I frequently get asked about options following a previous caesarean. Unfortunately the answer is not straightforward. Hospital policies continue to influence things both overtly in terms of encouragement towards VBACs (Vaginal Birth After Caesarean) and whether or not there is a ban on requested caesareans, but also less overtly through their common practises e.g. their approach to induction / tolerance for the length of 2nd stage labour etc. In addition to hospital policies there are also differences of opinion among practitioners which can alter the options you may be presented with on any given day.
It is very important therefore that you know your rights. “Calmly discussing your options, knowing what can and cannot be insisted upon and the difference between a ‘required’ and ‘suggested’ caesarean, puts you in a strong negotiating position.†‘Caesarean Birth: A positive approach to preparation and recovery’
Trying to avoid a caesarean:
For those wanting to avoid automatically having another caesarean this is increasingly possible, always assuming of course that the reason for the first caesarean is not likely to recur in each pregnancy. Hospitals are being actively encouraged to support VBACs and NICE guidelines state that “Women have the right to choose VBAC.” (pg 22)
Some hospitals offer special clinics aimed at encouraging just this. It is worth asking what is available at your hospital and local doctor surgery as these classes can provide lots of information and support about how to manage your pregnancy and labour such that you may increase your chances of achieving a vaginal birth.
If you continue having difficulty gaining agreement for a VBAC it is worth knowing that the NICE guidelines are very clear on this “For the process of seeking consent to be meaningful, refusal of treatment needs to be one of the patient’s options. Competent adults are entitled to refuse treatment even when the treatment would clearly benefit their health. Therefore a competent pregnant woman may refuse CS, even if this would be detrimental to herself or the fetus.” (pg 71 )
That said it is very important that you understand why a VBAC is not being supported this time round. Just a few examples of the reasons are: there may be genuine medical indicators meaning this is not the safest route for this pregnancy, the practitioner is less confident with VBACs (in which case you may want to consider alternative providers) or you are hearing a practitioners personal opinion coloured by fears of scar rupture rates. I dedicate a whole chapter in my caesarean book to the many things you can try in order to help influence your chances of avoiding another caesarean. In particular I address the mis-information often presented to women on scar rupture rates so that you can make an informed decision about the level of risk yourself.
Requesting a repeat caesarean
For those preferring to have another caesarean this will, in many cases, be dependent upon the opinion or policy of those responsible your care. Some hospitals do not permit maternal request caesareans, even after a previous one, if there is no medical need. (A previous caesarean no longer constitutes a ‘medical need’, unless as already mentioned, your first caesarean was for reasons which are likely to recur in this pregnancy). Where your request is being refused you will need to seek a second opinion and may even (if the opinion is a hospital policy rather than the personal opinion of the practitioner you are talking to) need to approach a different hospital.
The NICE guidelines are very clear on this:
“Recommendation 39: An obstetrician has the right to decline a woman’s request for a CS. If this happens, they should refer the woman to an NHS obstetrician in the same unit who will carry out the CS.” NICE guideline (pg 12)
However the guidelines are just that – ‘guidelines’. NHS hospitals are not required to follow them to the letter so you may find you are requesting a caesarean at a hospital where maternal requests, in the absence of any medical need, are indeed banned in which case you will need to seek an alternative place to deliver.
I talk in a lot more detail in my caesarean book about things to know if you want to avoid or indeed plan a caesarean. In both cases you may find significant barriers are put in your way, but there are quite a lot of things you can do to help you case.
