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Birth options after a previous caesarean section

This information is provided for those women who have had a previous caesarean section, and who are now considering the options for birthing their next baby.

What are my options?

There are two options, both with benefits and risks:

  1. Plan a vaginal birth after caesarean section (VBAC). The best available evidence suggests that VBAC is a safe choice for the majority of women who have had a previous caesarean section.
  2. Plan an elective repeat caesarean section (ERCS). For some women, a repeat caesarean birth will be recommended for either medical or obstetric reasons relating to the health and wellbeing of you or your baby.

You are encouraged to meet with an obstetrician and midwife, early in your pregnancy, to discuss your birth options so that you may make an informed choice.

How successful is a VBAC likely to be for me?

At Mater, more than half of the women who plan for a VBAC will have a vaginal birth. The success rate varies depending on several factors, as outlined below:

Increased success (about double)

  • Previous vaginal birth
  • Your labour starts on its own i.e. you are not induced
  • Your last caesarean section was performed for a reason other than obstructed labour, e.g. breech presentation or placenta praevia

Reduced success (about half)

  • Your last caesarean section was due to obstructed labour
  • Your baby is estimated to weigh more than four kilograms
  • Your body mass index (BMI) is greater than 30
  • Your baby is overdue by more than seven days
  • You are over the age of 38

What are the risks and benefits of each option?

Both VBAC and ERCS have risks and benefits, which may depend on your individual circumstances. Some of the risks are short-term such as infection and bleeding while others are longer-term, including problems in future pregnancies. You are encouraged to consider all of the risks that differ between vaginal birth and a cesarean section before deciding on the best option for you, and your baby.

Vaginal birth after caesarean section

The benefits of VBAC

  • Faster recovery from birth and shorter hospital stay
  • Earlier return to normal activities such as lifting and driving
  • Earlier mobilisation helps to reduce the likelihood of a blood clot in the legs or the lungs. This is especially important in the days and weeks following birth because this is when women are at the greatest risk for blood clots
  • For those considering larger families, VBAC may avoid some of the risks associated with multiple caesarean sections (such as hysterectomy, bowel or bladder injury, transfusion)

The risks of VBAC

The most serious but rare risk of women attempting a VBAC is uterine rupture. A uterine rupture is a tear or hole in the uterus. There is an increased risk of uterine rupture with VBAC compared to ERCS. The rates of uterine rupture are approximately one in every 200 women who labour and have previously had a caesarean section, and one in every 5000 women who choose ERCS.

A uterine rupture can be very small or large. In most circumstances this is quickly identified and we are able to make plans for the safe delivery of your baby. While very rare, uterine rupture can be associated with significant bleeding for you (including the potential need for a blood transfusion or even hysterectomy (removal of the uterus)), and the need for urgent delivery of your baby who can be deprived of oxygen. The evidence tells us that in most cases, when an emergency caesarean section is performed, no serious harm comes to the mother or baby.

In some situations the risk of rupture is increased. Factors associated with an increased risk of uterine rupture include the following:

  • short interval of less than two years between births
  • complicated surgical incisions on the uterus at your last caesarean section e.g. 'classical', 'J' or 'T' incisions
  • induction of labour
  • two previous caesarean sections
  • previous caesarean section was performed before 36 weeks gestation
  • previous caesarean section was complicated by a serious wound infection
  • previous surgery on the uterus e.g. to remove fibroids.

Elective repeat caesarean section

The benefits of ERCS:

  • A planned caesarean offers some advantages over an emergency caesarean as it is less likely to involve injury to other organs during surgery, to lead to infection, or to cause emotional distress.
  • Greater certainty as to the date of birth of your child; however, more than one in 10 women labour before their planned caesarean section date.

The risks of ERCS:

  • Maternal surgical and anaesthetic complications, such as bleeding, infection, adhesions, or bladder and bowel trauma.
  • Short-term breathing difficulties for your baby which require observation in the Neonatal Critical Care Unit (three to four babies per 100 ERCs1).
  • Future pregnancy complications.The number of children you are planning is an important consideration because the chance of placenta accreta occurring increases with each caesarean section. Placenta accreta is a condition where the placenta embeds itself deep into the uterus. Following birth it does not separate easily and is associated with heavy bleeding at the time of birth, blood transfusions and a hysterectomy. The risk of this occurring is one in every 1000 women for your second caesarean, increasing to one in 20 by your sixth caesarean.

Special situations

What if I need an induction of labour and I am planning a VBAC?

Labours that are induced by artificial rupture of membranes (ARM) or by a catheter to help open the cervix are less likely to be associated with an increased risk of uterine rupture.

When labour is induced with a syntocinon infusion (drip), the risk of uterine rupture is increased by two to three times. When labour is induced, unfortunately the chances of having a vaginal birth are reduced. The decision to induce labour would only be made after a balanced discussion of the risks and benefits between you and an obstetrician and midwife.

I have had two previous caesarean sections

Most women with one or two previous caesarean births, with no additional risk factors, are candidates for planned vaginal birth after caesarean section (VBAC).

I am pregnant with twins or triplets

There are limited studies available to answer this question; multiple pregnancy is not a contraindication to VBAC. Your will have an opportunity to discuss your individual suitability for VBAC with an obstetrician throughout your pregnancy.

What will my care comprise when having a VBAC labour?

The recommendations include:

  • coming to hospital early in labour
  • having an intravenous cannula (drip) inserted and a sample of blood taken
  • continuous monitoring of your baby’s heart rate
  • regular internal examinations of the cervix to check your progress
  • having access to pain relief (including epidural) as required.

When should I decide?

You should decide when you feel that you have had a chance to consider all the information and you have discussed it with your partner or support person. For planning purposes, it is useful to have made your decision by your 34-36 week appointment.

Summary

The decision between having a VBAC or an ERCS can be a difficult one. At Mater Mothers' Hospitals, all women who have had a previous caesarean section will be given detailed information during pregnancy about the benefits and risks of planned VBAC versus ERCS. You are encouraged to ask questions to ensure you understand your options and are able to make an informed choice about the option that is best for you.

References

  1. Mater Health Services Vaginal Birth after Caesarean Section Policy No: MHS-WCH-W-069.
  2. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists C-Obs 38 Planned Vaginal Birth after Caesarean Section (Trial of Labour) 2012
  3. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists C-Obs 33 Collaborative Maternity Care 2010.
  4. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists C-Obs 1 Obstetricians and Childbirth: Responsibilities 2010.
  5. Horey D, Kealy M, Davey MA, Small R, Crowther CA. Interventions for supporting pregnant women's decision-making about mode of birth after a caesarean. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD010041. DOI: 10.1002/14651858.CD010041.pub2.
  6. Dodd JM, Crowther CA, Huertas E, Guise JM, Horey D. Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD004224. DOI: 10.1002/14651858.CD004224.pub2.
  7. Guise JM, Eden K, Emeis C, et al. Vaginal birth after cesarean: New insights. Evid Rep Technol Assess (Full Rep). 2010;(191)(191):1-397.

Further information

  1. Queensland Maternity and Neonatal Clinical Guidelines Program. Vaginal Birth after Caesarean Section (VBAC). Parent information sheet. Version 3.4. Queensland Centre for Mothers and Babies. Brisbane. 2011.
  2. Choosing how to birth your baby: A decision aid for women with a previous caesarean section. Queensland Centre for Mothers and Babies. Brisbane. 2011.
Mater acknowledges consumer consultation in the development of this patient information.
Last modified 28/10/2015.
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