Birth after caesarean patient information

This leaflet contains information and evidence that you may find helpful in making decisions about giving birth vaginally following a previous caesarean section.

If you do not understand any of the words or phrases used in this leaflet, ask your midwife or doctor to explain them to you clearly. You can bring someone with you to your appointments if you think you might need some support in understanding what is said or in making decisions.

What are my choices for birth after caesarean?

If you have had one or more caesarean births, you may be thinking about how to give birth next time. Whether you have a vaginal or caesarean birth in a future pregnancy, either way is safe with different risks and benefits. Overall, both are safe choices with only very small risks.

In considering your care, your midwife or doctor will ask you about your medical history and about your previous pregnancies. They will want to know about:

• The reason you had the caesarean birth 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 straight forward or have there been any problems or complications?

You and your midwife or doctor will consider your chances of a successful vaginal birth, your wishes and future fertility plans when making a decision about vaginal or caesarean birth (RCOG, 2015).

What is VBAC?

This is known as vaginal birth after caesarean section or ‘VBAC.’ Most women who have had a previous caesarean section can safely have a vaginal birth in a subsequent pregnancy.

What are the benefits 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 normal birth in future pregnancies
• a shorter recovery and a shorter stay in hospital
• less wound pain after birth
• not having had surgery and the risks associated with this such as infection, thrombosis (blood clots in the leg or lungs), bleeding and blood transfusion

When is a VBAC likely to be successful?

Overall, about three out of four women (75%) with a straightforward pregnancy who go into labour spontaneously give birth vaginally following one previous caesarean delivery.

If you have had a vaginal birth, either before or after your caesarean delivery, about nine out of ten women (90%) and birthing people who choose VBAC have a vaginal birth.

If you have had two previous caesareans you can chose to have a vaginal birth and can have a discussion with either a consultant obstetrician or a consultant midwife to plan care. If you go into labour spontaneously the chance of a successful vaginal birth is 70 to 75%.

What reduces my chances of a successful VBAC?

There are several factors (risk factors) that make the chance of a VBAC less successful. These are when you:

• have never had a vaginal birth.
• have less than 12 months since your caesarean section.
• need to be induced.
• are over 40 years old and needed a caesarean birth because your labour progressed slowly, possibly due to the position of the baby.
• have a body mass index (BMI) over 30 at booking.
• previous baby weighing over 4.5kg.

What are the risk factors associated with having a VBAC?

These include:

Unplanned caesarean.

There is a chance you will need to have an unplanned caesarean birth during your labour. This happens in about 1 in every four VBAC labours (25%). This is only slightly higher than if you were labouring for the first time, when the chance of an unplanned caesarean birth is 1 in 5 (20%). The usual reasons for an unplanned caesarean birth are labour slowing or if there is a concern for the well-being of the baby.

Blood transfusion and infection in the uterus (womb).

If you choose a VBAC there is a 1 in 100 (1%) higher chance of needing a blood transfusion or having an infection in the uterus compared with women 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 2-8 cases in 1000 (about 0.2%-0. 0.5%). Being induced is associated with a 2-3-fold increased chance of this happening. If there are signs of these complications, you will be recommended an unplanned caesarean birth.

Risk to your baby

The risk of your baby being brain damaged is approximately 8 in 10,000 (0.08%). The risk of your baby dying due to birth complications is 4:10,000 (0.04%).

The risk of your baby dying before labour is 1 in 1000 (0.1%) after 39 weeks.

When is a VBAC not advisable?

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

• you have had three or more previous caesarean births.
• the uterus has ruptured during a previous labour.
• you have a high uterine incision (classical caesarean).
• you have other pregnancy complications that indicate a caesarean birth.

A detailed discussion with an obstetrician in all these situations is important.

What are the disadvantages of having a repeat elective caesarean (ERCS)?

A longer and possibly more difficult operation

A repeat caesarean birth 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 and a higher risk of haemorrhage.

There is a longer recovery period

An average stay following a caesarean is usually two days. You will also need extra help at home and will be unable to drive for about six weeks depending on your insurance cover. There are risks associated with surgery – you can read about these in the Planned caesarean birth (opens in a new tab) patient information leaflet.

Chance of a blood clot (Thrombosis)

Surgical procedures such as a caesarean are associated with a higher risk of blood clots forming in your legs, which can then go on to cause serious complications or death if untreated. You will therefore be recommended medication to take every day for either 10 or 40 days following your caesarean. You can read more about this in the information leaflet Reducing the risk of VTE in pregnancy and the postnatal period.

Breathing problems for your baby

A planned caesarean can occasionally result in breathing difficulties for your baby as the process of labour helps prepare babies for breathing once they are born. This may mean admission to the special care baby unit (SCBU) and artificial help with breathing. To make this less likely we do not perform elective caesareans (where there is no medical reason for the operation) before 39 weeks. The risk is then reduced to approximately 1%. Caesarean birth does not entirely protect against trauma to the baby, for example the risk of a laceration (superficial cut) is 1-2 in 100 caesareans (1-2%).

A need for planned caesarean birth in future pregnancies

Having another caesarean can make problems with your placenta more likely in a future pregnancy – for example placenta praevia (where the placenta is low and there is a risk of bleeding) and placental abruption (bleeding from under the placenta) could both result in the need for a hysterectomy at the time. As could placenta accreta – also known as invasive placenta, which is more likely following caesarean birth. Ectopic pregnancy (where the embryo develops in one of the fallopian tubes, instead of the womb), is also more likely.

Many of the complications associated with caesarean birth increase with every further operation.

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 you have a vaginal birth.

Where to give birth?

We recommend giving birth in hospital if you have had a caesarean before, as there are facilities for an urgent caesarean should it be necessary.

Can I have a home birth?

There is no evidence on the safety of home birth if you have had a caesarean before. At home monitoring of the baby’s heart rate is undertaken intermittently with a handheld device, as it not possible to monitor the baby’s heart rate continuously. The risks described above are based on labours that have continuous monitoring.

While there is no evidence to suggest that intermittent auscultation is less effective at detecting problems with the baby’s heart rate in uncomplicated pregnancies, it may not be possible to pick up early warning signs of scar problems as quickly compared to continuous electronic monitoring.

Home birth can mean a delay in receiving treatment should the need for a caesarean arise, which could have serious consequences for your baby and yourself, including severe brain injury and death

We would continue to provide midwifery care if you do decide to have a home birth after a full discussion of the potential risks and benefits with the consultant obstetrician, consultant midwife or senior midwife. An individual birth plan will be developed with you.

Water birth

Monitoring equipment, which is waterproof and enables continuous monitoring of your baby’s heart rate is available on delivery unit should you wish to have a pool birth. The pool is subject to availability, and you will be offered an opportunity to discuss your plans with a member of the clinical team on arrival in labour, based on your current preferences and risk factors.

When to come into hospital

Unless you are concerned, we recommend remaining at home in early labour as evidence shows this leads to higher rates of vaginal birth.

We recommend waiting until your contractions are in a regular pattern coming every three minutes and lasting for a whole minute, before coming in, unless you have any concerns or feel you would be more comfortable having an assessment. Reasons to call in include, but are not limited to:

• if you have any vaginal loss
• if your waters break
• if you have abdominal pain that is not related to your contractions if you have any worries about your baby
• you would like to discuss what you are experiencing with a midwife

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

Continuous fetal monitoring

Once you are in established labour (with strong, frequent and regular contractions) we recommend that your baby’s heart rate is monitored continuously with an electronic monitor. This will help us to detect any changes in your baby’s heart rate that could be related to problems with the scar on the uterus. We have wireless (telemetry) monitoring available which enables greater mobility.

Intravenous access

We recommend that you have an IV cannula put into a vein in the back of your hand or forearm, so that if you should need medication urgently, we can quickly attach a ‘drip’ (intravenous infusion). A blood sample for your blood group and a full blood count would be taken at the same time.

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

If you are planning a VBAC you should have an appointment with an obstetrician at 38-39 weeks to plan for birth if your baby is not born by 40 weeks. You will be offered an appointment in antenatal clinic where different options will be discussed with you by an obstetrician. These are:

• Continue to wait for labour to begin.
• Arrange for induction of labour – you can read more about this in the Cervical balloon catheter induction of labour PIL.
• Repeat planned caesarean birth.

Useful information

RCOG Birth after previous caesarean patient information (opens in a new tab)