Birth after Section

A GUIDE FOR PATIENTS

What are my choices for Birth After a Caesarean Delivery?
Whether you choose to have a vaginal birth or a Caesarean delivery in a future pregnancy, either choice is safe with different risks and benefits. Overall, both are safe choices with only very small risks. In considering your choices, your obstetrician will ask you about your medical history and about your previous pregnancies.

They will want to know about:

• the reason you had the caesarean delivery 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 straightforward or is there any problems or complications?

You and your obstetrician or midwife will consider your chance of a successful vaginal birth, your personal wishes and your future fertility plans when making a decision about vaginal birth or caesarean delivery.

What is Vaginal Birth after Caesarean VBAC?
(VBAC) is the term used when a woman gives birth vaginally, having had a caesarean delivery in the past.
What is an Elective Repeat Caesarean Delivery?
An elective caesarean means a planned caesarean. The date is usually planned in advance at your hospital antenatal visit.

When is VBAC likely to be Successful?
Overall, about three out of four women (75%) with a straightforward pregnancy who go into labour give birth vaginally following one Caesarean delivery. If you have had a vaginal birth, either before or after your Caesarean delivery, about nine out of ten women (90%) have a vaginal birth. Most women with two previous Caesarean deliveries will have their next baby by caesarean delivery.

However, should you go into labour your chance of a successful vaginal birth is slightly less than this (between 70% and 75%).

What are my Chances of a Successful VBAC?
A number of factors (risk factors) make the chance of a successful vaginal birth less likely.

These are when you:
• have never had a vaginal birth
• need to be induced
• did not make progress in labour and needed a caesarean delivery (usually owing to the position of the baby)
• are overweight – a body mass index (BMI) over 30 at booking.

What are the Disadvantages of VBAC?
• Emergency Caesarean delivery
There is a chance you will need to have an emergency Caesarean delivery during your labour. This happens in 25 out of 100 women (25%). This is only slightly higher than if you were labouring for the first time, when the chance of an emergency Caesarean delivery is 20 in 100 women (20%).

The usual reasons for an emergency Caesarean delivery are labour slowing or if there is a concern for the wellbeing of the baby.

• Blood transfusion and infection in the uterus
Women choosing VBAC have a one in 100 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 only in two to eight women in 1000 (about 0.5%). Being induced increases the chance of this happening. If there are signs of these complications, your baby will be delivered by emergency caesarean delivery.

• Risks to your baby
The risk to your baby is no higher than if you were labouring for the first time.
These disadvantages are more likely in women who attempt VBAC and are unsuccessful.

When is VBAC Not Advisable?
There are very few occasions when VBAC is not advisable.

These are when:-
• you have had three or more previous caesarean deliveries
• the uterus has ruptured during a previous labour
• you have a high uterine incision (classical Caesarean)
• you have other pregnancy complications that require a caesarean delivery.

What are the Advantages of Elective Repeat Caesarean Delivery?
• virtually no risk of uterine scar rupture
• knowledge of the date of delivery.

What are the Disadvantages of Elective Repeat Caesarean Delivery?
• A longer and possibly more difficult operation
A repeat Caesarean delivery 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.There are rare reports of accidental cutting of the baby at caesarean delivery.

• Chance of a blood clot (thrombosis)
A blood clot that occurs in the lung is called a pulmonary embolus. A pulmonary embolus can be life threatening (death occurs in less than one in 1000 Caesarean deliveries). There is an increased likely hood of a hysterectomy with every repeat Caesarean section preformed.

• There is a longer recovery period

You may need extra help at home and will be unable to drive for about six weeks after delivery (check with your motor insurance company).

• Breathing problems for your baby
Breathing problems are quite common after Caesarean delivery and usually do not last long. Occasionally, the baby will need to go to the Special Care Baby Unit. Between three to four in 100 babies (3–4%) born by planned Caesarean delivery have breathing problems compared with two to three in 100 (2–3%) following VBAC. Waiting until seven days before the due date minimises this problem.

• A need for elective Caesarean delivery in future pregnancies
More scar tissue occurs with each Caesarean delivery. This increases the possibility of the placenta growing into the scar making it difficult to remove at Caesarean (placenta accreta or percreta). This can result in bleeding and may require a hysterectomy. All serious risks increase with every Caesarean delivery
you have.

• Increased Risk of Peripartum Hysterectomy

The rate of peripartum hysterectomy with first vaginal delivery is 1 in 30,000, following first Caesarean section the rate of risk increases to 1 in 7,000. For subsequent deliveries following 2 previous Caesarean sections the rate of risk increases to 1 in 220.

How can I Prepare for a VBAC
• You can best prepare for a VBAC by firstly keeping an open mind on a BACS being a positive option in this pregnancy.

• Have a discussion with you obstetrician and midwife to get the facts and how they relate to you.

• Arrange a meeting with a VBAC clinic midwife to have additional antenatal preparation.

What happens if I Do Not Go into Labour when Planning a VBAC?
If labour does not start by 41 weeks, your obstetrician will discuss different options with you. These are:
• continue to wait for labour
• induction of labour. This increases the risk of scar weakening and lowers the
chance of a successful VBAC
• repeat elective caesarean section. Some women choose to aim for VBAC if they labour spontaneously but opt for a repeat elective Caesarean delivery rather than induction of labour.
What Happens if I have an Elective Caesarean Planned and I Go into Labour?

Telephone the hospital to let them know what is happening. It is likely that an emergency Caesarean will be performed once labour is confirmed. If labour is very advanced, or if the labour is early (before 37 weeks), then VBAC may be more suitable. Your obstetrician will discuss this with you. Remember that going into labour spontaneously is normal and has advantages for your baby.