Making decisions about birth after caesarean

Women's experiences of making the decision

Women who've had a caesarean and are pregnant again need to decide how they want to give birth to their next child. For some women, their medical history or complications such as breech position of the baby will mean that a planned caesarean is judged to be a safer option for them than vaginal birth after caesarean (VBAC, also sometimes called a 'trial of labour'). But for many women there won't be strong medical reasons why one way of giving birth would be considered more advisable than the other. So they should be able to make a decision based on their personal values and preferences. 

A few women were surprised to learn at their 20 week scan that there was a decision for them to make. Some had assumed that unless there were medical complications, they would have to attempt vaginal delivery. On the other hand, a couple of women had assumed that having had one caesarean meant they would definitely need to have another one.

All the women interviewed for this project were also taking part in a clinical trial to examine the effects of a decision aid for making decisions about birth after a previous caesarean. (For further information see 'About the interviews and the DiAMOND trial'.) Two women were allocated to a group in the trial which only had information from health professionals. All the other women who were interviewed had also received one of two versions of the decision aid. Both decision aids were computer-based and designed to give balanced information about the risks and benefits of different ways of giving birth. We asked women how they had experienced the process of decision-making and whether the decision aids had helped them in reaching a decision. 

Women had very different experiences when making the decision about how to give birth. Many women had a clear birth preference throughout their pregnancy and had made up their mind before they came to use one of the decision aids. A few women said they had made the decision even before conceiving again. However, others had changed their minds back and forth throughout their pregnancy and found it helpful to keep all options open for as long as possible.

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A few women felt unsure which way to go so took the strategy of booking a caesarean for after their due date. They thought that if they went into labour spontaneously and things progressed well, they would go along with having a VBAC, but if they went overdue, another caesarean might be the better option.

Some women said they took a very rational approach, weighing up all the risks and deciding on what they thought was the safest birth choice for them considering their personal circumstances. For others, the decision was based more on their gut feeling and they were more strongly influenced by their hopes and values than by the relative likelihood of complications. 

Several women said having comprehensive and well-balanced information available was important for them in reaching a decision. Many felt very positive about being able to make a choice that they thought was right for them rather than having things decided for them by other people. Several said they felt they had been '100% in control' of the decision.

However, a few women didn't feel very comfortable with making the decision about how to give birth by themselves. One woman worried that her doctor and midwife might not have given her all the information because they did not want to put her off the idea of vaginal birth. She said she would have preferred honesty rather than being given the illusion that she was making a choice. Others felt overwhelmed by the responsibility of having to decide even though they felt well-informed about all the risks. Knowing that all ways of giving birth carried some risks just made them more worried about making the wrong decision and living to regret the consequences. 

A couple of women said they were half hoping that the decision might be taken out of their hands by their baby turning into breech position. A couple of women also said they would have liked more guidance from health professionals (see also 'Role of health professionals in decision-making'.)

A few women who had hoped to have a vaginal delivery had to adjust their plans due to unforeseen complications, such as their baby turning into breech position half way during the pregnancy, a low-lying placenta or the baby's head not engaging. A few women received information later on in their pregnancy that made them feel less confident that they would have a vaginal birth, and a couple were strongly advised to have a caesarean on medical grounds. A couple of women said they felt upset about having the decision taken away from them at the time, but a couple of others felt that, looking back, it had also relieved them from the pressure of having to make the 'right' choice. 

Last reviewed April 2015.

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