Making decisions about birth after caesarean

Information needs & attitudes in next pregnancy

Women who become pregnant again after a previous caesarean have specific information needs. How much information women feel they need is a matter of personal preference, but usually they want to find out how having had a caesarean previously might affect their next pregnancy and birth. Many women we talked to said it was important to know that information was balanced and trustworthy and that it was presented without a hidden agenda. Several pointed out that it could be difficult to know which sources of information could be trusted. A few women thought it was safer to rely on information from health professionals than try and find out things for yourself. (See 'Views on information from other sources' and 'Views on information from health professionals'.)

The women we talked to in this study took part in a clinical trial that tested two computer-based decision aids. Both decision aids provided detailed information about a broad range of risks and benefits of different ways of giving birth after caesarean. All but two of the women used one version of the decision aid or the other. 

A few women had been told about the implications of caesarean for future pregnancies immediately or soon after their previous birth. Many others could not recall having received information about this issue from a doctor, midwife or health visitor, though some acknowledged that it might have just passed them by at the time because they were focussed on their new baby. A few women had assumed that they would just have to have another caesarean as a matter of course. Others were surprised to learn that they could choose to have a caesarean even if it was not medically necessary.

Many women worried how having a previous caesarean scar on their uterus might affect them during pregnancy and birth. Almost all of them had heard about the risk of 'uterine rupture' - the very rare complication of the previous scar coming apart during labour or the late stages of pregnancy - but many did not know how much of a risk it really was. Several women who thought about having a planned caesarean felt unsure whether this would remove their choice over how to give birth for future pregnancies. Some had heard rumours about the maximum number of caesareans a woman could have and worried whether their risk of complications would increase with the number of caesarean they had. And because caesarean delivery is usually 'quicker' than vaginal birth, a few women wondered whether this meant it was 'safer' for the baby. 

Many women who thought about attempting vaginal birth after caesarean (VBAC) wanted to find out how likely they were to have one. They also wanted to know how their labour would be managed and monitored, at what stage they should go into hospital and what kind of interventions they would be likely to receive.

Women who wanted to attempt VBAC were especially keen to refresh their knowledge about labour and pain relief. A few of them hadn't experienced labour previously, so they felt very much as if it was their first birth. One woman wanted a planned caesarean but went into labour before the scheduled date. Looking back she wished she could have had more detailed information about the kinds of pain relief available to her. A couple of women had wanted to attend antenatal classes again, but didn't manage to get a place. However, another woman who was given a place didn't attend the full course because she felt she knew as much as she needed to already (Interview 26).

Several women commented that they had less contact with their midwives than in their previous pregnancy and therefore less opportunity to seek information or advice from them when they felt they needed it. They thought that having available written information that they could read and revisit in their own time, such as that provided by the decision aids, could go some way to addressing this need.

Not all women agreed that having had a previous caesarean had increased their need for knowledge. A few women said that they hadn't been looking for as much information as they had with their first pregnancy. As some of them pointed out, looking after a young child meant they simply had less time available to read or search the internet. However, they also thought they knew more about what to expect second time round or questioned the practical value of gathering lots and lots of information. Two women who were certain that they wanted a planned caesarean thought they knew enough about the possible risks from their previous experience. A few women who were hoping to have a vaginal birth thought that seeking out too much information might worry rather than reassure them. One woman felt that “a little knowledge can be a dangerous thing,” and another one pointed out that “no matter how much you read, you still won't know what it's going to be like”. 

Several women said they liked using the decision aids because it stated the risks of complications clearly and without bias. Many women took the view that even though learning about the risks of different ways of giving birth could be scary, it was better to know than not to know. As one woman said “If you know what's ahead of you, you can accommodate it better”. Several women said they had felt empowered by having additional information through their participation in the DiAMOND trial, but a few felt that with increased knowledge also came the burden of responsibility.

However, a couple of women felt that using the decision aid had given them more information than they wanted or needed. One woman thought that knowing too much about all possible complications might put off women getting pregnant again. Another one said that the task of ranking risks according to her personal values had felt like 'tempting fate'. 

Women used information in different ways to support their decision-making. Some women wanted to find out as much information as possible before making up their mind about how to give birth. They were keen to make a decision that was informed by weighing up all the risks as much as possible. For some of these women, additional information gained from using the decision aid had influenced the outcome of their decision. 

However, other women said that factual information had not been all that important for reaching a decision and that they had been guided more by personal values. Nevertheless, they, too, found it useful to find out more information because they thought it would help them to prepare themselves for the birth and feel more confident about the decision they had made. 

 
Last reviewed April 2015.
Last updated November 2010.

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