Making decisions about birth after caesarean

Women's views on choice about birth

National Institute of Health and Care Excellence (N.I.C.E.) guidance to health professionals* is that decisions about how to give birth after a previous caesarean should be guided by the woman's preferences, as long as there are no strong medical reasons why one birth method would be more appropriate than the other. In other words, pregnant women who've had a previous caesarean and do not have specific medical complications should be allowed to choose the way they want their next child to be born. Vaginal birth after caesarean (VBAC) and a second, planned, caesarean carry different kinds of risks. Whilst the majority of women (3 out of 4) who attempt VBAC will have a vaginal birth (who have had a straight forward pregnancy and who go into labour naturally)**, about a quarter will require an emergency caesarean. The risks of emergency caesarean are typically greater than those of a planned section. For this reason, different women are likely to reach different conclusions when weighing up the risks and benefits of different ways of giving birth. 

Many women we talked to felt that they had a choice in how they delivered their next baby. However, several women suggested that the process of making the decision hadn't followed the clinical guidance. They felt that doctors or midwives had tried to push them to have a VBAC or, less often, a caesarean. Even though some of the women had managed to assert their birth preference in the end, they felt that their wishes and concerns had, on occasions, been side-lined in the discussions they had with health professionals (see also 'Women's experience of making the decision'). 

We were interested to find out what women thought about the idea of 'choosing' how they wanted to give birth' Did they think it was a good idea for women to be offered a choice? Or did they think that health professionals should be able to make the final decision, whilst taking into account women's views? How realistic did they think it was to treat method of birth as a real choice?

Not all women had been aware they would be able to decide how they wanted to give birth when they became pregnant again after a previous caesarean. A few had assumed that having one caesarean meant that they would have to have another. A couple of others were surprised to find out that they could actually ask for a caesarean even if it was not medically necessary. 

Most thought that women should be involved as much as possible in decisions about how to give birth. But they had different views about who should have the final say if women's preferences were at odds with the recommendations of doctors. Several thought that women want to have and should have full choice over how they give birth. However, some of them also said that they personally disagreed with the idea of having a caesarean for the sake of convenience. A couple of women stressed that it was important for women to receive trustworthy and balanced information so they could make a well-informed decision.

For some women, their way of thinking about birth choices was influenced by their experience of not getting the birth they had wanted. One woman who had wanted a vaginal birth but had accepted doctors' advice to have a caesarean when she went past her due date, felt it was important to remain realistic about how much control women could actually have over the birthing process. Other women who had not been able to give birth in the way they wanted nevertheless stressed that being involved in decision-making had been very important to them.

A few thought that giving women complete choice over how they want to give birth could be a problem and that if a woman's preference for birth was questionable for medical reasons, the final decision should rest with medical experts. They felt that 'a little knowledge can be a dangerous thing' and that women might be swayed towards 'wrong decisions' by media stories and other less reliable sources of information. One woman said she just didn't feel she had enough medical knowledge to take an active part in decision-making. 

A few women felt burdened by the responsibility of deciding how they should give birth. They worried whether they were making the right decision for their baby and would have liked more guidance from health professionals than they actually got. As one woman put it, 'sometimes people just like to be told'. (See also 'Women's experience of making the decision'). 

A few women who were in favour of women having complete choice over how to give birth felt that exercising that choice might be easier for some women than others. One woman thought that as a nurse she had been able to 'play the system' and assert her wish to have a VBAC and stay at home for the first part of her labour even though doctors had advised her against it. Another woman who had decided to go private for a planned caesarean acknowledged that other women might not have the money to do the same if they found it difficult to assert their wishes against the views of their NHS doctors.

A couple of women thought that those who don't have a strong preference about how to give birth at the start of their pregnancy might end up being pushed into a particular direction by the views of health professionals. They felt that women generally did have a choice, but only if they were sufficiently vocal and well-informed to argue their case.

* The guideline on caesarean section was published in 2011 by the National Institute of Health and Care Excellence (N.I.C.E.). Nice guidance states' ‘Inform women who have had up to and including four CS that the risk of fever, bladder injuries and surgical injuries does not vary with planned mode of birth and that the risk of uterine rupture, although higher for planned vaginal birth, is rare.
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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