These are answers to questions that women have frequently asked us. If you do not find an answer to your particular question or you need more details than the answers below provide, then please email Gina (email@example.com) or Debbie (firstname.lastname@example.org). We hope to continue to extend this FAQ to answer more of the commonly asked questions about caesareans and VBAC. Many more detailed answers can be found in the books on the reading list, and in the various articles
Although you do not have a right to demand a caesarean in this country (UK), you can often negotiate one. Many women with a fear of birth have a psychological need for a caesarean and this IS a medical reason. Many women are surprised when they discuss their concerns with their health professionals that a caesarean birth is agreed to without argument. Other women prefer to organise a caesarean privately.
Women with a fear of birth should be offered counselling and support. Sometimes, with good support, women have gone on to have really good vaginal birth experiences - births that they really could not have seen as a possibility before. Good one-to-one midwifery support has usually been crucial in these cases.
Where a woman cannot come to view vaginal birth more positively, then a report from a psychologist or counsellor can be helpful to the obstetrician when making the decision to offer a caesarean section on the basis of psychological need.
All women considering a caesarean, for whatever reason, should be fully informed of the realities involved, including the possible challenges of recovery. Women should also be aware that caesareans are not without risk and that although these may be small, for the unlucky few they can be quite significant. If you are in the process of negotiating a caesarean, then demonstrating you are aware of what you are opting into, makes it easier to argue your case.
There is no set time before you can drive again. However, it is important that you are able to be in full control of the vehicle, and this would include being able to do an emergency stop, without hesitation due to pain or even the fear of pain.
There is also the issue of insurance, although most insurance companies will be able to reassure you that your cover would not be affected, it is worth making sure that yours is not an exception. Occasionally companies will advise getting written comfirmation from a doctor that you are fit to drive.
Most women do not feel fit to drive for a few weeks after a caesarean, and it has been common for women to be informed not to drive for 6 weeks. It is likely that this advice was linked to the timing of the routine postnatal follow up appointment which used to take place around 6 weeks after the birth. Providing you are recovering well, and that you have checked your insurance cover, it may be possible to drive safely before this time.
The gap that you should have between your last pregnancy and the next is your decision, although there is evidence that the uterine scar does become stronger over time. Research has looked at different gaps between pregnancies from those grouped as "less than 6 months" up to those grouped as "longer than 2 years". The risk of uterine rupture or of the scar separating remains small even with small intervals, but gaps of less than 6 months had the highest risk.
However, the risks are tiny in all cases and most mothers who go on to have a small gap between pregnancies do not encounter problems. Despite research showing slightly higher scar separation rates when inter-pregnancy gap is shorter, it can still be argued that a VBAC is the safer choice.
Child spacing is a very personal decision, which is far more complex than consideration of caesarean scar rupture statistics. It is your decision to make and factors such as your age, how easily you are likely to conceive, your general level of health, and how ready you feel to start another pregnancy, are all likely to be important to you in making that decision.
There are plenty of women who have had perfectly straightforward vaginal deliveries when the gap between pregnancies has been very short.
There have been lots of research studies into VBAC, and there is a very large amount of data about the risks of uterine rupture and scar separation.
It can sometimes be difficult to differentiate between what the research papers are referring to in terms of a scar separation and a uterine rupture, but what is clear is that serious cases of uterine rupture are rare.
It is these cases of true uterine rupture that are the concern, as on the rare occasion that it does occur it is a serious problem, requiring an immediate caesarean section for the sake of both the mother and the baby. The NICE Caesarean Guideline www.nice.org.uk/cg013 quotes a rate of rupture during VBAC as 0.35%, which is taken from an audit carried out in 2000. This audit also found the rate of rupture at a repeat caesarean to be 0.12%
Research incidates that there may be a defect or 'anomaly' of some sort in a many as 2% of cases. However, in the majority of these cases no problems are caused to mother, baby or labour. In many cases it is believed that such scar anomalies may go unnoticed or are 'silent' - that is they do not cause any problems; they are benign.
Even in the serious cases, the woman's uterus is usually repaired and her baby unharmed (see Louise's and Claire's birth reports). We are not aware of a single case where a mother has died from a uterine rupture with no other complications or illness.
Research has also shown that rupture rates are increased by the use of induction and it is unlikely that any study other than those looking directly at the effects of induction, will have excluded induced labours from the data. We have noticed that most of the rupture stories that we read on the internet have followed induction, and many with tragic outcomes have involved poor standards of maternity care.
Although women are often told that they can't have a VBAC for a variety of reasons, there are very few cases where a VBAC is not a real and a reasonable option. The article Caesarean Myths Exploded deals with the issues of VBAC when you are thought to have had CPD (cephalopelvic disproportion - where the baby's head is believed to be too big to go through your pelvis) and VBAC when you have a non LSCS (Lower Segment Caesarean Scar) such as a classical or a low vertical uterine incision.
There are many reasons women are given for not being able to have a VBAC including having had more than one caesarean , having a gap between pregnancies that is considered too short (see How long after a caesarean should I wait before having another baby?), your baby is breech or you are expecting twins, you are too old, too fat; the list is endless.
Really the only reasons that you would need to have a repeat caesarean is if you had a reason in the current pregnancy that would warrant a caesarean even if you had not already had one. These issues are covered really well in the book Birth After Caesarean by Jenny Lesley.
Many women are told that if they have already had two or more caesareans, that any future babies will need to be delivered by repeat caesarean. This is usually not be the case.
Many women have had VBACs after 2 or 3 caesareans. We are aware of at least 12 women in the UK who have had a VBA3Cs (Vaginal Birth After 3 Caesareans) in just over a decade and two who have had a VBA4C; the numbers after 2 caesareans are much larger. Some of these women have also chosen to give birth to their babies at home. (Debbie's, Jenny's and Nikki's birth reports)
There is concern that multiple caesareans would lead to a weaker uterine scar and that risk of rupture would therefore increased. However there is a lack of research evidence to support this theory and an article appearing in the British Medical Journal in 1991 asking "Elective section after two sections - Where's the evidence?" basically came to the conclusion that there wasn't any evidence to support this common policy. (Ref: Roberts, Lawrence W; British Journal of Obstetrics and Gynaecology, December 1991, Vol 98, pp 1199-1202)
Recently the RCOG (Royal College of Obstetricians and Gynaecologists) have made a statement of reluctant support for VBA2C, and say in their VBAC guideline that was published in February 2007:
"Women with a prior history of two uncomplicated low transverse caesarean sections, in an otherwise uncomplicated pregnancy at term, with no contraindication for vaginal birth, who have been fully informed by a consultant obstetrician, may be considered suitable for planned VBAC."
Whether or not a women is considered suitable or not for VBAC does not alter her right to make her own decision about whether or not to labour and give birth
Here in the UK women have the right to refuse any treatment that is offered, therefore you cannot undergo a caesarean until you have consented. Knowing you have a right to refuse though is one thing, having the courage and confidence that you can go against medical advice without harming your baby is another. If this option is of interest to you it is likely you may want further information and support, so please don't hesitate to contact us.
There is no set limit on the number of caesareans that can be carried out on an individual woman. We are aware of at least one women in this country (UK), that has had a seventh caesarean fairly recently.
A first caesarean is considered to be a relatively simple operation, but subsequent caesareans are not so easy or predicatable, due to the scar tissue that remains from the previous surgeries. Damage to the bladder or bowel may be more difficult to avoid during subsquent surgery and women can be unaware that they have had such damage repaired during a caesarean. The risk of requiring a hysterectomy increases, but as at least one women thinking about having another caesarean and considering the risks has said: "There is no point having my uterus, if I am not going to use it!"
Many women have found themselves put under pressure to be sterilised because they have had several caesareans. Even offering sterilisation at a caesarean is considered by some to be unethical. The NICE guideline www.nice.org.uk/cg013 states that if a woman requests sterilisation it should be agreed and documentated at least a week before the caesarean is performed - this gives the woman time to reconsider should she need to.
Some women have found it helpful to make an appointment to speak to their consultant about the last caesarean, to check whether there were any specific problems during the surgery that might suggest additional risks in their individual case.
No, not usually and when they are it should be in the direction of the muscle, so that the fibre of the muscle should on the whole remain intact.
It is rare to use a knife or other cutting implement other than for the skin and for small incisions in the peritoneum (the membrane that lines the abdominal cavity) and the wall of the uterus which are then extended "bluntly" - usually using a finger.
So, usually the skin is cut, the abdominal/rectus muscles underneath are separated, then a small cut is made in the peritoneum which is then torn apart further (and may or may not be repaired). Then a small cut is also made in the uterus which is also enlarged by tearing. There is good evidence that tissue that has been torn rather than cut heals better.
The following description comes from the NICE CS guideline www.nice.org.uk/cg013
"Pfannenstiel, Maylard and Joel Cohen all described transverse abdominal wall incisions used for CS. The Pfannenstiel incision consists of a curved skin incision, two fingers breadths above the symphysis pubis, transverse incision of the sheath, rectus muscles are separated bluntly and the parietal peritoneum is incised is the midline. Maylard incision is similar but the rectus muscles are cut transversely with a knife. The Joel Cohen incision is a straight skin incision 3 cm above the pubic symphysis, then subsequent layers are opened bluntly and if necessary extended with scissors and not a knife." [page 62 - full guideline]
The following give a descriptions of techniques used at caesarean sections
WHO(world health organisation) - Managing Complications in Pregnancy and Childbirth - caesarean section
Cochrane database - review protocol - Abdominal surgical incisions for caesarean section