As a result, women who opt for an induced VBAC are only offered one Prostaglandin gel and you are admitted to hospital for the whole process. Alternatively mechanical methods can be used e.g. Dilapan rods, which avoids the additional risk of Prostaglandin gel. Please ask your midwife for more information.
What to expect during your VBAC?
- All women in labour receive 1:1 care from a midwife. This is to support you and to ensure you and your baby are safe. You will also be routinely reviewed by our doctors during labour. If any problems occur, the midwife will ask the doctor to attend again. We will always keep you informed about what is happening and what your options are.
- Due to the risk of the scar on the uterus opening up, we would advise continuous monitoring and tracing of the baby’s heartbeat once labour becomes established (this means regular frequent contractions and the cervix is at least four centimetres dilated.) This is one of the ways we can closely observe that your baby is coping well with labour.
- All self-help and pharmacological methods of pain relief will be available to you including epidural, with the exception of using the birthing pool. This is because it is not possible to continuously monitor the baby’s heartbeat when you are in the birthing pool. Many women like to use the bath or shower in early labour (when the cervix is less than four centimetres dilated) and this is also fine for women having a VBAC.
- Vaginal examination will be carried out with your consent every 4 hours to see how labour is progressing. On average, we would expect you to have birthed your baby (or be close to doing so) within 8 – 10 hours of being diagnosed as being in established labour.
- If labour slows down it may be possible to try and correct this by breaking your waters or using a hormone drip. This will be discussed with you by your midwife and a senior doctor. Using the hormone drip does increase the risk of a scar rupture, for this reason the dosage and duration of use will be closely monitored.
Can I have a VBAC after more than one caesarean section?
There is not a lot of evidence about the safety of this but it can and does happen. Please discuss your individual circumstances with the hospital consultant.
What happens if I have an ERCS planned but I go into labour?
Let your maternity team know what is happening. It is likely that an emergency caesarean section will be offered once labour is confirmed. If labour is very advanced, it may be safer for you and your baby to have a vaginal birth. Your maternity team will discuss this with you.
Points to remember which could help you decide
- If you are fit and healthy, both VBAC and ERCS are safe choices with very small risks.
- 3 out of 4 women who have had one caesarean section and then have a straightforward pregnancy and go into labour naturally give birth vaginally.
- 9 out of 10 women will have a successful VBAC if they have ever given birth vaginally. Successful VBAC has the fewest complications.
- Giving birth vaginally carries small risks for you and your baby but, if you have a successful vaginal birth, future labours are less complicated with fewer risks for you and your baby.
- Having a caesarean section makes future births more complicated.
- Most women who have a planned caesarean section recover well and have healthy babies, but it takes longer to get back to normal after your baby is born.
Shared Decision Making
At the Queen Elizabeth Hospital Maternity Unit, we advocate a shared decision making approach to all decisions made by our patients. This leaflet aims to give you additional information and to act as a point of reference following a discussion with your obstetrician or midwife. If you are asked to make a decision about your own care please make sure you have asked all the questions you need to ask and are given the appropriate time to do so. Some questions you might want to ask could be;
- What are my options?
- What are the pros and cons of each option?
- Who will support me making the decision that is the right one for me?
Contact numbers
Please discuss any queries or concerns with your midwife or consultant during your appointment; alternatively, if you need any more information, please do not hesitate to contact the Maternity Pregnancy Assessment Unit to speak to a midwife.
We are currently improving the way we deliver care to women and families during their pregnancy. As part of these improvements, we have a small team of midwives who are developing information and discussion sessions for mothers who have had a previous caesarean section. We hope that these sessions will support you in making informed decisions regarding the birth of your baby.
For further information please contact:
