Birth After Caesarean

 Birth After Caesarean

This information is for you if you have had one previous uncomplicated caesarean birth. It may also be helpful if you are a partner, relative or friend of someone who is considering their birth options after a previous caesarean. Our role as maternity health professionals is to ensure that women have choice and control over their care which is planned and received based on ‘what matters’ to you to include your individual needs and preferences. If you have had a previous uncomplicated caesarean birth, we will book you in our birth options clinic to discuss your options.

Why do some women consider trying for a vaginal birth?
Many women take into consideration the following in relation to vaginal birth:

• You may want to avoid having surgery where possible.
• You want to recover quicker following the birth, particularly if you have other children to care for.
• You are concerned about the restriction in driving in the first few weeks, particularly if you have other children to care for.
• You have had a vaginal birth prior to or since your caesarean and preferred this over your caesarean birth.
• You want to avoid where possible some of the increased risks that are present with a caesarean birth.

Why do some women consider a repeat caesarean birth?
Women consider a repeat caesarean birth for many reasons. Your thoughts and feelings about giving birth will be influenced by the culture you grew up in, your previous birth(s) and experiences, and the experiences of the people around you.

• You may have had a difficult birth(s) in the past.
• You may have concerns about damage to your pelvic floor during a vaginal birth.
• You may think that a planned caesarean birth is safer for your baby.

• You may have anxieties about having a vaginal birth for the first time, including about
  how you might react to vaginal examinations and labour pain.
• You may want to avoid the chance of needing an emergency caesarean or an assisted
  vaginal birth.
• You may want to avoid having an induction of labour.
• You may feel that a planned caesarean birth gives you a better sense of control.
• You may have had a previous traumatic experience or sexual abuse.
• You may be concerned as many of your family members have required emergency caesarean births.
• You have considered the benefits and risks and have decided you would prefer a caesarean birth.

We may offer you support from specialists with experience supporting women with anxieties and
other mental health issues in pregnancy. If you had a difficult birth previously, discussing your birth
with us to help you understand what happened may help. Many complications that happen
during one birth do not, or are unlikely to, happen again.

Discussing your options for pain relief might be helpful. Safe and effective options for pain relief including epidural analgesia are available. For more information about pain relief during labour see
the Labour Pains website. https://www.labourpains.org/   You may wish to talk about your options with an anaesthetist.

If you are anxious about the need for vaginal examination or about any other aspect of birth, your healthcare professional may offer ways of caring for you in labour that may be more acceptable to
you and offer referral to a specialist to explore the underlying reasons for your anxiety. There are
tools available to help you feel more in control when you are in stressful situations (during birth and beyond). There is a chance that vaginal examinations may be needed even after a caesarean birth
(for example if you have heavy bleeding afterwards).

If you are concerned about the timing of labour and its unpredictability (for example, if your planned birth partner is going to be away for work or if you need childcare for an older child), you can ask to have your labour started in a controlled way. This process is called an ‘induction of labour’. If you would like to discuss this option alongside the option of a planned caesarean birth, then please let us know.

What are the outcomes of having a planned caesarean birth compared to a vaginal birth after caesarean (VBAC)?
The figures quoted in this information are based on the best available research, which is limited. When considering the benefits and risks of your different options, it is important to bear in mind that we have to rely on studies of variable quality, including some that compare planned caesarean births for all reasons (including caesarean births for women who have medical factors) with vaginal births, or emergency caesarean births with vaginal births. For some women who plan a vaginal birth, an assisted birth with forceps or ventouse (suction cap) or an emergency caesarean may be recommended in labour. This information will be discussed further with you at your birth options appointment. The estimates of risk for poor maternal or fetal events in vaginal birth after caesarean are based on women receiving continuous electronic monitoring during their labour.

What are the chances that I will have a successful VBAC?

What anaesthetic will I have during a planned caesarean birth?
A spinal anaesthetic is the most common way of ensuring your comfort for a planned caesarean birth. However, in uncommon individual circumstances, a caesarean can also be performed using an epidural, combined spinal and epidural or with you asleep under a general anaesthetic. If any of these alternative techniques are being planned for you it will always be explained and discussed with you in advance before your caesarean.

A local anaesthetic drug is injected through a needle between the bones of your back into the fluid that surrounds the spinal cord. The anaesthetic acts to numb the nerves that supply sensation to your body from the level of your chest down to your feet. It will make you numb for at least 2-3 hours. Furthermore, painkillers added to the injection that will provide additional pain relief for several hours beyond this.

If I choose to give birth by caesarean, when will it be done?
You will usually be offered a date at or soon after 39 weeks of pregnancy. Babies born by caesarean earlier than this are more likely to need admission to the neonatal unit for help with their breathing (1 in 24 babies at 38 weeks compared to 1 in 56 babies after 39 weeks). Even a short stay in the neonatal unit can be very stressful for new parents, and rarely babies can be affected in the longer term as well. This is why we recommend planning for your caesarean to take place after 39 weeks, unless there are other reasons why your baby may need to be born earlier.

Your caesarean is a planned operation and there may be one or two planned for that day. In exceptional circumstances we may need to move your caesarean date prior to the day or may need to delay it on the day due to emergencies from the labour ward arising which do take priority. We will inform you of any changes and may be able to offer you a drink or snack while you are waiting. You can continue to drink 250ml per hour of clear fluid up until you go to theatre.

What happens if I go into labour before my caesarean date?
There is a chance that you may go into labour before the date of your planned caesarean (approximately 1 in 10 women). It is important to discuss your preferences should this happen. Complication rates for caesarean birth are higher when they are performed during labour (about 1 in 4 women experience complications) compared with during a planned procedure (about 1 in 6 women experience complications). Complication rates are higher when a woman is in the active stage of labour where contractions are regular and the cervix is dilated (1 in 3 women may have complications) compared with when she is in early labour and the cervix has not dilated much (1 in
6 women may have complications). If you do go into labour before the date of your planned caesarean you will be offered a choice of continuing with labour or of having a caesarean birth as planned.

In the event that you arrive in advanced labour (e.g. end of first stage of labour or in second stage of labour) the doctor may advise that a vaginal birth is safer than an emergency caesarean. An emergency caesarean at the end of labour can result in difficulty in delivering the baby due to the baby’s head being lodged deeply in the pelvis, particularly in babies over 37 weeks gestation. This can result in complications for yourself including tears in your womb and serious bleeding. For your baby, the complications can include damage to their head and face, lack of oxygen to the brain, nerve damage and in rare cases death. Having a caesarean when you are fully dilated also carries an increased risk of preterm birth in any future pregnancies. We would advise you to call maternity straight away if you have any signs of labour prior to your booked caesarean birth including
waters breaking or any contractions.

What happens if I am planning a VBAC and an induction of labour is recommended?
Most women who have had one previous caesarean can be induced if it is recommended. This should be discussed with you by one of the pregnancy doctors.

All women whose pregnancy continues after their due date are offered an induction of labour from 41 weeks. Having an induction from 41 weeks may reduce the risk of an emergency caesarean being needed in labour and may also reduce the risk of both stillbirth and admission to the neonatal unit. For women who have had a previous caesarean birth, the risk of stillbirth increases from 39 weeks rather than from 41 weeks. This risk of stillbirth increases from 1 per 2000 women to 2 per 2000 women if your pregnancy continues after 39 weeks.

If you wish to have a vaginal birth but do not wish to await labour after 39 weeks then please discuss this with the birth options clinic who can arrange for a review in our antenatal clinic with one of our doctors in order to discuss induction of labour. If you wish to wait to see if labour starts naturally after 39 weeks then your community midwife will discuss referring you for a review with a doctor in your 40^th week of pregnancy.

You need to be aware that:

• If your labour is induced when you have had a previous caesarean, then your risk of uterine rupture goes up from 1 in 200 / 0.5%, to 2-3 in 200 / 1 to 1.5%
• You are also 1.5 times more likely to need a caesarean if you are induced compared to if you go into labour spontaneously
• If induction is offered then you still have the choice to try to have a vaginal birth, or you can request a planned caesarean
  
  

What does my intuition tell me?
Midwives and doctors have a professional duty to recommend evidenced based care; to treat women as individuals and work in collaboration with you. Our role includes listening to your individual preferences, to have an informed discussion regarding your birth options, and to agree a plan of care needs based on your own personal wishes, bearing in mind a risk assessment of your medical, social, psychological and obstetric needs. It is important to consider the benefits and risks carefully. People view risk differently and how you view risk depends to a large extent on your own preferences and experience.

We will not usually recommend a caesarean birth unless there are specific issues complicating your pregnancy. However, there are many factors that can influence how you feel about the way you give birth. The risks of caesarean and vaginal births will also depend on your individual circumstances. Your personal feelings, concerns, interpretation of risks and opinions are all important and will be respected when you speak with us about your birth plan.

What are the next steps if I wish to book a planned caesarean birth?
If you already have an appointment in the antenatal clinic with a doctor then they will discuss your consent for the caesarean and book this in for you following your appointment with the birth options clinic.

If you have been seeing a midwife throughout your pregnancy then the birth options clinic will refer you for a review with the doctor who can discuss your consent and book your caesarean.

This leaflet is to give you general information about your birth options, most of your questions should be answered by this leaflet. It is not intended to replace the discussion between you and your midwife or doctor but may act as a starting point for discussion. If after reading it you have any concerns or require further information, please discuss this with a midwife or doctor.
If you wish to read further information about the caesarean procedure itself then please search for the Planned Caesarean Birth leaflet in the library on your Badger app or ask your community midwife for a copy.