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Making decisions about birth after caesarean

Reasons for wanting a planned caesarean

Women who have had a previous caesarean are likely to think particularly carefully about how they want their next child to be born. They can try a vaginal birth after caesarean (VBAC) or have a repeat caesarean that is planned (sometimes also referred to as an 'elective caesarean'). Not all women will be able to choose between these two ways of giving birth after caesarean - some women might have to have another caesarean due to medical reasons. Nonetheless, most women have clear ideas about which way of giving birth they would prefer. We asked women about the main reasons why they wanted to have a repeat caesarean. 

Women's birth preferences were influenced by a wide range of factors. These included their previous experience of labour and caesarean birth, considerations for the future, their current family situation and the availability of support, as well as 'gut feelings' and more general ideas on what childbirth ought to be about. Naturally, all women wanted to give birth in a way that would be safe for themselves and their baby. Many looked to medical professionals to help them decide which option would be best for them (see 'Women's experiences of making the decision' and ' Role of health professionals in decision-making').

 

She was convinced that she would not go into labour naturally because of her previous experience...

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She was convinced that she would not go into labour naturally because of her previous experience...

Age at interview: 38
Sex: Female
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'you know, I just had such a horrible, awful and traumatic three days before that caesarean that I just, I just really would never go through that again. And it was just such a horrible way to start off being a mother, because I was just so tired and I was just so battered, and exhausted, that I hope that this time I'm much calmer. I'm quite happy about going there for the caesarean now, so, I'm hoping that the day after the caesarean I'll be quite rested and' and quite ready to start looking after my second baby. So it's, it's like all of this is behind my decision. 

If I had had some doubts that I may be would not have been able to have an elective caesarean at the end of the second pregnancy, I might have hesitated about getting pregnant a second time. Because it was just such a horrible experience being induced and... and trying to, to get into labour and not. 'Those two or three days were just so horrific, and just the fact that I was quite certain I could have the elected caesarean made me quite calm.

And when were you told that you could have an elected caesarean with a next baby? 

I just assumed so, to tell you the truth. And then when I saw' because I know because of my background it would be difficult for somebody to deny me a caesarean' whereas with the first birth I'm sure you can't just' well, I don't think it would be right to just instantly want an elective caesarean, but I think that I was pretty certain that after my, with my track record, nobody could really deny me an elected caesarean for my second child.
 

A couple of women made the decision to have a planned caesarean as soon as they found out that they were pregnant again. One woman who never went into labour during her previous birth felt certain that her experience would repeat itself, as several women in her family had had the same problems with dilating. She felt very sure there was no point in trying for vaginal birth and requested a caesarean early on in her pregnancy. Another woman had developed lichen sclerosus (a chronic inflammatory skin disorder affecting the genital area). She was concerned that a tear during vaginal delivery might cause the condition to flare up again and decided on a caesarean to avoid that risk.

 

She chose a planned caesarean to minimise the risk of her lichen sclerosus returning. It annoys...

She chose a planned caesarean to minimise the risk of her lichen sclerosus returning. It annoys...

Age at interview: 32
Sex: Female
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So, what's the overriding factor for you for having a section? 

Why I'm having it? It's the lichen sclerosis, which is fairly stable, just now. And I really don't want to go in tear and' then have to go through another day case operation, but' and also we're going to Australia for a year in July and then what would happen if we were out there, would I have to have it there, and it's just'

Yeah, bit of a nightmare, isn't it?

Yeah.

And you, you say that you would have liked to' you thought about the possibility of having a vaginal delivery. Is there any way that you would have tried for a trial of labour?

'Well, if I hadn't had the lichen sclerosus, definitely. I mean, I guess, there's a small part of me, even though I'm ninety-nine percent sure, there's a small part of me that if I went into labour now and if things were going great' I would be sort of partly tempted to carry on. 'But it's a very small part [slight laughs]. There's, there's a little bit of pressure that I sort of feel in some ways I should be' going for a normal delivery. And that, a lot of people who maybe don't know the reason will perceive that I'm' I don't know, just being lazy or don't want to go through the pain or whatever. 'so that does slightly annoy me. And in many ways, it would be great to have a normal delivery, because hopefully my recovery would be faster and I wouldn't have to, you know, wait for several weeks to drive but'so still, I'm pretty sure that a section is probably the right thing to do.

I mean, you say you feel this pressure from outside, but do you really see it as an easy option yourself? 

Well I don't, I don't actually. No, really I mean, I did go so well the last time, but it's just with the boys' it's completely different this time. So, I don't want to not be able to drive for four weeks or whatever. I think it was about three or four weeks the last time. Because they're not going to want to be stuck in the house. Well, thankfully people will be coming over, so it won't be an issue, but' And I don't really particularly want to have another spinal or have another catheter in, but' So no, I don't think it's an easy option, but maybe'I don't know. 

Most women who decided on a planned caesarean with their next child had considered vaginal birth during the early stages of their pregnancy, although with varying levels of enthusiasm. They changed their minds after talking to doctors or midwives and finding out more information at their hospital appointments. One woman who had been very keen to try vaginal birth was disappointed to learn that she had a low-lying placenta (placenta praevia) and therefore would have to have a caesarean, so the decision was taken out of her hands. Another couple of women were advised that a planned caesarean would be a safer option than vaginal birth on the grounds of their medical history or aspects of the current pregnancy such as breech position or large size of the baby, or in one case, a rupture during her first birth. One woman, who had a very difficult first birth, followed by a more positive experience of planned caesarean, said she felt safer with medical intervention. 

 

After a very difficult first birth and a comparatively easy planned caesarean, she feels safer...

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After a very difficult first birth and a comparatively easy planned caesarean, she feels safer...

Age at interview: 38
Sex: Female
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So overall for you what's the most important thing that's informed your decision this time to go for the elective section? What's been the one thing that's really made you want to go for a'?

The security of knowing that it's going to happen on a certain date and that it's going to be medical intervention right from the start instead of if something goes wrong. You see I've never been one of these people that think that they should have a home birth, I always think that doctors and midwives are the right people and they've got the experience to deal with it. I don't think that the mother always does know best.

And are there any other factors that have been really important for you in your own personal decision do you think?

I had quite a lot of pressure from my family who thought' who remembered how ill I was or looked according to them after the first time and they said that I looked a lot better the second time. So they were not wanting me to go through you know a bad birth experience.
 

For several women, the overriding reason for wanting a planned caesarean was wanting to avoid a second emergency caesarean. They didn't want to risk going through the pain and exhaustion of labour only to be rushed to the operating theatre at the last minute. They didn't like the idea of having another operation but they felt that a planned caesarean would be much less stressful for mother and baby than an emergency one. One woman who had missed out on immediate contact with her baby after her previous caesarean because she had felt so tired and unwell, hoped that after a planned c-section she would be well enough to breastfeed her baby straightaway and bond with him more quickly. Similarly, one woman who'd had her first caesarean under general anaesthetic wanted to make sure she would be awake when her next child was born and therefore felt that a planned caesarean was a better option. Another woman was angry that with her previous birth, doctors had waited until her baby showed signs of distress before deciding to do a caesarean. She couldn't face the idea of going through a similar experience with her second child. 

 

Her previous birth was so traumatic that she feels very anxious about vaginal delivery. She...

Her previous birth was so traumatic that she feels very anxious about vaginal delivery. She...

Age at interview: 42
Sex: Female
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A lot of women, after they have one caesarean want another one, so I think it's quite normal, especially an emergency one. I think more common if you've had a breech and, and people want to try birth don't they, but, you know, I've had quite enough of that [laughs].

I think there's also sometimes women feel they've missed something?

Yeah, and I don't have that, [You don't have that] yeah.

What factors have most influenced your preferences regarding the mode of delivery this time? 

What factors, gosh. Probably, the most of it is the emotional one of thinking I can't bear to hear another baby in distress. I think the reason I've gone where I'm going is if I, you know, if I had taken the advice I was given, I was going for a natural birth at [hospital]. I was very nervous that again, I'd be, carry on too long 'til distress so that's another issue I was worried about. So it's really that, because medically, I'm not particularly pleased I'm having an operation and I think if I knew that I'd deliver naturally, fine, I'd have that option.

Right. So if you could, could guarantee a hundred percent that you could have a good natural birth, you'd go for it [I'd go and have a go, yeah] but it's the indecision'?

'because I'd be running around two weeks later wouldn't I? It's the, it's the not, not knowing and the fact that I've had one experience of things going horribly wrong, I just can't face it.

 

She thinks a planned caesarean will allow her to bond better with her baby because she will be...

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She thinks a planned caesarean will allow her to bond better with her baby because she will be...

Age at interview: 31
Sex: Female
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And how have you wanted to deliver this time? What have been your thoughts about that?

It's been varied, but I've finally decided on an elective section.

So, if you can talk me through why you varied and, and why you've come down on the side of a section this time?

For the same reasons as I wanted a natural birth the first time; mainly bonding with, with the baby. That's kind of made me think, 'Well, maybe I should go for a natural delivery if I can', but then I think about it and I think well, I don't, I don't really believe that the problems I had after I had [son's name] were due to the section. I think they were more to do with it being an emergency section, whereas I think if it's an elective section then that would be fine because I'd be more with it. I wouldn't be so tired, I would be able to feed him straight away myself rather than having to have him latched on, and that sort of thing.

I've got quite a few friends who are in the same position as me. They've had an emergency section the first time round and they've then gone on to have a second, and I have asked them, and they've all said that, you know, an elective section compared to an emergency section is like night and day, and none of them have had any problems or complications afterwards. They said it was fantastic, so, I have to say I've been swayed a bit by what, what they've said as well.
 

A few women were particularly worried about the risk of uterine rupture. Even though uterine rupture is very rare, for many women it is the complication that causes them most anxiety. (The risk of uterine rupture, where the scar on your uterus may separate and/or tear, can occur in 1 in 200 women. This risk increases by 2 to 3 times if your labour is induced.*). A few women who decided to have a planned caesarean had been encouraged by doctors and midwives to try VBAC. However, this hadn't made them any more confident that they would be able to have one, and a couple of women resented being given what they perceived to be one-sided information. Some felt health professionals were pursuing their own agenda in promoting vaginal birth. One woman felt so little confidence that her wishes would be respected that she chose to see a private consultant instead. Another woman also worried that if she was to attempt VBAC, health professionals might let her labour on for longer than she would want to. 

 

She was scared about rupture of the scar and did not feel reassured that she would be able to...

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She was scared about rupture of the scar and did not feel reassured that she would be able to...

Age at interview: 31
Sex: Female
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Overall, what do you think is the one main reason why you didn't want to have a trial of labour and why you wanted to opt for another section? If you had to say one reason?

One reason, I was worried of rupturing and going through an horrendous labour, even though they say to you, even though midwives did say to me, 'Oh, we won't let you go as long', there is no definitive, there's nothing written anyway, or cast in stone that says, 'Okay, a lady that's had a previous section will only labour for x amount of hours and if this happens, you know, this will happen', nothing is written, it's very wishy-washy, it's almost a case of, 'See how much pain this woman can stand, if it gets to a point where the baby is not making progress then we'll, then we'll think about a section', so there was no definitive answer for me and that was very worrying and I didn't want to go through hours and hours and hours of labour with, with the threat of rupturing, only to discover that I'd have to have an emergency section, that was my biggest fear.

Several women mentioned the convenience of knowing when their baby would be born as an important advantage of planned caesarean. Having a date booked for the operation meant that they could arrange childcare and support for the time after the birth well in advance. Being able to plan was particularly important for one woman, whose husband worked away from home for long stretches. She wanted to make sure that he would be around for the birth. Nevertheless, she found the decision difficult, as it conflicted with her view that women should not have a caesarean for personal convenience.

 

There is no longer a medical reason for her to have a caesarean but after battling with herself...

There is no longer a medical reason for her to have a caesarean but after battling with herself...

Age at interview: 31
Sex: Female
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And what was your preference for delivering this time? You said to start with that you wanted a natural birth?

Yeah, it was a natural birth and the twenty week scan showed that the placenta was lying low. So I had to come back for another scan at thirty-four weeks and as time went on 'well, my husband works off-shore and I was' you know, it's just one of these things that, I think because I had the choice this time, that it's probably why I've gone for a section. So I had' another scan at thirty-four weeks and the placenta had moved. So I mean' well, that wasn't the reason for having a section, it was me that decided ultimately to have another caesarean. And a lot of it'well, I hate saying it but it was convenience, because it's not something I've ever, it's not something I agree with, it's like, you know, like first pregnancies and that, just, 'I am not having a natural birth' and you go and pay for a caesarean, that's not something that I agree with. You know, I really don't. 'But, I mean, if you've got money that's fair enough, that's what people do. So, I didn't really like opting for a section 'it's just a personal kind of battle I've got going on in my head. But anyway, just for my circumstance, and that my husband is home now and we know when it's going to happen and I've managed to get my mum to take time off work to look after' you know. So' it's' it literally is convenience for me rather than any health reasons.

Women's decision to have a planned caesarean was often also influenced by the concerns of their partners and other family members.

*Birth Options After Previous Caesarean Section - Royal College of Obstetricians and Gynaecologists (July 2016)
 

Last reviewed August 2018.
Last updated August 2018.

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