Approximately 28% of babies are born by caesarean each year in the UK, so this is a subject many women are likely to need to consider. Not too long ago Doctors used to say ‘once a caesarean, always a caesarean’. Fortunately this has changed and national guidance (from NICE) fully supports women choosing their preferred mode of delivery after a caesarean. Of course there are benefits and risks associated with each choice you may make, but the evidence used to inform the NICE guideline suggests there is little difference in the outcome for the baby with whatever choice you make.
So what are the choices then? You can either choose to have a vaginal birth, known as a vaginal birth after caesarean or VBAC, or you can choose to have an elective (planned) caesarean section. Let’s look at the choices in a bit more detail.
If you have no preference, and there are no other concerns in your current pregnancy, then generally you will [should be?] be encouraged to have a VBAC. This is because the hospital stay is shorter and generally the recovery is likely to be quicker and easier (which is even more of a concern now that you will have two little people to take care of!).
Approximately 75% of women succeed in having a VBAC and this is even higher if you have had a vaginal birth before, as well as a caesarean. However, naturally this means that approximately 25 % of women will require an unplanned repeat caesarean during labour, for a variety of reasons, which understandably many women find more than a little discouraging.
The other rare but serious consideration with planning a VBAC is the risk of the scar [tissue from the previous operation] breaking down, which affects approximately 1 in 200 VBAC women. Fortunately, if this is detected early then it can be dealt with by performing another emergency caesarean. There are often tell-tale signs that this is occurring such as pain being present between contractions or feeling like the contraction is there all the time and usually the baby’s heartbeat has “drops” due to distress caused by lack of blood flow, but this is not always the case.
This is where it gets a bit tricky. There are two methods for monitoring the baby’s heart during labour. Either intermittent monitoring, which is using a sonic aid (the one that the midwife uses at your antenatal appointments) or continuous monitoring also known as a cardiotocograph (CTG for short). The continuous method monitors the baby’s heart rate more closely and therefore it is assumed that it would pick up a scar breaking down quicker than the intermittent method. However, there isn’t actually any evidence to demonstrate this is the case which leaves us in a bit of a dilemma, as we already know that for women with uncomplicated pregnancies (i.e. no scar on their uterus), using continuous monitoring increases the rate of caesarean and instrumental birth (forceps and ventouse) without any improvement in the outcome for the baby, (i.e. these interventions weren’t actually necessary). As a midwife it’s easy to recognise how this happens, your mobility can be very restricted by continuous monitoring – not just because the wires get in the way and can prevent you from getting in the pool, but also because it is hard to get a good signal for the baby’s heartrate in the upright and forward leaning postures that women instinctively adopt during the course of labour. There has been great debate recently on this subject. In March this year NICE published new guidance on labour care for women with medical or obstetric conditions and this includes a section on women choosing VBAC. It recommended that continuous monitoring is only indicated if the woman also has the hormone drip, but this sparked controversy and following objection from the Royal College of Obstetricians and Gynaecologists (RCOG) this was withdrawn and a call put out for research to be carried out. However, it still very clearly stipulates that women should be offered all options of analgesia including labour and birth in water (this is in spite of the fact that not all hospital units currently offer access to CTG in water). In summary, the evidence is ambiguous and based on certain assumptions, if you feel that having continuous monitoring stands in the way of you having the birth you would like then consider choosing intermittent monitoring instead. If however, you would feel safer following the recommendation from NICE and the RCOG then feel free to accept continuous monitoring. The important thing is that you are given accurate information about both options to make an informed decision of what is right for you and your individual circumstances and preferences.
What about if I have had more than one caesarean?
The evidence suggests that either mode of birth is equally safe in women who have had up to four caesareans and therefore the NICE recommendation applies to women who have had up to 3 caesareans already.
What if I need an induction?
If an induction of labour is indicated for any reason, the obstetric team will have a discussion around the risks of VBAC induction as they are higher than for both induction in non VBAC women and VBAC women in spontaneous labour. This increased risk of the scar [tissue] breaking down is associated with the use of hormones, which is the most common method of induction. It may be that you choose to have what’s called a ‘balloon induction’ because this uses a balloon rather than hormones to encourage the cervix to start to open. You may decide that neither of these are what you want and you choose to have an unscheduled caesarean at this point, which is fine too. If you feel very strongly about not wanting induction of labour due to your previous experience it is worth raising this in the initial discussion with your obstetric team. This way you have more time to make think about your options and make a decision that feels right, without the sense of urgency you might feel discussing it for the first time when the situation first presents itself.
If you would prefer you can choose to have a repeat caesarean. This will be booked for when you are 39 weeks as earlier than this can cause difficulties with a baby’s breathing. The risks associated with having a repeat caesarean are that generally it can be trickier to perform, as there is already scar tissue present from the first caesarean. Also the risk of performing a caesarean per se (irrespective of whether it is the first or subsequent) puts mums at an increased risk of heavy bleeding, infection and damage to nearby organs in comparison to vaginal birth, as well as having a slower recovery time. Performing a caesarean for a lady who has had previous caesareans increases in difficulty with each caesarean, therefore it is worth considering at this point that if you plan to have a large family, it is probably safer to opt for a VBAC.
What if I go into labour before my planned caesarean?
This happens from time to time with all women who are planning a caesarean. Normally you are invited to the labour ward to assess how established labour is. At this point you will be given the choice of whether to go ahead with labour and have an ‘unplanned VBAC’. Or, whether you would like to go ahead with the caesarean albeit an unplanned one as it would need doing urgently.
So as you can see there are many elements requiring consideration in order for you to make the choice that is right for you, but remember exactly that – doctors and midwives can give you information to aid your decision making, but the choice ultimately is yours and yours alone. Hopefully this post will help you to make a positive one!