Around 1 in 4 of all births in the UK are by C section. You might have had a planned C section in your first pregnancy, or were taken by complete surprise and had an abdominal operation that you never planned on having. You may have had an easy, uncomplicated recovery or you may have struggled in ways you barely coped. Once your body has been through a C section it may be confusing and scary trying to decide how best to approach the birth of your next baby.
Here is the guidance from RCOG:
The options are:
1. A VBAC = vaginal birth after c section
2.Elective/ planned repeat C section after 39 weeks
Success rates:
– 75% of women successfully have a vaginal birth after CS
– Success is more likely if:
✔️You have previously had a vaginal birth
✔️Labour begins spontaneously, ie without induction
What is uterine rupture?
Traditionally, the reason all women who had a C section were advised to continue having C sections for future birth was because of the risk of uterine rupture. We now know that although this is a risk, there are a lot of benefits to having a successful vaginal birth so most doctors consider it beneficial to discuss the option of both. It is important to understand what rupture is.
After you had a C section you were left with a scar on your uterus as well as your skin. During pregnancy, and particularly during contractions, the scar on your uterus can be put under pressure and if this pressure becomes too high the scar can begin to open, whilst the scar on your skin remains closed. In the worst case scenario, this can mean the baby is born into your abdomen although this situation is extremely rare.
The signs that rupture may be happening:
- Severe abdominal pain which doesnt go away between contractions
- Hardening of your abdomen
- Vaginal bleeding
- Blood-stained urine
- Signs of distress on fetal heart rate monitoring
If there is any suspicious of uterine rupture, the treatment would be immediate C section to deliver the baby.
VBAC
Advantages:
– quick recovery
– less operation risks
– shorter hospital stay- Improved outcomes for future pregnancies with reduced risk of placenta praaevia and less complications of repeated operations
Risks:
– Mainly it is unpredictable because 25% of women will still need a C-section in labour, and others may require an instrumental delivery.
– 1 in 200 have uterine rupture where their scar opens during labour which can be risky to the baby
– with any vaginal birth there is the risk of perineal tears which may be severe involving the anal sphincter (3rd or 4th degree tears)
Elective (planned) C-section
Advantages:
– lower risk of scar rupture, especially if the C section is done before labour begins
– It is very convenient because you can be given a fixed date for the birth of your baby, allowing you to plan ahead. There is less ‘unknown’ as you can prepare for being in hospital for a few days.
Risks:
– The main complications are bleeding, infection and damage to surrounding organs such as your bladder or bowels
– You are likely to spend longer in hospital
– Longer recovery, where you are advised not to lift heavy objects or drive for 6 weeks.
– You will usually be advised to have a C section in the future, because once you have had more than 2 C sections, the risk of uterine rupture increases further so C section is advisable.
– Risks of chronic pain from adhesions and higher risks of any future abdominal surgery
Making your decision
This is not something you need to decide on your own. If you have had a C section in then past, you will usually have an appointment with a specialist midwife or doctor at 28 weeks. It can be really useful to bring any notes from your previous delivery if you have them. By discussing your previous birth it can help the team to guide you on the likely success if you were to try for vaginal birth. Some types of C section, where a vertical incision is made on the uterus, would mean you are not suitable for VBAC so it is really useful to advise the team of this. Together you can make a decision about the best plan.
Your options are:
– Aim for vaginal birth in any situation
– Plan a C section, which will usually be advised at 39 weeks if you wish to avoid the risk of spontaneous labour and VBAC.
What happens if you go into labour?
– regardless of how you plan to deliver, head to hospital as soon as it starts or your waters break
– if your plan was elective c section and labour starts you can still ask for a c section at any time
What happens if you dont go into labour?
If you wish to aim for VBAC but dont go into spontaneous labour, you can discuss whether or not you could consider an induction of labour. This would be required if you really want to have a VBAC, but carries higher risks of rupture. If you had an induction in your previous pregnancy that didnt work you may prefer to have a C section if you reach 41 weeks and didnt go into spontaneous labour.
There is quite a wide variation in the practice of induction of labour for women who have had a C section, so it is really important to discuss all outcomes with your own medical team.
It’s a minefield to make this decision, but your obstetric team can help you out. It is your decision so ask for as much information and time as you need.
Remember you have the right to change your mind at any time!