Maternity Leaflet: Birth After Caesarean Section

Birth After Caesarean Section: This leaflet has been designed to provide you with information to help you decide on the best mode of birth for you and your baby if you have had a previous caesarean section.

Leaflet Details

Patient Information

Introduction

This leaflet has been designed to provide you with information to help you decide on the best mode of birth for you and your baby if you have had a previous caesarean section.

Everyone will have had a unique experience of labour and birth previously and this may influence how you feel and the decision you will make for birth in this pregnancy.

It must be emphasised that both Vaginal Birth After Caesarean section (VBAC) and Elective Repeat Caesarean Section (ERCS) are safe and acceptable options. They both have their risks and benefits and both methods are supported by the National Institute of Clinical Excellence (NICE) and the Royal College of Obstetricians & Gynaecologists (RCOG).

Our aim is that you and your baby are healthy, that you have a positive birth experience and to give you and your baby the best start of life together.

Vaginal Birth After Caesarean Section (VBAC)

What are the main benefits and risks of VBAC?

For the majority of women, a successful vaginal birth has fewer risks and greater benefits than an ERCS

Benefits:

• You will have a greater chance of a vaginal birth in future pregnancies
   
• Your recovery is likely to be quicker
   
• Your stay in hospital may be shorter
   
• Your baby will have less chance of developing breathing problems
   
• Less risk of infection
   
• Less likely to experience heavy bleeding that requires a blood transfusion

Risks:

• There is a 20-25% chance that you may need an emergency caesarean section during labour
   
• There is an increased chance of needing a blood transfusion compared to somebody who is having an elective repeat caesarean section.
   
• The scar on your uterus may separate and/or tear (rupture) and this can occur in 1 in 200 women.
   
• Serious risk to your baby such as brain injury or stillbirth is higher than for a planned caesarean section but is the same as if you were labouring for the first time.
   
• You may need an assisted vaginal birth using ventouse or forceps
   
• You may experience a tear involving the muscle that controls the anus or rectum (third or fourth degree tear).

How likely am I to give birth vaginally?

For most women and their babies, a vaginal birth after caesarean section is safe. Studies show that, on average 72-75% (1) of women who have a straight forward pregnancy and who go into labour naturally after a previous caesarean will give birth vaginally. In the last 3 years at Ashford and St Peter’s 78% of women who have laboured after a previous caesarean have delivered vaginally.

When is 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
   
• you have other pregnancy complications that require a planned caesarean
   
• a previous caesarean section involved an incision in the upper part of the uterus.

Elective Repeat Caesarean Section (ERCS)

What are the benefits and disadvantages of an ERCS?

Benefits:

• There is a smaller risk of uterine scar rupture (1 in 1000)
   
• It avoid the risks of labour and the rare serious risks to your baby (2 in 1000)
   
• Avoidance of tears to the vagina, perineum and anal sphincter
   
• Longer term lower risk of prolapse of the womb and vaginal walls, urinary stress incontinence, reducing risk of surgery (please note that this does not mean that you have NO risk, just that the chance of it occurring is lower)
   
• You do not have to have surgery with the risk of complications afterwards.

Disadvantages:

The disadvantages of an ERCS include:

• You may have a longer recovery time and stay in hospital
   
• You can get a wound infection that can take several weeks to heal.
   
• A repeat caesarean can take longer than a first operation because of scar tissue which can make the operation more difficult and result in damage to your bowel or bladder
   
• Surgical injury to the baby skin (laceration) which can happen in 2 out of every 100 caesarean deliveries.
   
• You have a higher risk of developing a blood clot in your legs (deep vein thrombosis) or lungs (pulmonary embolism)
   
• You may need a blood transfusion
   
• You are more likely to need a planned caesarean section in future pregnancies. More scar tissue occurs with each caesarean section. This increases the possibility of the placenta growing into the scar, making it difficult to remove during any future deliveries (placenta accreta or percreta). This can result in bleeding and may require a hysterectomy. All serious risks increase with every caesarean section you have.

What happens in a VBAC labour?

• We recommend that you give birth to your baby in the Labour Ward so that an emergency caesarean delivery can be carried out if necessary. The team providing your care will include midwives and obstetricians.
   
• We recommend that you contact the Surrey Heartlands Pregnancy Advice Line 0300 123 5473 as soon as you have signs of labour and you will be given advice when to come into the hospital.
   
• We recommend that your baby’s heartbeat is continuously monitored to ensure they remain healthy in labour. This may be offered using Telemetry (wireless monitoring) if it is available. If you have an epidural for pain relief your ability to keep mobile may be reduced.

Are there any additional precautions you will take in my labour?

There is a small risk that the scar on your uterus may separate and/or tear (rupture) and this can occur in 1 in 200 women. We will monitor the progress of your labour carefully with the aim of the labour being as normal as possible. If at any time there are warning signs of this such as severe constant pain, abnormal bleeding or changes in your baby’s heartrate the team would deliver your baby by emergency caesarean section.

What pain relief can I have?

You have the same options for pain relief that all women in labour have. These include gas and air (Entonox), pethidine and an epidural. Your midwife will talk you through these and help you decide what choices are right for you and your baby depending on what stage of labour you are in. Our expert anaesthetic service is available on labour ward 24 hours a day.

Can I give birth in the Abbey Birth Centre?

We advise birth on our labour ward as Abbey Birth Centre cannot offer continuous monitoring of your baby. We can offer a safe active birth in one of our labour rooms; we have a pool room and can offer telemetry. Some women who have had a vaginal birth of a baby choose the birth centre and we support an informed choice. If you want to explore this please ask your midwife and we will arrange further discussion and create an individual birth plan with you.

Can I give birth in the pool?

Yes, we have a birthing pool on our labour ward. We also have a waterproof mobile heart rate monitor which can be used for women labouring in the pool. We cannot guarantee this room will be available but we will do our best to support your birth plan. Please ask the midwife if a pool birth is possible when you come to the labour ward.

What are my options if labour has not started naturally by my due date?

If labour has not started by 40 weeks you will have a discussion about your options in our antenatal clinic. The best time to have your baby obviously depends on your individual pregnancy, your midwife and doctor can explain this.

Your choices are:

• Induction of labour, usually at 41 weeks. We offer balloon induction as this is highly effective, well regarded by women and avoids the need for hormone pessaries. If you want more detailed information we have a leaflet on balloon induction and what it involves, this is available on your BadgerNet app.
   
• Planned caesarean if induction does not feel like the right choice for you. You can book an elective caesarean section at 41 weeks of pregnancy with the hope that you will have gone into labour naturally prior to this date and then can cancel the booked caesarean.

If I choose an ERCS how is this arranged?

This would usually be booked for after 39 weeks. The obstetrician will book the date once you have made your decision when you attend your next routine antenatal clinic appointment.

Please see our leaflet on planned caesarean section for details of what to expect. This is available on your BadgerNet app.

What if I go into labour before my operation date?

For a lot of women, going into labour before a planned caesarean date is a worrying thought. For many this is associated with fear of the unknown and for others, the fear of a long protracted labour. Often, women who have had a caesarean section before will have had an induction of labour that has not worked. In this instance, a naturally occurring labour is a very different situation because inductions of labour are less efficient and less effective than a natural labour. In this situation, the advice would usually be to see how labour progresses before deciding for a caesarean section.

We will always do our best to support your preference for your birth, however a caesarean in advanced labour may not be the best or safest option for you or your baby. Your midwife and doctor will assess and explain the situation to you.

How do I make a choice?

Now you need to consider how you feel about your upcoming birth and how you would like to proceed.

Your community midwife can answer questions and help support you in making your choice. Your community midwife will arrange an appointment with an obstetrician to confirm your plan.

My wishes

Space below to write down any specific wishes and requests that you have for the birth of your baby to make the experience more positive for you.

Please write down any questions you want your midwife or doctor to answer.

There is also space in your BadgerNet app in your birth plan.

My Options and My Choice:

1. VBAC with induction of labour - Book a balloon induction at about 41 weeks of pregnancy and a back-up caesarean the following day.
    
2. VBAC without the option of Induction of labour - Book a caesarean section at 41 weeks of pregnancy
    
3. ERCS - Book a caesarean section after 39 weeks of pregnancy

References

1. Birth After Previous Caesarean Birth; Green-top Guideline No. 45; October 2015
    
2. NICE guidance of normal labour
    
3. Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Obstet Gynecol 2006;107:1226–32.
    
4. Marshall NE, Fu R, Guise JM. Impact of multiple cesarean deliveries on maternal morbidity: a systematic review. Am J Obstet Gynecol 2011;205:262.e1–8.