I’ve really enjoyed reading the birth stories on the blog over the past week, from those of you who’ve had a vaginal birth after Caesarean section (VBAC). I meet so many pregnant couples who’ve had a previous Caesarean section (C-section) and are trying to decide what to do for their subsequent birth, so it’s really good we’re talking about it.
It’s also an issue close to my heart, as my wife and I are expecting our second baby, having had our first by emergency C-section 18 months ago.
More than a quarter of babies each year (28%), are born by C-section. It used to be the case that if you had one baby by C-section then it was advised that all your future deliveries should be this way. But things have moved on and now rightly, all couples are given the choice.
When making these decisions, it’s really important to know what the different options are and have a clear understanding of the risks and benefits of each. This way you can feel calm and confident with the decision you and your support team come to.
The options are either to try for a VBAC, or to have a planned, or elective, C-section.
There are risks and benefits with both options and, like with all decisions in pregnancy, it’s the balance of these risks that’s important to weigh up. These risks will be different for each woman and will depend on your thoughts, your medical background and the reasons you needed a C-Section in your first pregnancy. It’s important that you discuss this decision with your team, who will help to personalise the advice to your individual circumstances.
So, let’s look at the two options and the risks and benefits of each.
The majority of women will be encouraged to have a VBAC if they have had one previous C-section and there are no other concerns with their current pregnancy.
Statistically, between 70-75 out of every 100 women who aim to have a VBAC will be successful in having a vaginal birth. This number is likely to be higher if you have had both a previous C-section and a previous vaginal delivery. If you are successful in having a VBAC then your hospital stay will usually be shorter, and your recovery will usually be easier than if you had a repeat Caesarean section. Additionally, your chance of having a vaginal birth in any future pregnancies will be higher (approximately 80-85%).
However, there is the chance when aiming for VBAC, that you may end up needing an unplanned, or emergency Caesarean section. 20-25 women out of every 100 who aim for a VBAC will find themselves in this situation.
The less common, but major complication that we want to avoid, is of the C-section scar breaking down. This is not common, but affects approximately 1 in every 200 women. The reassuring thing is that if this is detected early it can usually be dealt with by delivering the baby by emergency C- section. However, if this goes undetected it can put you and you baby at significant risk, so it’s important to discuss monitoring options with your team.
If the scar starts to break down in labour, it will usually cause pain over the site of the previous C-section scar. There can be early signs with the baby’s heart beat and with the strength and frequency of your contractions which may raise the suspicion but sometimes the early signs are very subtle.
That’s why it has traditionally been recommend that women aiming for a VBAC have continuous monitoring during the active stage of labour when they are having regular contractions and that they are in a place where they can have an emergency Caesarean section if required.
However, the National Institute for Health and Care Excellence (NICE) has recently published new guidelines about VBAC. The wording has been contentious and it is unclear whether they are now supporting the use of intermittent monitoring rather than continuous monitoring during labour, for women having a VBAC. The Royal College of Obstetricians and Gynaecologists have issued a statement saying they still recommend continuous monitoring and they are working with NICE to clarify this guideline. Others have welcomed this possible change, saying it gives more freedom of choice to women about how and where they give birth. Essentially, guidelines are there for guidance, so discuss your options with your team and remember the ultimate decision should always be yours.
What about if I have had two previous Caesarean sections?
If you have had two or more previous C-sections, then it is still possible to aim for a VBAC. Your team will discuss your individual risks and will help you to come to the decision that you feel most comfortable with.
If you decide you would rather have a further C-section, this would normally be planned for after 39-weeks of pregnancy.
Remember, a further C-section may be recommended for entirely independent reasons, for example if a new and significant risk factor is found in the current pregnancy, e.g. a low-lying placenta.
There is little difference in the risks for your baby compared to if you have a VBAC or a C-section.
The main risk of having an elective C-section is that there will already be scar tissue from your first operation and so there is an increased risk of bleeding, infection or damage to other organs. The recovery following a C-section can also be more difficult and is usually longer than if you had a vaginal delivery. This may be more challenging than after your first C-section, as you will have your older child and a new baby to look after.
Another consideration is whether you plan to have further pregnancies after this one. If you plan to have a large family, then the risk of complications increases with each repeated C-section because of the increased scar tissue from each surgery.
If you get to the point where your medical team would normally have recommended an induction of labour e.g. reduced movements of your baby; they will discuss with you the options. This may include an induction with breaking your waters or with a balloon which sits in the neck of the womb (cervix), or they may at this point recommend an elective C-section. This is because the risk of the previous C-section scar breaking down is more than doubled with induction using the hormones which we usually use and the risk of emergency C-section is also increased, when compared to if your labour comes on naturally.
So, what happens if you had planned to have an elective Caesarean section, but you go into labour?
Your support team will help you to have a plan in place for what to do. Usually, this will include coming to hospital for an assessment to see how established your labour is. You may decide to allow your labour to continue and try for a VBAC or to have an unplanned C-section at this time.
As you can see, there are many factors that need to be taken into consideration when deciding what type of birth to have after a previous C-section. The facts and figures can seem overwhelming, but I hope this has made the options a little clearer. Remember, that you, your midwives and doctors are a team. Discuss the options, ask about alternatives and remember that the final decision should always be yours.
Good luck and I wish you the most positive birth experience possible.
Please do get in touch with your thoughts or views on this topic. You can find me on Instagram @hphbantenatal or www.happyparentshappybaby.com