Birth options after previous caesarean birth

At least 1 in 3 women in the UK currently give birth by caesarean. About half of these are as a planned operation and the other half are unplanned or emergency caesareans. Many women have more than one caesarean birth. A caesarean birth requires an anaesthetic, either regional or general. More information about anaesthesia for caesarean birth can be found on the Labour Pains website (external link).

If you have had a caesarean birth, you may be thinking about how to give birth next time. Planning for a vaginal birth after caesarean (VBAC) or choosing a repeat caesarean birth have different benefits and risks.

In considering your options, think about your previous pregnancies and medical history, including:

• The reason you had your caesarean.
• Whether you have had a previous vaginal birth.
• Whether there were any complications at the time or during your recovery.
• The type of cut that was made to your uterus (womb).
• How you felt about your previous birth.
• Whether your current pregnancy has been straightforward or whether there have been any problems or complications.
• How many more babies you are hoping to have in future. The risks increase with each caesarean birth, so if you plan to have more babies it may be better to try to avoid another caesarean birth if possible.

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 experience and preferences. You can find out more about risk from the RCOG patient information Understanding how risk is discussed in healthcare.

To help you decide, your healthcare professionals will discuss your birth options with you at your antenatal visits, starting early in your pregnancy, and again as your pregnancy progresses.

If you are considering a vaginal birth but have had more than one caesarean birth, you will be advised about the potential benefits and risks of birth options in your individual situation.

VBAC stands for ‘vaginal birth after caesarean’. It is the term used when a woman gives birth vaginally, having had a caesarean birth in the past. Vaginal birth also includes birth assisted by forceps or ventouse (vacuum cup).

ERCB stands for ‘elective (planned) repeat caesarean birth’. You will usually have the operation after 39 completed weeks of pregnancy. This is because babies born by caesarean birth earlier than 39 completed weeks are more likely to need to be admitted to the neonatal unit for help with their breathing.

Having a vaginal birth tends to have fewer complications than a caesarean birth. If you have an uncomplicated vaginal birth:

• You will have a greater chance of a vaginal birth in future pregnancies.
• Your recovery is likely to be quicker. You should be able to get back to everyday activities more quickly and you should be able to drive sooner.
• You are likely to have a shorter stay in hospital after your baby is born. Women having straightforward vaginal births can often be discharged the same day. Women having straightforward caesarean births are usually discharged after an overnight stay (24–36 hours).
• You will avoid the risks of an operation.
• While the risk of any woman dying during or soon after birth is very low, a planned vaginal birth carries a lower risk than a planned caesarean birth (four compared to 25 in 100 000 women).

Three out of four women who have had one caesarean birth and their labour starts naturally will go on to give birth vaginally.

You are more likely to have a vaginal birth, if:

• You have had a previous vaginal birth, either before or after your caesarean birth (about 8–9 out of 10 women can have another vaginal birth).
• Your labour starts naturally (without medical intervention or induction).
• Your body mass index (BMI) is less than 30 at your first antenatal check.

• You may need to have an emergency caesarean birth during labour. This happens in around 1 out of 4 women. This is only slightly higher than if you were giving birth for the first time, when the chance of an emergency caesarean is around 1 in 5 women. An emergency caesarean birth carries more risks than a planned caesarean birth. The most common reasons for an emergency caesarean birth are if your labour slows or if there is a concern for the wellbeing of you or your baby.
• You have a slightly higher chance of being recommended to have a blood transfusion compared with women who choose a planned second caesarean birth (around 4 women receiving a transfusion for every 1000 women during VBAC compared to 3 in 1000 women having ERCB).
• You may need an assisted vaginal birth using ventouse or forceps. See the RCOG patient information Assisted vaginal birth (ventouse or forceps).
• You may experience a tear involving the vagina, perineum or the anal sphincter, the muscle that controls the anus or rectum (a third- or fourth-degree tear).
• See the RCOG hub for Perineal tears and episiotomies in childbirth for more information, including how to reduce the chance of having a serious tear during birth.
  • See the RCOG patient information Care of a third- or fourth-degree tear that occurred during childbirth.
• The scar on your uterus from your previous caesarean birth may separate and/or tear (uterine rupture) and this can happen in up to 1 in 200 women. If there are warning signs of uterine rupture, it will be recommended that your baby is born by emergency caesarean. Warning signs of uterine rupture include unexpected vaginal bleeding or changes in your baby’s heart rate pattern. In most cases, both you and your baby recover well, although sometimes uterine rupture can happen without any warning signs and it does have a small risk of serious or long-term harm both for you and your baby.
• Uterine rupture can cause heavy bleeding, which can be life-threatening, and up to 1 in 3 women who experience a uterine rupture may need an emergency hysterectomy (removal of the uterus). Serious risks to your baby, which include brain injury or death around the time of birth, are slightly higher with planned VBAC than with a planned caesarean birth (affecting around an extra 10 in 10 000 babies). Most often, these complications are related to uterine scar rupture leading to lack of oxygen reaching your baby. However, the risk of your baby dying because of a planned VBAC is very low and is about the same as if you were giving birth vaginally for the first time (about 4 in 10 000 births).
• If your labour is induced, there is a higher chance of needing an emergency caesarean birth. The risk of uterine rupture can be increased by two to three times, although this depends on how labour is started. Your healthcare professional will discuss the risks and benefits for your individual situation, and the alternatives of waiting for labour to start naturally or having a planned caesarean birth.

VBAC is usually an option for most women, but it is not advisable when:

• You have had three or more previous caesarean births.
• Your uterus has ruptured during a previous labour.
• Your previous caesarean birth was ‘classical’, i.e. where the incision involved the upper part of the uterus.
• You have other pregnancy complications that require a planned caesarean birth.

• There is a smaller risk of uterine scar rupture (less than 1 in 4000).
• You will know the expected week of your planned birth although the precise day may only be confirmed shortly beforehand to allow for the work of the maternity unit. However, 1 in 10 women go into labour before this date and sometimes this date may be changed for other reasons.
• You can choose to breastfeed your baby after having a caesarean birth. You are no more likely to have problems with breastfeeding than if you have had a vaginal birth. You can have skin-to-skin contact with your baby immediately following a caesarean birth.

• A repeat caesarean birth can take longer than the first operation because of scar tissue. Scar tissue may also make the operation more difficult and can result in damage to your bowel or bladder.
• Infection – this can be of your wound or your uterus. It is common (2–7 in 100 women) and can take several weeks to heal. You will be offered antibiotics through a drip at the start of your caesarean to reduce this risk.
• Your recovery period is likely to be longer, usually about 6 weeks, although this is variable. Your wound will be painful while you recover and 1 in 10 women will experience discomfort for the first few months. You may be unable to drive for up to 6 weeks after surgery, but it is important to check with your insurance company as this varies widely.
• More scar tissue occurs with each caesarean birth. This increases the chance of the placenta growing abnormally into the scar on the uterus. This makes it more difficult to remove the placenta during any future births (placenta accreta or percreta) and can result in bleeding. This is around three times more common when women have had a previous caesarean, affecting around 1 in 1000 women. If severe bleeding occurs, this can be life-threatening, and an emergency hysterectomy may be required. For more information, see RCOG patient information Placenta praevia, placenta accreta and vasa praevia.
• You are more likely to need a planned caesarean birth in future pregnancies. All serious risks increase with every caesarean birth you have.
• Your baby’s skin may be cut during the caesarean birth. This happens in 1-2 out of every 100 babies, but these cuts usually heal without long-term problems.
• There is a small chance of injury to your bladder (around 1 in 1000) or other abdominal organs during a planned caesarean. This may require further operations to repair any injury. Your healthcare team will discuss with you the chance of this happening, as it will depend on your individual circumstances.

You will be advised to give birth in hospital so that an emergency caesarean birth can be carried out if necessary. Contact the hospital as soon as you think you have gone into labour or if your waters break.

Once you start having regular contractions, you will be offered to have your baby’s heartbeat monitored continuously during labour (CTG monitoring). This is to monitor your baby’s wellbeing, since changes in the heartbeat pattern can be an early sign of problems with your previous caesarean scar. Sometimes this can make it harder for you to move around or adopt some positions in labour. You will also be recommended to have a blood sample taken and an intravenous cannula in place.

You can choose various options for pain relief, including an epidural. For more information about pain relief during labour see the Labour Pains website (labourpains.org, external link) from the Obstetric Anaesthetists’ Association. You should be offered a chance to talk about your options with an anaesthetist.

If labour does not start by 41 completed weeks of pregnancy, or if birth is recommended earlier than this because of your individual situation, your healthcare professional will discuss your birth options again, and potential risks and benefits of each, with you. The options are:

• continue to wait for labour to start,
• induction of labour; this can increase the risk of scar rupture and lowers the chance of a straightforward VBAC,
• ERCB (elective [planned] repeat caesarean birth).

You will usually be offered a date at or soon after 39 completed weeks of pregnancy, unless there are other reasons why your baby may need to be born earlier.

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 with 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 your healthcare professional will recommend planning for your caesarean to take place after 39 weeks.

The planned date of your caesarean may change because of emergencies on the day of your operation. If this happens your healthcare team will arrange a new date with you as soon as possible.

Let your maternity team know what is happening. It is likely that you will be offered an emergency caesarean birth once labour is confirmed, although you may choose to continue with labour. If labour is very advanced, it may be safer for you and your baby to have a vaginal birth. Your maternity team will discuss this with you.

Making the choice between VBAC and ERCB can be difficult and stressful. Sometimes it can reawaken emotional distress from your previous birth. If you are feeling anxious or worried in any way, please speak to your healthcare team who can answer your questions and help you get support. The support may come from healthcare professionals, voluntary organisations or other services.

Further information and resources are available on the NHS pregnancy information pages (external link).