Birthing following a previous caesarean birth - Angela Willis, The Eco Midwife

Birthing following a previous caesarean birth

Congratulations on your pregnancy. Having had a previous caesarean birth before might trigger many different feelings for this pregnancy. You may be feeling happy, excited, overwhelmed, anxious, nervous, sad or scared. If you had a traumatic birth before, any anxieties or PTSD symptoms you previously had following your last birth might be reappearing. Your feelings and your emotions are totally justified and valid. Accepting these feelings, and understanding them is a way of moving forward positively with any of your future pregnancies or in this pregnancy if you are already pregnant. This blog post outlines ways you can have birth this time round, whatever you decide is right for you and I hope you find this blog useful.

In the UK 25% to 30% of women will have a caesarean birth for a variety of reasons. Caesarean birth can be planned or unplanned. For the majority of women with a previous caesarean, a vaginal birth is safe and is successful around 75% of the time in women who have never had a previous vaginal birth and around 90% of the time for women who have had one previous vaginal birth.

IMG-20191003-WA0002 (1).jpg

It is advised in the UK to book with a midwife around 8-10 weeks of pregnancy and your midwife will make the referral into the Consultants to be cared for by them. Having had a previous caesarean birth you are more at risk of miscarriage, stillbirth, uterine rupture, placenta previa, placenta accrete and preterm birth if you had a caesarean birth at 10 centimeters dilated last time. As a result the consultant will usually see you in the middle and at the end of pregnancy and undertake a risk assessment with yourself. If all is well and you've had a previous lower segment incision (bikini line rather than up and down incision) then you will be given the choice to have a vaginal birth after caesarean birth or repeat elective caesarean birth. Sometimes only a repeat caesarean will be advised if there has been an up and down incision, if you have had more than 4 previous caesarean births, if there has been anything else in you medical history where a vaginal birth might not be advisable.

However, you get the final consent and say over anything which happens to you and whichever way you choose will be totally up to you. You might also want to consider whether or not you plan on having any more babies in the future as the more caesarean births a person has the more chances of complications and risks going forward in future pregnancies and in relation to fertility and therefore making the decision for a vaginal birth isn't always a straightforward and easy as you might think. Where possible try to listen to your own thoughts, feelings and wishes after gaining all the knowledge and information you need to make the decisions which are right for you. However, whichever way your baby comes into the world you decide have so many choices to help you birth this time around.

Trying to conceive after a previous traumatic caesarean birth

Prior to pregnancy one of the first things that you can do is have talking therapies to help you manage the emotions and feeling you may have regarding your previous birth. Birth rewind therapists, trauma focused CBT can help some women who maybe have high anxieties about having another baby or pregnancy because of the complexities that may have happened in the previous birth. Birth rewind Services can also be used during pregnancy if you are reading this already pregnant. Trauma focused CBT will be advised against within pregnancy itself because of the chances of anxiety and stress and the implications that can have on a developing baby. It is worth noting that if there had been any high risk complications from your previous experience which might complicate a future pregnancy, then it might be worth having some pre pregnancy counselling with an obstetrician or GP.

Choosing and having a positive vaginal birth after a previous caesarean birth

If you choose a vaginal birth, there are many things you can do to help have a positive birth this time around. It’s about having as positive a pregnancy as possible as well as a positive birth. You have one of two choices to make: either you can spend your whole pregnancy worrying, anxious, and unhappy or you can choose to have a positive mindset, look into your options and have a great pregnancy. Knowledge and information is power, and women who have a positive experience in labour and birth have been the ones in the driving seat of their pregnancy and birth, rather than a passenger. 

I highly recommend joining the vaginal birth after caesarean closed Facebook group. It's full of positive birth stories (home births, hospital births, and vaginal births, planned and unplanned caesarean births) and it’s all from incredible mums who have had caesarean births in the past. And as we know social interaction with other people with similar circumstances can help improve mental well-being for many mums. It is worth having a long conversation with your own community midwife about what choices you want. As an antenatal teacher and private antenatal teacher, this is one of my most common private one to one sessions – hypnobirthing and individualised birth planning for this baby.

Next hypnobirthing can actually really help going forward in all births. It's not as wacky as it sounds hypnobirthing is not chanting and singing and dancing to the gods and hoping and praying for a natural vaginal birth. Instead hypnobirthing is a tool box of different elements, which help you to have a much more positive birth going forward. It's about questioning and using EBRAINS to give you a huge amount of knowledge so that you can make informed choices which feel right for you personally. It's about questioning the system the policies and the guidelines as this vary depending on where you live. Hypnobirthing gives you coping strategies, breathing techniques, scripts and instils positive values, beliefs, stories and affirmations during pregnancy to help reduce any anxieties or worries you may have, and facilitate you having a calm and positive pregnancy which then helps you in having a calmer and more positive birth. It’s about reframing your subconscious mind so fear doesn’t hold you back during the birth of your baby. Using hypnobirthing puts you in control of your decision making which in turn gives you the power to experience a much more positive birth.

Next have a look into all your choices available, those recommended and then look at the research which exists on the recommendations. For example, the RCOG will recommend birthing in a delivery suite and continuous monitoring because in the small chance of uterine rupture an abnormal CTG will be present in 60-70% of all of uterine ruptures (category C/D evidence – low grade, category A/B is the best available evidence and there is none available on fetal monitoring with VBAC). Uterine rupture is one of the most common risks following a previous caesarean births at 0.5% chance or 1:200 which is overestimated by the RCOG when looking into all available research which exists to date. However, there are a few factors which increase this chance which include having less than a 12 month interval between pregnancies, a previous uterine rupture, being induced with syntocinon or prostaglandins, having a prolonger pregnancy past 42 weeks or a prolonged pushing stage all increase these chances. Essentially what this means is that we will be monitoring around 996 women unnecessarily to predict 4:1000 women having a uterine rupture during their VBAC. Interestingly because of the limited evidence available on the recommendations of CTGS in straightforward VBAC with no other complicating factors, when the NICE guidelines updated in March 2019 for birth after a caesarean the recommendation was to give women choice and let them choose what was right for them in relation to fetal monitoring in labour. Two weeks later the RCOG made expert recommendations that this was changed to advising women to have continuous monitoring in VBAC.

For some women continuous electrical fetal monitoring gives them a reassurance that all is well with them and their baby, and sometimes there are additional factors where a CTG would be recommended for other medical or obstetric factors. For some mums, having continuous fetal monitoring inhibits their movements, inhibits their place of birth choice and also increases the chances of interventions, which they might not necessarily want because of previous experiences in birth. CTG’s can be waterproof and wireless in many cases (and NICE state that any continuous monitor offered should be wireless, however these are expensive and not everywhere has these available or enough of them to provide to all women). Ultimately as with anything in labour and birth, it’s having a think about what is right for you, trusting your instincts and doing what is right for you.

With regards to place of birth following a previous caesarean, the rate of transfer is higher for women with a previous caesarean than in first time mums from the research which exists (again category C/D) and the recommendations from the research available on adverse outcomes from home births is that if uterine rupture is suspected then a caesarean birth should be performed in around thirty minutes to prevent a stillbirth, cerebral palsy or haemorrhage and mortality to women. Many women in the UK choose to have alongside maternity unit births instead, but this is often against the local guidelines. This is where having antenatal discussions with consultant midwives or your own consultants and even considering writing to birth rights is an option if this is something you would like. Often a ‘complex care plan’ and discussion of all the risks and benefits are undertaken ahead of time so it reduces the stress during labour for you on the day as all these discussions and scenarios have been discussed ahead of time with you, leaving no fighting, arguing or stress on the day. At the primary care live conference in 2018, the consultant midwife at Serenity birthing centre stated the transfer rate was 5% of VBAC’s from a co-located birth centre and a 95% successful VBAC rate for women choosing to birth there. And the satisfaction from women regarding their birth preferences and choices was incredibly high on audits. There are a few alongside midwifery units offering this so it is worth taking a look at the facebook VBAC group for extra information. There are many things which can increase your chance of a successful VBAC. These include: 

  • continuous support from a supportive caregiver or doula

  • One to one care from your named midwife

  • Being upright and mobile in labour

  • Having a baby in an optimum position during birth – spinning babies are an amazing resource

  • Entering labour spontaneously rather than being induced

  • Remaining hydrated and ensuring you empty your bladder frequently

  • The power of words and language from your supporting partners and caregivers

  • Being calm and relaxed and avoiding stress or fear

  • Consider being at home in the early stages of your labour

Positive VBAC birth plan: 

If I enter spontaneous labour, this is what I would like:

Home/ midwife led unit (both need a discussion ahead of time as this is often against local guidelines and policies, but can sometimes be implemented in many units with a discussion from a consultant midwife. Worth writing to birthrights too if they won’t facilitate this). 

Continuous monitoring: I would like: Wireless or wired telemetry or Intermittent monitoring. 

If I choose intermittent monitoring but other risks appear in labour such as meconium (baby poo) or signs of infection, would I choose to have continuous monitoring? 

I do/do not choose to have a cannula in my hand

I would like a:  Water birth            entonox           pethidine/diamorphine               epidural

I would/would not like Skin to skin contact

I would/would not like delayed cord clamping

I would like to cut the cord

I would like myself or my partner to have my hands on my baby as they are being born

I would/would not like the injection for my placenta 

I do/don’t have a music playlist/speaker to bring with me

I do/don’t have fairy lights to decorate the room

I would like the lights dimmed

I have a birthing ball and plan to have an upright birth where possible

I have a tens machine to use during birth

We do/do not know the sex of our baby and we do/don’t want to discover this first

Other elements to consider:

If I have not started spontaneous labour by X amount of weeks, would I like expectant management where I have daily or twice weekly monitoring and scans, would I like an induction, or would I like to opt for a repeat caesarean birth? 

If I opt for an induction of labour am I happy having the whole induction from ripening of the cervix, having waters broken or syntocinon or if I don’t want everything what don’t I agree to and if I do choose to have an induction what pain relief would I like? 

Choosing a repeat caesarean birth

A repeat caesarean birth can be just as empowering for mums as a vaginal birth and just as positive when it comes from a place of choice and knowledge and not fear. There are increased risks with a caesarean birth than a vaginal birth both for yourself, your baby and any future pregnancies, but ultimately it is your body, your birth and your baby and if a caesarean is what you want then stand up, speak out and get your caesarean. 

Positive caesarean birth plan

Firstly up breathing from Hypno birthing and Hypno birthing scripts can help keep you remain calm and relaxed during a caesarean birth, especially if you are nervous or anxious about entering a theatre environment. 

Affirm to yourself stating that your baby's going to be born safely a caesarean birth, that this is the right choice for you and your baby and you anticipate your baby safe birth with excitement anticipation will enable you to feel calmer and more comfortable during the Caesarean birth. It’s a way of reducing any anxieties, worries and lowering your heart rate in times of stress

I would/wouldn’t like music played in theatre (as an alternative, you could take your phone with music on and having one headphone in so you are present and able to hear but also able to reduce the noise of everything going on around you).
I would/wouldn’t like the drapes lowered when my baby is being born

I would/wouldn’t like a natural/gentle caesarean (worth enquiring ahead of time as not everywhere is doing this yet – still a fairly new concept).

I would/wouldn’t like delayed cord clamping for as long as safely possible

I would like to discover the sex our baby, please don’t announce it

I would/wouldn’t like myself or partner to be involved in bringing my baby up to my skin (again needs enquiry ahead of time as not many places doing this yet)

I would/wouldn’t like skin to skin in theatre

I would/wouldn’t like to try breastfeeding in theatre if my baby makes feeding cues

I would/wouldn’t like to delay the weighing of my baby if all is well until we get back to the recovery room. If my baby needs weighing sooner please bring the scale close to me so I can see

I would/wouldn’t like pictures of the birth.

I would like my partner to cut the rest of the cord or apply the cord tie if we have one

Bio:

I am a Practicing midwife of eight years, a registered health visitor, I have a masters with my specialties in maternal mental health and birth after caesarean choices. I am also pregnancy massage, aromatherapy, baby massage and rebozo trained. I have a 22 month old daughter who I have just stopped breastfeeding now, and I am a breastfeeding peer supporter and cloth nappy volunteer and ambassador.

You can see more of Angela over at:

Website | Facebook | Instagram