1. B IRTH AFTER C AESAREAN Making your decision Royal Surrey Supervisors of Midwives @rschsupervision

2. W HAT ARE YOUR CHOICES ? VBAC Vaginal Birth After Caesarean ERCS Elective Repeat Caesarean Section Planned LSCS or ERCS; this is when a woman who has had a caesarean section plans to have another LSCS. Most babies that are delivered by LSCS are delivered by a horizontal incision in your abdomen at your pubic hair line. In a repeat LSCS the old scar will be removed to help the new scar heal. VBAC is when a pregnant woman who previously had a caesarean section plans to deliver her next baby vaginally. It is recommended that this birth takes place in hospital, so both mother and baby can be monitored for any potential problems during labour.

3. W HY DO CAESAREAN SECTION RATES MATTER ? In 1990 the National Caesarean Section rate was 12% In 2010 the rate had risen to 23% BUT Despite the increase in LSCS there has not: - Been a measurable improvement in the outcome for babies. - Hospital stays have increased - Infection rates have increased

4. W HICH WOMEN ARE BEST SUITED TO PLAN A VBAC ? MOST women with a single baby pregnancy In a head down position after 37 weeks After one previous caesarean section This is not dependent on having a previous vaginal birth

5. W HY YOU WOULD BE RECOMMENDED NOT TO HAVE A VBAC Previous Classical incision CS Previous uterine rupture Three or more LSCS Some uterine surgery – individualised plan of care Placenta Praevia

6. VBAC 75% of women who attempt a VBAC succeed and have a vaginal birth. 25% will have an emergency caesarean section if labour does not progress as expected or as an immediate danger to mum or baby. ERCS 98% of women who book to have a repeat caesarean section will have one. 10% will go into labour before they can have an elective caesarean section. If a woman arrives at the hospital in advanced labour it may be safer for her and her baby to continue with a vaginal birth. This would be discussed with you at the time.

7. V BAC SUCCESS RATES @ RSCH Maternal choice for deliveryMode of Delivery for those attempting VBAC However if you have had a previous vaginal birth the VBAC success rate is 85-90% 52%63% 16% 22%

8. W HAT MAKES A VBAC LESS LIKELY TO BE SUCCESSFUL Induced Labour Induction is only considered in a modified form after discussion with Obstetrician 2 – 3 fold increase in risk of uterine rupture 1.5 fold increase in risk of Emergency Caesarean Section in induced or augmented labour compared with spontaneous labour No previous vaginal birth BMI >35 Previous LSCS for an obstructed labour If ALL these risk factors are present then the success rate falls to 40%

9. H OW TO MAKE IT MORE LIKELY YOU WILL HAVE A SUCCESSFUL VBAC Prepare! Maintain a healthy weight Practise Hypnobirthing Use water to labour – we have wireless monitors to record babies heart rates Keep mobile & active in labour Remain calm Be supported by our staff experienced in VBAC

10. W HAT ARE THE RISKS OF VBAC? Uterine rupture – which is any separation of the scar Current research indicates a 0.5% risk (1 in 200 women) VBAC is associated with 1% increase in the risk of needing a blood transfusion

11. VBAC VS ELRCS

12. B ENEFITS TO VBAC Quicker postnatal recovery Shorter hospital stay Reduction in long term health risks - adhesions No limitations on driving Breastfeeding is easier to facilitate Reduces likelihood of baby needing SCBU care

13. D OES VBAC POSE A RISK TO THE MUM & BABY ? VBAC has an equivalent risk for birth related death to women birthing their first baby. 4:100,000 HIE (oxygen depravation during birth) is 0.08% in VBAC. The same as in any vaginal delivery

14. D OES VBAC GIVE ANY BENEFITS TO THE BABY ? VBAC reduces the risk of respiratory problems in the baby by 2% Immediate skin to skin is easier to facilitate with all its associated benefits Delayed cord clamping after vaginal birth benefits babies by giving: increased iron levels reduction in need of resuscitation

15. VBAC – WHAT TO EXPECT …. Women planning VBAC are advised to birth in an Obstetric Led Unit Continuous electrical fetal monitoring is recommended to assess both baby’s wellbeing and uterine activity. Wireless machines available to facilitate movement and labour in water One to One care in labour All forms of pain relief are suitable Regular vaginal assessments of progress

16. W HAT ARE THE RISKS TO MUM OF E LECTIVE C AESAREAN S ECTION ? Increase in serious complications for future pregnancies Placenta Acreta or Praevia 11 - 14% Infertility and miscarriage Increased risk of complications associated with surgery Infection Bleeding and need for blood transfusion Blood clots Hysterectomy Bladder or Bowel injury Admission to ITU Cardiac arrest

17. W HAT ARE THE BENEFITS OF E LECTIVE LSCS? Date of birth is planned (unless the baby has other ideas!) Reduces ‘uncertainty’ Reduction in vaginal injuries Option for sterilisation

18. R EPEAT C AESAREAN S ECTION AND RISKS TO THE BABY Increase in risk of breathing problems for baby TTN : ERCS 4-5% VBAC 2-3% RDS: ERCS 0.5% VBAC 0.05% These risks are higher in babies less than 37 weeks but can be reduced by the administration of steroids 24 hours prior to ERCS Lacerations to baby during surgery

19. S PECIAL C IRCUMSTANCES THAT CAN FACTOR IN MAKING YOUR DECISION Active maternal infections Breech presentation Preterm birth Most will deliver quickly if spontaneously labouring Multiple pregnancy Increased risk of preterm birth Increased risk of scar rupture – ERCS would be advised Short pregnancy interval VBAC not recommended within a year

20. E LECTIVE LSCS – W HAT TO EXPECT ….. Planned date after 39 weeks Pre-assessment appointment in week before surgery Timed admission to Delivery Suite for final preparations Nothing by mouth from midnight and pre-meds at home Recovered on Delivery Suite before transfer to LSCS Bay on Shere ward Minimum 2 day hospital stay CONSIDER – What will I do if I labour?

21. C OMPARISON OF R ISKS FOR M UM Uterine Rupture 0.05% Blood Transfusion 2% Maternal Mortality 0.0004% No complications to future pregnancies Endometritis same risk Uterine Rupture <0.02% Blood Transfusion 1% Maternal Mortality 0.013% Future pregnancy complications – placenta praevia/accreta, fertility issues, miscarriage Endometritis same risk VBACERCS

22. C OMPARISON OF RISKS FOR BABY Transient Repiratory Morbidity 2-3% Stillbirth after 39 weeks 0.1% HIE 0.08% Transient Repiratory Morbidity 4-6% Stillbirth after 39 weeks – negated by ERCS at 39 weeks HIE 0.01% VBACERCS

23. I S THERE A ‘ RIGHT ’ CHOICE ? Each woman and her partner will have their individual perspectives regarding risks and benefits Previous labour and birth experiences will influence any decisions made or preferences you may have Decisions should be made after thorough consideration of the current evidence and discussion with both senior Obstetric and midwifery staff to ensure you have all the information required to make an informed choice

24. The choice is individual and yours! We want you to have the right birth on the day for you. No two babies, pregnancies or labours are the same. We hope you found this evening informative. Thank you for coming. Questions?