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Making decisions about birth after caesarean

Women's expectations for their next birth

For all but one of the women we spoke to, their previous caesarean had been their first experience of childbirth. When they became pregnant again, their thoughts about how to give birth to their next child were invariably influenced by what had happened during their previous pregnancy and birth. For example, a couple of women who had experienced postnatal depression after their previous birth worried about how another birth might affect them. Others who'd had a planned caesarean due to complications in their previous pregnancy (a large baby, a baby in breech position or a premature delivery due to pre-eclampsia) were concerned that these complications might repeat themselves. A couple of women who miscarried in earlier pregnancies didn't want to start planning for the next birth before a crucial number of weeks had passed. 

 

Because of a previous miscarriage, she did not start to think about how to give birth until her...

Because of a previous miscarriage, she did not start to think about how to give birth until her...

Age at interview: 42
Sex: Female
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So, I, I basically didn't really think about it all until about twenty weeks. I think possibly, I'm not sure if I told you this before, but I had a miscarriage with the previous baby, so I kind of' it didn't become real until about twenty weeks and that was combined with my scan and my visit to my local hospital, [Hospital]. Where, obviously it was on my mind, but I hadn't really thought about it too much but I was, possibly at the back of my mind veering towards an elective caesarean because I had not had a good experience the previous time. I saw a junior, I saw, I think below registrar, so a junior doctor who was under the, you know, under the head obstetrician, who' so I sort of mentioned that I, I was thinking about options, but she basically totally recommended a natural birth. Told me that caesareans risk piercing your bladder, heavy bleeding, lots of things, but she mentioned nothing that can happen with natural births. So she tried to scare me off, wouldn't agree anything or really discuss anything and said, 'Well, just see us at thirty-four weeks and we'll talk again'. So that was that. So I went away and had a think. And that's when I really started thinking and to be honest, I panicked and I thought, 'Well, if they're going to be like that, I'm going to look into the private option'.

 

When she found out she was pregnant again she felt happy but also worried that she might...

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When she found out she was pregnant again she felt happy but also worried that she might...

Age at interview: 31
Sex: Female
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So before you got pregnant again this time had you had any concerns from last time?

Yeah, definitely, yeah' a lot of demons come back.

Yeah, and did it make you think about what you're going to do this time?

Yeah, I mean this pregnancy wasn't planned' at all. But I mean, it wasn't like, 'Oh my God, I can't stand it, I'm pregnant', sort of thing. We're very happy about it, but I just- I panicked a wee bit when I found out I was pregnant and about, you know, going through another section maybe and' you know, going through the baby blues again.
 

We talked to women after they'd had at least one hospital appointment with an obstetrician to discuss their birth preferences and previous medical history. Because the women we talked to were taking part in a wider study of decision-making about caesarean, many of them had also received a computer-based decision aid that was designed to help them compare the risks and complications associated with different ways of giving birth after caesarean (see 'About the interviews and the DiAMOND trial'). This is an unusual situation as most women in the country are not yet offered a formal decision aid.

Some women had strong preferences of how they wanted to give birth to their next child while others said they were just going to 'go with the flow' - in other words, they would see how things turned out when they went into labour but would not set their hopes on having a vaginal birth. Several women said they wanted to be more involved in decision-making about their next birth than they had been previously. At the same time, they felt more mentally prepared that things might not go to plan. One young woman had even made two birth plans, one for a caesarean and one for vaginal birth, to be prepared either way (Interview 14). A few women had to adjust their plans for giving birth at later stages of their pregnancy due to complications such as a low-lying placenta (placenta praevia), size or position of the baby. Others changed their minds after finding out more information about risks and complications. (See also 'Women's experience of making the decision'.)

 

She has decided to attempt VBAC even though she does not feel overly optimistic and is worried...

She has decided to attempt VBAC even though she does not feel overly optimistic and is worried...

Age at interview: 30
Sex: Female
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And how do you want to deliver this time? What's your preference?

Well, obviously, just pop it out and my husband will catch it [slight laugh]. I, yeah, I obviously I would love for it to be natural and be no problem, but I think I'm kind of' I've been told off for being too negative, and you sort of tend to think that everything's going to happen that happened the first time. And you think, oh, I'm probably going to end up having a caesarean anyway. You know, so' it did sort of cross my mind to go for the, the planned option, but I've kind of decided to give it a go and see what happens.

Did you have any particular worries this time? I mean, obviously work out the way that you were going to deliver, but what are your concerns?

Well that' the chances of it' the wound rupturing' was one thing. I guess, my, with what I've chosen, my worry is that I'll give it a go and it'll have a long traumatic labour and then still have to have an emergency caesarean. So you end up feeling a hell of a lot worse than I did last time.

Yeah. And, and have you talked about that with the midwife or the obstetrician, these worries?

Yeah, yeah.

And has that helped at all?

They just kind of say, 'Don't be so negative', which' and, 'Everybody's different', you know, 'Every pregnancy's different',' dah, dah, dah.

So how involved do you feel in the decision this time?

Well, I know it's my choice, but because I'm so indecisive and I find it so hard I guess I've gone with, I've just gone with what they've advised really. So' obviously, it's my decision, but I've, yeah, I've gone along with what they've advised.

 

She was disappointed to learn late in her pregnancy that her chances of having a vaginal birth...

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She was disappointed to learn late in her pregnancy that her chances of having a vaginal birth...

Age at interview: 37
Sex: Female
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I would really like to have a natural birth, but having had an appointment yesterday with the doctors, I- I don't think that's very likely from what they've said to me.

Which doctors was it yesterday that you saw at the hospital?

It was at [Hospital]' Doctor', I cannot remember her name, sorry. I don't think I even got given her name.

So what, what was confusing about that, or what changed your mind?

'I expressed that I wanted to have a natural birth but I felt that, having, I had to have an examination and a scan and everything and the Bishop's scale was reading very low already. And she basically, felt that looking at how my pregnancy was with [daughter] and the birth, that it was looking unlikely for me to have a normal, a natural birth. But what I think I was surprised about yesterday is that I had to make a decision about a section and I wasn't expecting to do that. So' and the decision as to whether to have it in two and half weeks or whether to go late, later and see if I went into labour naturally.

So it was whether to have an elective, or, or wait and see?

Yes. But, even with the wait and see I still had to book in an elective section. Which I thought- I thought if I went for the wait and see option, it would just be if- if I need a section, it would happen, not be booked in. 

I feel very strongly still in my mind that that's something I might, I really want to try and do, even though I've been told it's unlikely, that glimmer of, 'It might still happen'.

So the possibility is '

'yes, yeah. I think as well, advice about, you know, I went on the hospital visit and they take you round the fabulous new birthing suite, which, I knew I wasn't going to be able to even go onto because I'd had a section for the first delivery and if, people don't know that, I think it's quite insensitive really. Because there's this lovely birthing pool and things and'

But it's not for you?

That's not going to happen for me, I know that. I mean, it's important to know that right from the start, but I think, sometimes it can seem a bit, harsh on people when they have to go on those visits.
 

A few women looked to their next birth as an opportunity to put a negative first birthing experience behind them and to realise the hopes they had held during their previous pregnancy. For some, this meant wanting to go through labour and vaginal birth with as little medical intervention as possible. For others, it meant opting for a planned caesarean straightaway. As one woman said, 'My worry is that I'll give it a go and I'll have a long traumatic labour and then still have to have an emergency caesarean, so you end up feeling a hell of a lot worse than I did last time.' The idea to have an emergency caesarean after having laboured for hours was something that worried both women who wanted to attempt vaginal delivery and those who wanted a planned caesarean.


A few women who had hoped to have a water birth with their next child felt disappointed when they were told that they would not be able to use the birthing pool because medical staff wanted them to be monitored closely from early on in their labour. A couple of women were also concerned that being connected to a fetal heart rate monitor as soon as they arrived in hospital would not allow them to be as mobile as they wanted to be. One woman who had considered a home birth changed hospitals because staff at the first hospital insisted that she should come in as soon as dilation had started. She felt strongly that the medical atmosphere of the hospital environment had interfered with her previous labour, so she decided to hire a doula (a non-medical birth helper) who could support her at home during the early stages of labour.

 

She wanted to keep her next birth as intervention-free as possible and employed a doula - a non...

She wanted to keep her next birth as intervention-free as possible and employed a doula - a non...

Age at interview: 37
Sex: Female
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I want to have a natural delivery, I don't want any interventions, I do not want any drugs, and I hope to deliver outside the hospital environment as much as I possibly can. This morning I've just had an appointment with the consultant in another hospital who said that I can go to a birth suite rather than coming into' a ward to deliver.

Okay, that's important for us to know. So it's not just about avoiding interventions, it's also about the whole medical environment'

Absolutely.

'the ambience and everything?

It's about the interventions and the being taken over, because'. as you're labeled as a VBAC there's interventions and monitoring and stuff. And I know that doesn't help, and I believe that's where I fell down in labour last time. I suppose one thing I didn't mention, which I found very strong from my last labour, was that just as I was getting the epidural in, my husband was very, very supportive throughout the contractions, but just as I was getting the epidural in, the midwife just looked at me and visualised' looked at me and sort of breathed me' just helped me breathe through the contraction. And it was then after reflection I realised that actually I could have got through it because she got me through one of the worst contractions ever. 

Right

And as a result of that I've actually employed a Doula to help me during labour as well. 

 

She wants to attempt VBAC but is not too worried about having interventions. Being connected to a...

She wants to attempt VBAC but is not too worried about having interventions. Being connected to a...

Age at interview: 40
Sex: Female
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And how do you feel now that the choice is becoming more of an imminent one?

Same, I'm just trying to go with the flow and see what happens.

Have you made a birth plan this time? 

No! [laughs]. Although the midwife reminded me of that today. I had an appointment this morning with the midwife and she suggested I just take a look at, you know, maybe what I do and don't want. Because obviously if everything starts off naturally then I need to decide about the pain relief and that sort of thing, so I will do, I will have a look at that. But what they' I can't do is have the birthing pool this time because they'd have to put the monitor on straightaway.

And how do you feel about that?

Well, a bit disappointed because I would have liked to have had that. 'So I'll have to think about the pain relief side and'

But again is staying active something that's important to you this time?

It is although I don't know whether I'll be able to do that this time because I might have a monitor put on me' depending on where I'm up to' I'll probably have a monitor put on me because of having a previous section.

Most women had prepared a birth plan for their next birth or were planning to do so. Some had made a plan together with their midwife, but others had used the internet to help them or just based it on their own ideas. Several women who were hoping to give birth vaginally said they had gone into much more detail than for their previous birth. Having been through the process before, they had a clearer idea of their wants and needs regarding pain relief and birthing positions. One woman also said she felt more confident, second time round, to express her wishes. At the same time several women said it was important to keep an open mind - as one woman said, 'You can make a plan, but who's to say it's going to go that way?...You've just got to be open-minded about it and let nature do its thing.' A couple of women who had decided to have a planned caesarean didn't see the point of making a detailed birth plan, but a couple of others put down things like the kind of music they wanted to have playing and their wishes for contact with the baby afterwards.

 

She made a detailed birth plan for her VBAC and felt more confident to express her wishes knowing...

She made a detailed birth plan for her VBAC and felt more confident to express her wishes knowing...

Age at interview: 26
Sex: Female
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And have you made a birth plan with this pregnancy?

Yes.

You were just saying then about the midwife coming to talk to you?

Yeah.

And what have you said in this birth plan?

Well, to be honest, first of all I was thinking, 'What do I put?' I'm going to have a baby, it's like, 'Okay' mmm.' But I mean you can really go in depth. I mean, if you want music and if you want different oils and all sorts of things like that, because I'm actually having reflexology as well.

Oh, lovely.

So [hesitation], it's like that sort of side of it, did I want those in there, but the thing is because I've, I've had my son, I kind of know about the pains in my back and everything like that. To be honest, if I'm really in the throes of labour, I'm probably not going to want anyone to touch my feet so, you know...? But that option is there if I want it, so obviously I've sort of written about that. And, like I said, because of knowing that I've got labour pains in my back, I kind of have said, "Well if there's a chair I'd like to sort of maybe put my arms over the back of it then my partner can rub my back and'" I think it's because obviously I've sort of been there and done that, I kind of know what to expect and, like I said, I've got more confidence to say, "Well yes, I would like that and I would like room to move and I would like this and that...", you know? 

 

She does not think there is much point making a birth plan for a planned caesarean. It's more...

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She does not think there is much point making a birth plan for a planned caesarean. It's more...

Age at interview: 38
Sex: Female
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And have you made a birth plan with this pregnancy?

I was asked by the' I can't' I think I was asked by the midwife at the GP about doing a birth plan but there was nothing really much to say about it. I think the way I see birth plans, whether its right or wrong is for the first one it was quite detailed and it was would you want intervention, would you want this, would you want that and I didn't, I said I didn't really see the point in doing for a caesarean because it's not, I don't see it as the same.

And how do you think your husband feels now about pending '?

[Laughs] It's hard to say, I mean he's happy. I mean there's absolutely no question of him not coming you know he's come to every appointment and everything so he's been very supportive. And on the actual day, if its anything like last time I had' I don't think' I needed him there, I needed to have somebody there that I knew so you know it's helpful.

And what about feeding this time, have you thought that far ahead?

I'll just try breastfeeding again, if it works, it works.
 
 

She prepared a birth plan for her planned caesarean. She asked to have contact with the baby as...

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She prepared a birth plan for her planned caesarean. She asked to have contact with the baby as...

Age at interview: 19
Sex: Female
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I'm quite excited now. It's a bit worrying thinking that you know what day' so it is a bit confusing, because I know exactly the date and'

You know your baby's birthday beforehand. And have you made a birth plan this time?

Yeah, it's, definitely. I said to the midwife, I said well, when the baby's born, will I be able to have contact. That contact with him, because I felt like I missed out on that the first time, I felt' I don't know, I just didn't, I missed out. 'I didn't get to hold him for a good, quite a few hours after, and I felt like I missed out that, and this time I don't want to.

Okay. And how does your partner feel about you planning a section then?

I think he's, he's worried about the operation. From' obviously for me, more so than like the baby, because there's more risk for me than there is for the baby' But he's quite happy to support me with my decision. He's never, he's said like you know what's best, really you've got a gut instinct really, and I know that if I left it, I just don't think' I think the same thing would happen. I think he would get stuck again, because he's a good size again, so'
 

Last reviewed August 2018.

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