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. Some women may prefer to plan to give birth vaginally. The midwives and doctors involved in looking after you during your pregnancy will be able to give you advice and information on 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. 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 any another children at home)
- A shorter physical recovery for you
- A quicker return to normal activities due to less pain and discomfort
- Less chance of maternal bleeding and needing a blood transfusion
- Less chance of developing a blood clot in your leg or lung (thrombosis) after the birth
- Less chance of developing an infection
- 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 ready for being born
- Increased chance of successful breastfeeding compared with babies born by caesarean section
- Less chance of certain problems in future pregnancies such as low lying placenta or a placenta that gets stuck to the uterine scar (these can be very serious complications for women which sometimes mean a hysterectomy is needed)
- 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.
- 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 as this risk is mostly associated with labour following Caesarean section and uterine surgery e.g.excision of uterine fibroids).
What are the potential problems of attempting 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 (womb) will start to open up. This is called scar dehiscence or rupture. Rupture of the scar is uncommon – if 10,000 women attempt VBAC, 35 will have a scar rupture (0.35%). Having a planned caesarean section reduces the risk of scar rupture to 12 in every 10,000 (0.12%).
- 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 up, it would be necessary to carry out an emergency caesarean section to deliver your baby quickly and repair your uterus.
- A scar rupture may mean 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.
- In the very unlikely event that the scar on the uterus opens up during labour, the baby may become starved of oxygen and this could lead to handicap 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. We offer 1:1 care all through a VBAC to watch carefully for signs that baby is well and if we have any concerns, doctors will offer to deliver your baby by caesarean section.
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 chance of infection.
- Increased pain and difficulty moving around after the operation may make it more difficult for you to look after your baby and any 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. This is caused by failure to clear the fluid from the baby’s lungs that would normally occur during a vaginal birth. This can sometimes mean a baby needs to be admitted to 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.
Can I have labour induced if I have had caesarean section before?
Induction of labour can be done 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 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.
How can I find out more information?
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:
Other information
- National Institute for Clinical Excellence
- AIMS (Association for Improvements in Maternity Services)
- National Childbirth Trust
References:
Caesarean section NICE Clinical guideline [CG132] Published date: 23 November 2011 Last updated: 04 September 2019
Enkin M., Keirse MJNC., Renfrew M., Neilson J. (1996) A Guide to Effective Care in Pregnancy and Childbirth. 2nd Edition. Oxford University Press.
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