Having a vaginal birth after a previous Caesarean Section

What are the options for birth after a Caesarean delivery?

If you have had a previous Caesarean section, you may be planning to have a vaginal birth (VBAC) or choosing to have an elective repeat caesarean section (ERCS). Each have different benefits and risks, which we will explain in this leaflet, so you can make an informed choice.

There are only a few, uncommon, conditions that could make vaginal birth unsafe and a Caesarean section necessary. Your individual circumstances should be discussed with your doctor.

When is a vaginal birth not advisable?

There are very few occasions when a vaginal birth after a caesarean is not advisable and a repeat Caesarean delivery is a safer choice.

These include:

• Three or more previous Caesarean deliveries

• The uterus has ruptured during a previous labour

• A high or unusual uterine incision (including classical caesarean)

• Other pregnancy complications that require a Caesarean delivery

What happens in a vaginal birth after a previous Caesarean?

Labour is managed like any other labour, and most of your care will be exactly the same. We do, however, advise continuous monitoring of your baby during labour.

How likely is it I will be able to have a vaginal birth?

Two out of three women (60 to 70%) who attempt to deliver vaginally do so, irrespective of the reason for their previous Caesarean section.

If you have a straightforward pregnancy, and go into spontaneous labour, the likelihood of having a vaginal birth increases to three in four women (75%).

If you have had a vaginal birth before – either before or after your Caesarean – the likelihood increases again, to nine out of ten women (90%)

What else can affect my chance of having a vaginal birth?

There are some factors that can reduce the risk of you having a vaginal birth, including:

• If you need to be induced (labour doesn’t start naturally)

• If you’re overweight and have a BMI (Body Mass Index) of over 30 at booking

• If you have not had a previous vaginal delivery

What are the advantages of a vaginal birth?

• Many women achieve satisfaction from giving birth themselves

• The recovery time is usually quicker. You can usually go home within 24 hours, are able to move around more easily and can drive again within a few days

• Caring for your baby is easier after a vaginal birth, as you are not recovering from an operation

• There’s less abdominal pain after birth

• You avoid the complications of surgery and anaesthesia

• You have a greater chance of having an uncomplicated vaginal birth next time, should you become pregnant again

• There is less risk of blood clots forming in your legs and lungs

• There’s a lower chance that your baby will need to be admitted to the neonatal unit

What are the disadvantages of a vaginal birth?

Risk of emergency Caesarean being required:

• One in four women (25%) attempting a vaginal birth following a previous Caesarean will require an urgent or emergency Caesarean section during labour. This is usually as a result of labour not progressing (slow labour), or there being concerns about the baby.

• It’s not possible to tell in advance who will require an unplanned Caesarean section. The risk of needing an emergency Caesarean during a vaginal birth following a previous Caesarean is slightly higher than that of women who are labouring for the first time. Women labouring for the first time have a one in five (20%) chance of requiring an emergency Caesarean.

Scar weakening or rupture:

• There is a chance that the scar on your uterus from your previous Caesarean will weaken and open (rupture). This is not common, but the risk increases in subsequent vaginal births to approximately 0.5% (five in 1000 births). This risk increases by two to three times if your labour is induced.

• The observations and monitoring that are offered as part of your care during labour aim to identify this problem, in the unlikely event that it happens. You are advised to call the hospital as soon as you think you’re in labour, so you can be closely monitored.

• The scar rupturing is not common but it can have serious consequences. On rare occasions, it can cause life threatening bleeding and it may be necessary to remove the womb (hysterectomy) to stop the bleeding.

Risks to your baby:

• The risk of your baby having brain damage or dying as a result of having a vaginal birth after a Caesarean is very small. The risk of a baby’s death is one in 1,000 or 0.1% – the same as if you were labouring for the first time. It is slightly higher than if you have an elective repeat Caesarean (one in 10,000 or 0.01%). However, this has to be balanced against the risks to you if you have a Caesarean delivery.

What are the advantages of an elective Caesarean Section?

• This will be a planned procedure, with a set date for delivery – so you know exactly when your baby will arrive. However, there is a chance you could go into natural labour before this date. This happens to one in 10 women (10%).

• There is virtually no risk of uterine rupture

• It avoids the risks of labour and particularly reduces the risk of your baby suffering brain damage or being stillborn due to lack of oxygen during labour (1 in 10,000 or 0.01%)

What are the disadvantages of an elective Caesarean Section?

• It will be a longer and more difficult operation than the first time, due to scar tissue forming. This can make the surgery more difficult and increase the risk of damage to the bladder and bowel.

• There’s a higher risk of a blood clot forming (thrombosis) in your leg or lungs. A blood clot occurring in the lungs (pulmonary embolus) cane be life threatening. Death occurs in less than one in 1,000 Caesarean deliveries.

• Your recovery time will be longer than if you’d had a vaginal delivery. You’ll be admitted to hospital for one or more days; unable to drive for six weeks, and you will need to avoid heavy lifting. You will also need extra help when you return home.

• You may develop a wound infection that can take several weeks to heal.

• There’s an increased likelihood your baby will need to be admitted to the Neonatal Unit. Breathing problems for baby’s are quite common after Caesarean sections but don’t usually last long. Between four and five in 100 babies born by planned Caesarean at or after 39 weeks, have breathing problems, compared to two to three in 100 following a vaginal birth after a previous Caesarean. There is a higher risk if you have a planned Caesarean earlier than 39 weeks (six in 100 babies at 38 weeks).

• Your baby’s skin may be accidentally cut during the operation. This happens in two out of every 100 babies, but usually heals without any further harm.

• If you become pregnant again, you will likely need to have another Caesarean section, as we do not routinely recommend a vaginal birth in women who have had two or more previous Caesareans. More scar tissue develops with each Caesarean delivery, which increases the possibility of the placenta growing into the scar, making it difficult to remove (placenta accreta or percreta) This can result in life threatening bleeding and may require a hysterectomy. All serious risks increase with every Caesarean delivery you have.

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

If you don’t go into natural labour by 40 weeks, we will discuss your options with you. These may include:

• Continue to wait for labour

• Induction of labour – though the chance of a scar problem developing in labour is higher if labour is induced

• Caesarean section

Can I have a home delivery?

The recommendation is that all women who have had a previous Caesarean section should give birth in hospital, where we have the necessary facilities if an emergency occurs. Please discuss your individual case with your midwife/ obstetrician.

Summary

• If you are fit and healthy, both vaginal births and elective Caesareans are safe choices, with very small risks

• Three out of four women who have one Caesarean and then have a straightforward pregnancy, going into labour naturally, give birth vaginally

• Giving birth vaginally carries small risks for you and your baby but, if you have a vaginal birth, future labours will be less complicated, with fewer risks for you and your baby

• Having a Caesarean makes future births more complicated

• Most women who have a planned Caesarean recover well and have healthy babies. However, it takes longer to get back to normal after your baby is born