VBAC (Vaginal birth after C section)
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Dr Yana Richens OBE
Consultant Midwife University College London Hospital
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Birth and labour

Anxiety over birth

Most pregnant women have some anxieties and concerns how they will cope during pregnancy and childbirth.  At least one in four women have more anxiety and concerns than the majority of women, and this can lead some women to request that their baby is born by Caesarean Section.  However for women with no medical or pregnancy complications, vaginal birth is the best option for Mothers and their babies according to the National Institute for Clinical Excellence.  For women who do not wish to have a vaginal birth, at University College London Hospital we follow the guidance of National Institute for Clinical Excellence which states that “women who have anxiety and fears are offered support of health care professional that has experience of mental health”.
In Short
This is the leaflet given out at the UCLH hospitals in London.

1. Introduction

We recognise and respect women’s informed choice of how they give birth however it is important to find out the cause and reasons for anxieties or fears. This will enable us to provide the best care and support during pregnancy and after you have had your baby.

2. First baby

If it is your first baby reasons for increased anxiety and birth fears include:

  • Listening to birth stories from family and friends
  • Took a long time to conceive – this baby is precious
  • Watching programmes on the television or over the internet
  • Concerns about pain
  • Concerns about a vaginal birth this includes tearing and stitches
  • Would like to know what day the baby will be born.
3. Second or third baby

For women who have already had a baby, anxiety and birth fears are generally related to a previous poor experience. In this case we will refer you to the birth reflections clinic. This is a clinic which is led by an experienced senior team of midwives and doctors. At this appointment you will be able to discuss your previous experience of birth and ask questions.

History of Anxiety or Depression

We know that a history of anxiety or depression can increase anxiety and lead to birth fears during pregnancy. Please let your midwives know as soon as possible so that we can support you.

4. Elective caesarean section for maternal request

Tell the midwife as soon as possible if an elective Caesarean Section is a choice of birth that you would like to make. This is referred to as a maternal request caesarean section.

Depending upon your reason for an elective Caesarean Section you will join the pathway which could include the following:

  • An appointment with the Consultant Midwife at 16 weeks for assessment
  • An appointment to see and be supported by a clinical psychologist physiotherapist, or gynaecologist, depending upon identified needs
  • Detailed birth planning and support for your choices

Before making any decision we ask that you attend antenatal education session at the hospital. This will help you make a fully informed decision and provide you with the opportunity to ask lots of questions. The final decision is discussed with you at your birth planning meeting with your midwife at 34 weeks. If you decide that you would still like a C/S you will be referred to a consultant obstetrician who will confirm that you are aware of all of the risk factors involved. This leaflet outlines some of the common risks.

5. Risks to mother

Having a planned caesarean section may make you feel more in control and avoid the anxieties and uncertainties of going into labour naturally. However, it is surgery and can have complications. It will also affect your future pregnancies (see below).

Although you should not feel any pain during the caesarean section (because you will have an anaesthetic),the wound will be sore for the first few days. One in 10 women will experience discomfort for the first few months.

The main risks when having a caesarean section include:

  • wound infection – this is common and can take several weeks to heal
  • blood clots in the legs that can travel to the lungs (deep vein thrombosis and pulmonary embolism) – these are more common with a caesarean
  • bleeding more than expected.

These risks are increased if you are overweight.

Serious complications are rare if it is your first caesarean section and it is planned in advance, as long as you are fit and healthy and are not overweight.

However, serious complications become more common if you have repeated caesarean sections.

If you develop any complications, your recovery and stay in hospital will be longer.

6. Risks to baby

The most common problem affecting babies born by caesarean section is temporary breathing difficulty.

Your baby is more likely to need care on the neonatal unit than a baby born vaginally.

There is a small risk of your baby being cut during the operation. This is usually a small cut that isn’t deep. This happens in 1 to 2 out of every 100 babies delivered by caesarean section, but usually heals without any further harm. Thin adhesive strips may be needed to seal the wound while it heals.

Babies born by caesarean section are more likely to develop asthma in childhood and to become overweight.

7. What about effect on future births?

If you choose to have a caesarean section, any future births are more likely to be by caesarean section as well. You should consider the size of the family you want because the risks increase with the number of caesarean sections you have. Two caesarean sections do not appear to have a higher complication rate, but three or more carry serious risks which include the following:

  • Damage to your bowel or bladder (1 in 1000 women) or ureter (the tube connecting the kidney to the bladder) (3 in 10 000 women).
  • Extra procedures that may become necessary during the caesarean section such as a blood transfusion or emergency hysterectomy, particularly if there is heavy bleeding at the time of your caesarean section. A hysterectomy would mean you are unable to have any further children. The risk of needing to undergo a hysterectomy at the end of a subsequent pregnancy increases with each caesarean section but overall is still very low.
  • If you have had two caesarean sections before and have a low placenta in your third pregnancy, you have a higher chance of a serious complication called placenta accreta. This is where the placenta does not come away as it should when your baby is delivered. If this is the case, you may lose a lot of blood and need a blood transfusion, and you are likely to need a hysterectomy. The risk of placenta accreta increases with each caesarean section.
  • For reasons we don’t yet understand, the chances of experiencing a stillbirth in a future pregnancy are higher if you have had a caesarean section (4 in 1000 women) compared with a vaginal birth (2 in 1000 women).
8. How does a vaginal birth compare?

Having a vaginal birth is usually straightforward, particularly if you have had a vaginal birth before. It is normal for the area between your vagina and anus (perineum) to feel sore and uncomfortable for a while after you have given birth. This is because this area will have stretched as your baby is born and you may have stitches.

Complications can also happen, especially with first births. These include the need for forceps or ventouse to help deliver your baby (for more information, see RCOG patient information

Heavy bleeding in the first few days is more likely with a vaginal birth than with a caesarean section.

However, there is generally more blood lost with a caesarean section overall.

What are the benefits of having a vaginal birth?

If you do have a vaginal birth, it is worth remembering that:

  • you are more likely to be able to have skin-to-skin contact with your baby immediately after birth and to be able to breastfeed successfully
  • 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
  • if you have had a vaginal birth with your first baby, future labours are usually much shorter and the risks are very low to you and your baby.

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This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Essential Parent has used all reasonable care in compiling the information from leading experts and institutions but makes no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details click here.