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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.

 

She had not been aware that she could choose to have a caesarean instead of a trial of labour....

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She had not been aware that she could choose to have a caesarean instead of a trial of labour....

Age at interview: 31
Sex: Female
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I didn't know anything about it until I'd gone in for my twenty week scan and I was approached about it then and for me, it was almost like a breath of fresh air because at that point, up until that point, I really didn't know that I had a decision to make, it was almost drummed into me that because I'd had a section before, you'll have to go through a trial of labour this time. So, I really didn't realise that a) I had a decision, and b) I didn't realise, I knew the risks involved of having a section, but I wasn't really aware of all the risks involved of going through a trial of labour, so that was really good for me to read up on that as well. And to be able to compare both, and to work out in my head which, obviously I rated as the worst.

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.

 

She found it helpful to use a decision aid that was not driven by any particular agenda and was...

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She found it helpful to use a decision aid that was not driven by any particular agenda and was...

Age at interview: 42
Sex: Female
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I thought about it and then as the pregnancy got more and more advanced, I got heavier and heavier. And another complication, I got an awful lot of pelvic pain by the end, it started actually, it did start more like about thirty-six weeks, I suppose. That's when I made my final decision, so I hadn't totally made a decision, but obviously I had used your tool in between. Now that was interesting, because obviously that was geared towards my thoughts and what was going through my mind, which again are things you don't necessarily consciously think about that much. You- it's all in the unconscious and, you know, I was probably veering towards an elective caesarean, to be honest, during that time. Then I did your survey, and that was very interesting because again, it was' it highlighted all the risks and my, but it had my priorities on the different risks. And interestingly enough, that came out elective caesarean, so that was kind of, a bit of a' very interesting for me. And, you know, I do think it was helpful, because it obviously was focused on my feelings, not anybody else's, no agendas, so that was helpful. So' so, I do believe about thirty-four weeks, I did see him and we booked in a date for the caesarean and time, which was quite funny, and it was two weeks before I was due, so it was quite funny. But again, I had, you know, it was quite good, again, I had the option, if I changed my mind at the last minute, I could. So that was great. But I think as I got bigger and heavier and I got these pelvic pains and I think by week  sort of thirty-eight, I was due to have it on the week thirty-nine, I thought, 'I'm going to go for this, I'm so uncomfortable', and I was very, very scared of, you know, something going wrong with the natural birth, still so' So it was a combination of everything led me to, you know, I could have changed my mind right up until the last day so, you know, but, but also the tool did really help because it was my worries about the risks and not an agenda that natural birth is better. Which in many ways it is, but not necessarily if you've had a very difficult birth the first time. 
 

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.

 

She changed her mind throughout her pregnancy and kept her options open by booking a caesarean...

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She changed her mind throughout her pregnancy and kept her options open by booking a caesarean...

Age at interview: 31
Sex: Female
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So, have you got the section booked now?

I have, yes.

But if you were to start labouring naturally and everything looked okay'?

I think what I would do is, I mean, well, I know from my first time round that these things don't happen within a couple hours so I think I would, if it happened in the same order, where my waters broke and I had contractions and whatever, I would wait until they were regular and getting close together, and then once I got to the hospital, I think I'd make the final decision. If I was given advice that I was progressing well and that the, the head was definitely in the right position then I might still try for a natural'

You sound uncertain?

Yeah. I am quite uncertain really. I think the thing that makes me so uncertain is that there are risks on both sides, it's not that one is so much more problematic than the other, they are very much balanced. Where one's better than the other then the other one has positives as well. So it is really difficult to make a definite, definite, definite decision. So, again, I'm kind of going back to the, well, maybe see how things go a wee bit, but then if I haven't gone naturally by my date, then that's fine, it'll be an elective.

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. 

 

Her decision to attempt vaginal delivery was guided more by instinct and listening to her body...

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Her decision to attempt vaginal delivery was guided more by instinct and listening to her body...

Age at interview: 33
Sex: Female
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But where do you think the most important and useful information came from for you this time?

'I think it's instinct really, because I think if you want to ask something, or you' something crops up, obviously the midwives, the staff, the consultants, they are there, because I didn't hesitate when I had questions, I think first' I think you listen to your body and then some people don't listen to their body in' I don't know, it's another thing that depends on the individual again.

But for you, it was instinct?

Yeah. Because I think you... I think, same with anybody where you get an instinct where you know something's wrong, so you take the initiative and you phone up the midwife but then some people might delay that call, or' yeah.
 

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.

 

She thinks without the extra information she got from the decision aid she might have felt...

She thinks without the extra information she got from the decision aid she might have felt...

Age at interview: 32
Sex: Female
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To be honest, I felt like a lot of it was left down to me, you know, even when I went to see the consultant. He didn't sort of say, 'Right, this is what we're going to do with you and this is how it's going to be'. Even their attitude was you know, 'What do you want to do?'. And I think if I hadn't have had the information already on board, because I already had seen your program when I saw the consultant, if I hadn't had all that information, I might have felt a bit sort of overwhelmed by that' you know, that much choice sort of thing' not knowing, not knowing what was involved.

 

Having no choice over her first caesarean made her feel like she had failed. She is glad that she...

Having no choice over her first caesarean made her feel like she had failed. She is glad that she...

Age at interview: 19
Sex: Female
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So what do you think your role was in the decision making about the delivery, because the first time you didn't have that choice with the first birth?

No, I feel like I had a lot more sort of choice in this one, a lot more' I don't know, I just felt more informed. I think because you've got no choice you feel worse because you feel like you've failed. This time it was my decision to do that, and when you've got people' some people did look and say, 'Oh well, wouldn't you want to have a normal labour, wouldn't you like to try for a normal labour?' And at the end of the day I think if you' it's what you feel happy with, so' and I did feel happy with it... So yeah, I was quite'

So how do you feel about the way that this baby was born?

Brilliant, I feel differently actually than with' with [child's name] I felt, I just felt' after I felt ill and I felt like I'd failed. And I was quite, it got me quite down actually. But this time I was sort of' I couldn't believe how well I felt, I felt, like I felt too well, that I was going to' I was panicking that I was feeling too well really and that I was a lot more' I don't know, it just felt the way I would expect you to feel after you've had a baby, I felt this time. Unlike last time I didn't, I didn't feel' you're supposed to be happy when you've had a baby, but the first time I didn't. But this time I was just' it was really, really nice, it was a good experience. 

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. 

 

She initially struggled to reach a decision because she thought her doctor and midwife might be...

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She initially struggled to reach a decision because she thought her doctor and midwife might be...

Age at interview: 33
Sex: Female
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Basically they just went through, discussing my sort of previous pregnancy, my discussion on whether I would have a section this time or not and at that point in time I wasn't actually clear as to- as to how I wanted to go, so they arranged for me to have some time to think about it and, and come back. When I saw the midwife, but I had made a decision then so I didn't see the obstetrician again.

And can you tell me a little bit more about why there was an indecision there about what way to deliver? 

Mainly because I felt at that point in time although I had the information in front of me, I wasn't a hundred percent sure I was getting all the information I required from the sort of medical team. I was sort of, I didn't want them to tell me, 'Oh' you'll have to have it this way', but I had a sort of sneaking, unless, you know, at that time, that I might be, being allowed and (encouraged) to go with the trial labour even though at the back of their heads they knew that I was going to end up with a section, and I think I'd have rather been told that there wasn't a possibility than, than, 'It's up to you to decide', even though it's going to be taken out of your hands anyway. But then I explained that to the midwife the next time I went in that that was kind of what my concern was and she said, well, you know, obviously there wasn't really a clear explanation for why, I hadn't managed to deliver my first twin, even after all that length of time, so, you know, it was possibly worth a, worth a try and it was obviously more difficult with twins in the circumstances, high blood pressure and things, so, that was kind of fine. But at the time I didn't feel I was maybe getting all the information and I'm aware it's because of informed consent, you can't tell the patient, 'You have to have this', but on the other hand, I think I'd have felt comfortable if they'd have said, 'Well, you can have a trial labour, but in your particular circumstances there's a ninety-five percent chance it's going to be a section anyway because of x, y and z', rather than sort of say, 'Well, everybody's entitled to try', you know, so, but, that's why I couldn't make up my mind originally, so'
 
 

She was very worried about making the wrong decision.

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She was very worried about making the wrong decision.

Age at interview: 22
Sex: Female
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I've wanted someone to tell me what the right option is really. But nobody, obviously the doctors and midwife, they, they don't really necessarily recommend which one. They, they keep saying, 'It's up to you, it's up to you' and giving me the benefits and the risks, so I'm still sort of thinking, 'Oh, is it all down to me? Am I going to make the right one?' Whereas if somebody said, 'We think you should do this', I would go by that.

And how have you got on with your midwife in this pregnancy? 

Fine. Yeah, yeah.

Has she been able to answer any of your questions?

Yeah, I mean, we only discussed birth plan-wise yesterday, and she didn't really seem concerned about having' attempting for a normal delivery. And I've had a few talks with the consultant at the hospital and, it's the same really, they, they're not really concerned either way. 

Right. How do you feel about that? About that they're not worried. Has that made you less worried?

Not really, because I sort of think they don't understand that I am worried, if you see what I mean. 

Yeah, I do' So you've been able to discuss your fears and your expectations have you, this time?

A little bit, a little bit, yeah.

So how involved do you want to be in the decision, because it sounds from what you've been saying like you want them to make the decision for you?

Yeah, yeah.

Why do you think you want them to tell you? 

Because I think they've had a lot more experience with this, and I know they say the percentages on the risks and everything, but I just think it - from a medical opinion I think it would be better if they took reign and said, 'This is what you should do'.
 

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'.)

 

She struggled to make up her mind about how to give birth and almost wished the decision would be...

She struggled to make up her mind about how to give birth and almost wished the decision would be...

Age at interview: 30
Sex: Female
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And what kind of information have you wanted with this pregnancy? Have you thought about different things this time? 

Well, obviously the, the main different thing has been obviously I've known that I'm going to have to have this decision at the end of what option to go for, whether, you know, the planned or the natural. And it's sort of been at the back of my mind, but I've been very indecisive all through really, which is me, I guess. I am an indecisive person, and because it's something so important, it's just really horrible actually, I'd rather' My sister's second delivery, she' her baby was breech so, you know, the option, it was sort of- the decision was taken away and I, I kind of almost wished that, that this baby was breech, you know. So I wouldn't have to decide and it wouldn't be, you know, if it was the wrong decision, that it wouldn't be my decision' which is really silly.

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. 

 

Her low-lying placenta meant that she had to have another caesarean. Looking back, she thinks the...

Her low-lying placenta meant that she had to have another caesarean. Looking back, she thinks the...

Age at interview: 30
Sex: Female
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It was a fait accompli, so I had no- I've got no emotional baggage, I suppose about having chosen that. If I'd been given the option, I mean, in the early stages of the pregnancy, I thought I had the option, and at that time I was thinking, 'Well, I'd really like a natural delivery', but part of me was saying, 'Perhaps I should go for an elective because it's easy and I don't have to push and it won't hurt at the time and you know when it's going to happen'. So there was a temptation towards that. And I think if I'd have had the choice right to the end and chosen the elective, a part of me would always then be thinking, 'I should have given it a try, doing it 'properly' i.e. naturally'. 

And I think if I'd left it and intended to choose a natural delivery, part of me would be saying, when I was one day overdue, 'Why didn't I choose an elective, I would have had it by now'.

So, in some ways this takes the pressure off'?

'it does, yeah'

'this was out of your hands?

Yeah.

 

She felt anxious when a growth scan at 34 weeks showed her baby to be breech as she did not want...

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She felt anxious when a growth scan at 34 weeks showed her baby to be breech as she did not want...

Age at interview: 33
Sex: Female
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Yeah, I mean, I actually went for a growth scan at thirty-four weeks and the baby was breech [right] at that stage, and I was actually booked in for a Caesarean, which was really upsetting for me. But luckily obviously the baby's turned and the section has now been cancelled, because I was due to have it next week.

Did that cause you anxiety?

It did, yeah, I didn't' because again I felt like everything was out of my control and I had no choice in the matter, it did cause a bit of upset.
 

Last reviewed August 2018.

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