VBAC or Repeat C-Section

Why is the decision between VBAC (vaginal birth after cesarean) and repeat c-section
important?

Why do I hear conflicting information about VBAC vs repeat c-section?

How can this website help you learn about, decide on and plan for a VBAC or a repeat
c-section?

Why is the decision between VBAC (vaginal birth after cesarean) and repeat c-section
important?
If you have had one or more cesareans, your decision about whether to plan a VBAC ("vee-
back") or a repeat cesarean section can have far-reaching consequences for you, your baby,
and any future pregnancies. You will want to become well-informed about VBAC, understand
the trade-offs between VBAC and repeat cesarean, and weigh your own values and concerns
so that you can come to a decision that is best for you. Once you reach a decision about
VBAC delivery or cesarean delivery, careful planning can help you reach your goals.

Unfortunately, a growing number of hospitals and doctors, fearing lawsuits, do not allow you
to weigh the facts, consider your preferences and choose for yourself regarding VBAC and
planned repeat cesarean. If you wish to use their services, you must accept surgical delivery.
Your best approach is to become informed and clarify your goals well in advance and then
seek care that is in line with your preferences and birth plan.

Why do I hear conflicting information about VBAC vs repeat c-section?

During much of the last century, a woman who had a cesarean section almost always had a
planned repeat c-section and not a VBAC for any births that followed. Doctors were
concerned that the scar from the past cut in the uterus could open during labor (uterine
rupture), and cause serious complications for mother or infant.

During the last quarter century, however, many health professionals, advocates, pregnant
women, policy makers and researchers encouraged vaginal birth after cesarean (VBAC) in
light of:

• change in location of the uterine cut to an area much less likely to open during a
VBAC labor
• growing body of research establishing the safety of VBAC

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 • growing recognition of c-section risks.

Now the pendulum is swinging back from vaginal birth after delivery, with new calls for
routine repeat c-sections. This reversal leaves many women with cesarean scars struggling
to make sense of conflicting, incomplete, and sometimes misleading information about the
safety of VBAC vs. repeat c-section and about what birth plan to make this time around.

How can this website help you learn about, decide on and plan for a VBAC or a repeat
c-section?
This section of the website provides reliable information and support to help you understand
the issues surrounding planned VBAC vs. planned repeat cesarean. In it, you will find:

• an in-depth look at your options and the current medical climate for women in
your situation
• results of the best available research comparing risks of VBAC with repeat
cesarean, including shorter- and longer-term outcomes in mothers and babies and risks
for any future pregnancies
• tips for reaching your childbirth goals, whether your birth plan is for VBAC or a
repeat cesarean
• VBAC and cesarean resources: websites, books, and organizations for information
and support.

Options: VBAC or Repeat C-Section

Which is safer for my baby: planning a VBAC or a repeat c-section?

Which is safer for me: planning a VBAC or a repeat c-section?

Which will be safer for me and my babies in any future pregnancies: planning a VBAC
or a repeat c-section in this pregnancy?

Why is it important to keep options open for VBAC or repeat c-section?

How does my right to "informed consent" or "informed refusal" relate to my decision

about VBAC vs. repeat c-section?

How can I learn more about my specific situation?

What if a cesarean is recommended for a new problem that is a not an urgent matter?

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What are some special scar-related situations when a planned c-section might be
recommended, but research has not found any extra risk of having problems with the
scar?

Are there any factors that do increase my risk of having problems with the scar?

Are there any situations where the risk of the scar giving way (uterine rupture) is so
high that labor should not be attempted?

Does starting labor artificially (induction) affect the likelihood of uterine rupture?

Are there any situations where the risk of the scar giving way (uterine rupture) is
somewhat lower than average?

What factors increase my chances of having a vaginal birth if I prefer VBAC?

Though I prefer VBAC, would it ever be wise to plan repeat c-section due to a
situation with very low chances of having a vaginal birth?

What can I do if fear of repeating another difficult labor is holding me back from
considering VBAC?

What if deep fear of labor is holding me back from considering VBAC?

I've gotten the information, and I'm feeling torn: how can I decide?

Which is safer for my baby: planning a VBAC or a repeat c-section?

The choice between vaginal birth after cesarean (VBAC, "vee-back") and repeat c-section is
sometimes presented in black and white, with some holding the opinion that another
cesarean is safest for your baby. It is true that the c-section scar can give way (uterine
rupture) during labor and that this is on rare occasions life-threatening for the baby. The
decision is not so simple, however, as a c-section also poses risks to babies. This website can
help you consider the full range of risks involved when making your decision. You can find
detailed information about these risks in Best Evidence: VBAC or Repeat C-Section and Best
Evidence: C-Section.

Which is safer for me: planning a VBAC or a repeat c-section?

Both vaginal birth after cesarean and repeat c-section involve some increased risks to
mothers. However, without a clear, compelling and well-supported need for c-section in the
present pregnancy, planned vaginal birth is safer overall for you than a planned repeat c-
section. With supportive care, 75 or more out of 100 women who plan VBAC give birth

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vaginally. The others go on to have another cesarean, primarily for reasons that are
unrelated to the scar.

A planned cesarean offers certain advantages over a cesarean that takes place after labor
is underway: a planned cesarean is less likely to involve injury to other organs during surgery,
to lead to infection after surgery, and to take an emotional toll. Nonetheless, whether
planned or unplanned, cesarean sections are major surgery and involve pain, a post-operative
recovery period, and greater risk for mothers in many areas. You can find detailed
information about these risks in Best Evidence: VBAC or Repeat C-Section and Best
Evidence: C-Section.

Which will be safer for me and my babies in any future pregnancies: planning a VBAC
or a repeat c-section in this pregnancy?
A VBAC in your current pregnancy is the far safer choice for any future pregnancies you
may have. Each additional cesarean operation increases the amount of internal scarring
(adhesions) and the number of uterine scars. The accumulating scar tissue makes it more and
more difficult for the egg to make its proper way from the ovary into the uterus and for
the placenta that nourishes the baby to grow and attach normally. These problems can pose
life-threatening risks to babies and mothers. The scarring can also pose challenges for
future surgical procedures, cesarean or other.

A VBAC this time around has other advantages in future pregnancies. If a woman who has a
VBAC has more children, she almost always gives birth vaginally and her uterine scar almost
never gives way during future labors.

Why is it important to keep options open for VBAC or repeat c-section?

Dozens of studies involving tens of thousands of women have concluded that planned VBAC is
a reasonable choice in nearly all cases. Unfortunately, other factors have come into play on
this issue. These include changing cultural views of c-section, VBAC and vaginal birth in
general, and fears of legal claims and lawsuits. Many discussions of this matter fail to
recognize the full range of risks involved with surgical birth. For these reasons, caregivers
and hospitals that offer VBAC are becoming ever more difficult to find. Nonetheless, every
woman should have the opportunity to carefully weigh the benefits and potential hazards of
planned c-section versus planned VBAC and make the decision she feels is right for her, her
baby, and her family.

How does my right to "informed consent" or "informed refusal" relate to my decision

about VBAC vs. repeat c-section?
Informed consent is a process to help you decide what will and will not be done to you and
your body. In the case of maternity care, informed consent also gives you authority to
decide about care that affects your baby. The purpose of informed consent is to respect
your right to self-determination. It empowers you with the authority to decide what options
are in the best interest of you and your baby. Your rights to autonomy, to the truth (as best
as it can be known at the time), and to keep yourself and your children safe and free of

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harm are basic human rights. As the person receiving care and mother of your baby, you are
in the best position to decide what risks are important to you.

Whether you wish to plan a VBAC or a repeat c-section, it is important to make this decision
on the basis of complete, accurate, unbiased information. In practice, you will not always
have access to your choice, as providers, hospitals and birth centers also have rights and
may choose not to offer some types of care. However, others in your community or
surrounding communities may offer the type of birth you want, including emotional support
that addresses fears or anxieties that you may have.

How can I learn more about my specific situation?

It is essential that you seek information beyond what is provided here. Your caregivers are
an important source of this information. If your caregiver proposes a repeat cesarean or a
VBAC, ask:

• What is involved in this particular course of action?

• Are there any special considerations for my specific situation?
• What benefits do you believe the recommended care offers?
• What potential problems or disadvantages could there be?
• What are the pros and cons of the alternative route?

Your decision affects the likelihood that you, your baby, and any future babies will
experience dozens of risks. You can learn about these in Best Evidence: VBAC or Repeat C-
Section and Best Evidence: C-Section. Your caregiver can help answer questions about this
information.

Especially if you decide to plan vaginal birth when the chances of the scar causing problems
are greater than usual, you may wish to choose a hospital capable of handling an urgent
cesarean at any time. To do this, the hospital must have obstetricians, anesthesiologists, and
pediatricians immediately available around the clock and a blood bank that is open at all
times.

What if a cesarean is recommended for a new problem that is a not an urgent matter?
In many cases, where some caregivers would recommend a cesarean, others would disagree
that a cesarean is necessary. When the situation is not urgent, you have time to discuss the
advantages and disadvantages of a cesarean with your caregiver. You can consult this
website's separate Pregnancy Topic on Cesarean Section.

What are some special scar-related situations when a planned c-section might be
recommended, but research has not found any extra risk of having problems with
the scar?

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 • type of uterine scar not known: Many years ago, studies showed that a side-to-
side cut on the lower part of the uterus (low transverse incision) produced a much
stronger scar than the previously used vertical ("classical") incision. As a result, virtually
all women who had a previous cesarean and are pregnant now have a scar that goes from
side to side. Exceptions may be a past cesarean for: placenta previa (placenta overlays
the cervix), an emergency situation, premature (preterm) birth, or breech (baby in feet-
or buttocks-first position).
• previous cesarean for premature (preterm) birth: The lower portion of the uterus
may not have developed enough at the time of the past cesarean to permit a cut that goes
from side to side (transverse incision). For this reason, doctors may make an up-and-down
incision at the bottom of the uterus (low vertical uterine incision). However, the low
vertical incision appears to be just as strong as a transverse incision.
• baby expected to be larger than average: Some have thought that babies
expected to weigh more than 8 pounds, 13 ounces (4,000 grams), so-called macrosomic or
"big bodied" babies, would put extra pressure on the scar. However, studies don't show
this to be the case.
• pregnancy goes beyond the due date: Studies do not show an increase in problems
with the scar in pregnancies going beyond 40 weeks.
• twin pregnancy: Studies haven't shown an increase in problems with the scar during
labor with twins compared with one baby. However, limited information on VBAC labors
with twins is available at this time.
• baby is in a buttocks- or feet-first (breech) position: Few care providers will
agree to vaginal breech birth even when the mother has no cesarean scar, so the question
here is whether it is it safe to have a procedure in which the care provider uses hand
maneuvers on the belly to try to turn the baby into a head-first position (external
cephalic version). As with twins, we have little research on this point, but what little we
have has not found extra problems.

Are there any factors that do increase my risk of having problems with the scar?
Overall, fewer than 1 in 100 women who labor after a cesarean experiences the scar giving
way during labor, which generally leads to an urgent c-section. Researchers have found that
some factors increase this likelihood. None of these factors raises this risk higher than 4
out of 100, and most do not raise it higher than 2 out of 100. In other words, 96 to 98 out
of 100 women who have these factors will labor without any problem with the scar.

In VBAC labors, loss of the baby occurs much less frequently than scar separation and
urgent c-section. A recent major government report found that, on average, over 7,100
planned repeat cesareans (and their associated risks) are required to prevent the death of 1
baby as a result of problems with the scar.

The following situations have been shown to increase risk for scar-related problems:
more than one prior cesarean

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 • uterine infection following the previous cesarean
• mother aged 30 or older
• due date less than 18 months after the previous cesarean.

Are there any situations where the risk of the scar giving way (uterine rupture) is so
high that labor should not be attempted?
In some rare situations, it is thought that substantially more women 8 to 12 out of 100 or so
will have the scar give way. Almost all care providers, including those who usually encourage
VBAC, would strongly recommend planned cesarean in the following situations:

• certain uterine scars from a cesarean that aren't the usual horizontal cut made
at the bottom of the uterus (low transverse scar): In these rare situations, the
concern is that the scar on the uterus may be weaker and more likely to give way
(rupture) and cause serious problems than the usual cesarean scar.
o a high cesarean scar that runs up-and-down (vertical or "classical"
uterine incision): a vertical incision may have been used if you had a placenta that grew
over the opening to your uterus (placenta previa), for some urgent cesareans, or in
some cases previous baby was in a buttocks- or feet-first (breech) position. (It is
possible to have a low horizontal scar on your skin but a vertical cut on your uterus.)
o inverted T- or J-shaped incision
• mother had previous uterine surgery for gynecologic problems, such as for removal
of fibroid tumors
• uterine scar opened and caused problems in a prior labor: The key point here is
that the scar has caused problems before. Many times, scar openings are small, harmless
"windows" (dehiscences). These windows are not thought to have any ill effects in future
labors.
• uterus does not have the usual pear shape: Examples of this are a heart-shaped
(bi-cornate) uterus or a uterus that is partly divided down the middle (septate uterus).
• ultrasound in late pregnancy finds that the area of the scarred uterus is
unusually thin: There may be a concern if the scar is 2.5 millimeters thick (about the
height of 2 stacked dimes) or less.

Does starting labor artificially (induction) affect the likelihood of uterine rupture?
Agents used to soften and shorten the cervix (the opening to the uterus) may increase the
likelihood that the scar will open and lead to problems in labor (some studies find a
relationship, and others do not). Some researchers think these agents may soften the
uterine scar as well. They belong to a family of hormone-like substances
called prostaglandins. They may be put in a woman's vagina or, less commonly, given by
mouth. Brand names include Cytotec, Cervidil and Prepidil.Please note: although a recent

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independent review concluded that evidence is unclear at this time, the manufacturer of
Cytotec includes a warning on the official Food and Drug Administration (FDA) "label" that
use of this product for laborinduction increases risk for uterine rupture, which is higher for
women with a previous cesarean (see references for Searle and for Guise, McDonagh and
colleagues.).

Using synthetic oxytocin (Pitocin or "Pit") by itself to try to start (induce) labor may also
increase the likelihood that the scar will give way. In this case, at most 2 women in 100
experience this problem compared to the rate of less than 1 in 100 in women not being
induced. Giving oxytocin early in labor to strengthen contractions
(labor augmentation or stimulation) may also increase the risk of scar problems.

Given the increasingly casual use of labor induction in the U.S., many women have the option
of waiting for labor to begin on its own, or at least waiting to induce labor until changes in
the cervix signal that it is ready to open. If your caregiver recommends induction to you, it
is important to consider together the risks and benefits of waiting for labor to begin on its
own, inducing labor, or scheduling a cesarean section.

Are there any situations where the risk of the scar giving way (uterine rupture) is
somewhat lower than average?
If you have given birth vaginally in the past, your chances of having scar problems with a
VBAC labors appear to be reduced.

What factors increase my chances of having a vaginal birth if I prefer VBAC?

If you have already had a vaginal birth (in addition to your c-section), you are more likely to
reach a goal of VBAC than a woman who has not had a vaginal birth. See Tips & Tools: VBAC
or Repeat C-Section for things you can do in pregnancy and during labor to increase your
likelihood of having a vaginal birth this time around.

Though I prefer VBAC, would it ever be wise to plan repeat c-section due to a
situation with very low chances of having a vaginal birth?
VBAC is associated with risks and trade-offs, so deciding whether to give birth vaginally
after c-section is a choice that only you can make. It may help you to know, though, that
some doctors developed a scoring system to try to identify the likelihood that a woman
would end up having a vaginal birth, from 0 (least likely) to 10 (most likely). As expected,
almost all women scoring 8 to 10 had vaginal births, but half the group scoring 0 to 2 still
gave birth vaginally. Studies that have looked at such factors as suspected big baby, slow or
stalled labor as the reason for the previous cesarean, going past the due date, more than
one previous cesarean and others have found that despite these disadvantages half or more
of women who planned VBAC achieved their goals.

What can I do if fear of repeating another difficult labor is holding me back from
considering VBAC?

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If you can identify what elements of your labor distressed you, you may be able to avoid
repeating the problem. Here are some ideas:

• If you feel that you didn't have good supportive care from your caregivers, you
may wish to choose a different caregiver, birth setting, or both.
• If you feel that you didn't get the support you needed from your partner or
others who were with you, hire adoula (trained labor support companion) or invite a
friend or relative to assist you and your partner.
• If the problem is the frustration of long, non-productive hours in labor or
pushing, you can:
o know that your next labor may proceed very differently; the first is usually
the longest.
o learn about factors that can interfere with labor progress and gather ideas
on how to help labor progress more smoothly. This is another reason to hire a doula as
she will know these things.
o decide ahead of time on reasonable limits for the cervix to dilate fully and
then for you to push the baby out. Knowing you have an end point can help you feel less
anxious and more in control. If you reach this point, you can choose whether to go
beyond it. Keep in mind when setting limits that women with prior cesareans tend to
labor more like first-time mothers than women who have given birth vaginally.
• If your concerns are with the pain of labor, become informed about epidurals,
which tend to offer effective pain relief, and consider planning to have one. Epidurals and
spinal analgesia have a particular drawback for VBAC labors that you should be aware of:
they can slow the baby's heart rate and may create a "false alarm" that the scar has
ruptured. Nonetheless, some women value feeling in control of pain relief in this way.
A doula can also help with many measures for comfort and calming in labor.

What if deep fear of labor is holding me back from considering VBAC?

Although many pregnant women have moments of apprehension about labor, some experience
continuing deep-seated fear of labor. If you find yourself in this situation, a series of
counseling or psychotherapy sessions during pregnancy may help you overcome these fears
and keep your options open. If you decide to seek counseling, be sure to get help from a
trained individual who has both good counseling skills and an understanding of maternity
issues. With this help, about one-half of women who previously requested planned c-section
change their minds. Continuous support during labor by a trained labor support companion
(doula) may also be of special value in this situation. If you still have deep fears of
childbirth despite counseling, cesarean birth may be your best option. Should this be your
choice, Tips & Tools: VBAC or Repeat C-Section can help you have a safer and more
satisfying cesarean birth.

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I've gotten the information, and I'm feeling torn: how can I decide?
Pay attention to the feelings that arise as you consider these questions:

• If you decided on VBAC and it ended with another cesarean, would you feel better
for having tried or worse because you went through labor only to have another c-section?
• If you scheduled a cesarean, would you feel relieved that you wouldn't have to labor
again or upset because now you would never know what would have happened if you had
chosen a VBAC?
• If you planned a VBAC and had one, what would that mean to you?

Best Evidence: VBAC or Repeat C-Section

Best evidence: When making important maternity decisions, women should have information
from the best available research about the safety and effectiveness of different choices.
In general, we can be most confident about results of systematic reviews that summarize
randomized controlled trials (or RCTs, a type of study).

Unfortunately, for many decisions we must rely on less definitive research; and many
important questions even in the case of widely used drugs, tests and procedures have hardly
been studied at all. Although this situation is discouraging, an awareness of weak or missing
evidence can help you make informed choices about care.

What is the bottom line?

What are some concerns about risks of c-section compared with vaginal birth?

What are some concerns about risks of vaginal birth compared with c-section?

What are some ways that a planned c-section may differ from an unplanned c-section?

What is the added likelihood that the scar will give way (uterine rupture) during
a VBAC labor?

What is the added likelihood that the baby will die as a result of the scar giving way
(uterine rupture) during a VBAC labor?

What is the added likelihood of the scar giving way (uterine rupture) with any of the
following factors listed below?

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What is the added likelihood of the scar giving way (uterine rupture) with twin
pregnancy or the use of external cephalic version (turning a baby in a buttocks- or
feet-first (breech) position to a head-first position by manipulating the woman's
belly)?

What is the added likelihood that a woman planning VBAC will require
a hysterectomy compared with a woman planning repeat c-section?

What is the added likelihood that a woman will require a hysterectomy as a result of
the scar giving way (uterine rupture)during a VBAC labor?

What is the added likelihood that a woman will develop an infection after a planned
cesarean?

What are some concerns about effects of accumulating uterine scars on future
pregnancies and births?

This page presents results of recent systematic reviews that can help women compare risks
of planned vaginal birth after cesarean(VBAC) and of planned c-section (see references at
end of page). While more high-quality studies are needed, a large body of research already
exists and sheds light on these questions for those who need guidance now.

When deciding whether to plan a VBAC or a repeat cesarean, it is important to understand

the full range of risks to you and your baby. This means comparing the short- and long-term
risks of cesarean surgery and risks of accumulating cesarean surgery scars to mothers and
babies on the one hand, to the risk that the uterine scar will give way (uterine rupture) and
lead to problems and a few risks that are worse for vaginal birth generally.

Even if you do not plan to have more children, you should be aware of risks of multiple
cesarean scars to future pregnancies and babies. Many women change their mind and decide
to become pregnant again or continue with unplanned pregnancies.

What is the bottom line?

If you do not have a clear and compelling need for a cesarean in the present pregnancy,
having a VBAC rather than a repeat c-section is likely to be:

• safer for you in this pregnancy

• far safer for you and your babies in any future pregnancies

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When thinking about the welfare of your baby in the present pregnancy, there are trade-
offs to consider: VBAC has some advantages, and a repeat c-section has others. You can
learn more below.

KEY MESSAGES ABOUT VBAC VS. REPEAT CESAREAN SECTION:

See details about scar-related effects after the following summary lists.

Despite limitations of the best available research, the following conclusions seem clear:

• Scar giving way: The scar is more likely to give way during a VBAC labor than in a
repeat c-section; for most women (exceptions noted below), the added risk of the scar
giving way is about 27 in every 10,000 VBAC labors. In other words, nearly 400 women
would need to experience the risks involved with repeat c-section to prevent one uterine
rupture during a VBAC labor.
• Death of baby: While the scar giving way poses a threat to the baby, the added
risk that the baby will die from a problem with the scar during a VBAC labor, compared
with women planning repeat c-sections, is about 1.4 in every 10,000 VBAC labors. In other
words, over 7100 women would need to experience the risks involved with repeat c-
sections to prevent the death of 1 baby due to uterine rupture.
• Hysterectomy in mother: If the scar gives way, some women have
a hysterectomy (removal of the uterus). The added risk of needing a hysterectomy from
this cause is about 3.4 in every 10,000 VBAC labors, when compared with women planning
repeat c-sections. However, considering risk for hysterectomy from all causes, women
who plan a VBAC are not more likely to experience an unplanned hysterectomy than
women planning repeat c-section.
• Concerns about specific risks: The following factors do not increase risk of the
scar giving way during labor:
o type of uterine scar not known
o low vertical uterine incision for prior c-section (may have been used if c-
section was performed earlier in pregnancy before growth in lower part of the uterus)
o baby estimated to be large, and to weigh more than 4,000 grams (8
pounds, 13 ounces)
o pregnancy goes past 40 weeks.
• Concerns about other risks: The following factors have not been shown to increase
the risk of the scar giving way, but too few cases have been studied to be confident:
o twin pregnancy

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 o use of external cephalic version: turning a baby who is positioned
buttocks- or feet-first (breech) to head-first position by manipulating the woman's
belly
• Infection: Women planning c-sections are more likely to develop infections than
women planning VBACs.
• Multiple scars in uterus: Accumulating c-section scars increase risk for
experiencing a number of serious problems relating to future pregnancies and births.
These include:
o scar rupture in a subsequent labor
o ectopic pregnancy: the embryo develops outside the uterus
o placenta previa: the placenta grows over the cervix, the opening to the
uterus
o placental abruption: the placenta separates from the uterus before the
baby is born
o placenta accreta the placenta growing abnormally into or even through the
uterus.

What are some concerns about risks of c-section compared with vaginal birth?
When weighing planned VBAC versus planned c-section, the focus is often on potential
problems with the uterine scar in labor or on problems associated with accumulating scars.
But this results in an incomplete picture because it overlooks other risks that also differ
between vaginal birth and cesarean section. Summarized here are some of the many extra
risks associated with cesarean surgery as well as the few advantages. (In Best Evidence: C-
Section, you can find a detailed comparison of risks of cesarean and vaginal birth, including
how likely these problems are to occur.)

Most of what we know about these risks comes from studies of cesarean in general, not
planned c-section. Available research suggests that some of these risks may be lessened
when the c-section is planned. The next question: What are some ways that a planned c-
section may differ from an unplanned c-section? points to adverse effects where research
finds differences in risk.

As you consider these, keep in mind that on average, 3 out of 4 women who labor after a c-
section will give birth vaginally with care that encourages and supports VBAC (and fewer
than 1 in 100 will experience the scar giving way). Even in cases where women scored 0 to 2
on a scale where 10 indicated greatest likelihood of vaginal birth, half gave birth vaginally.

• Physical problems for mothers: Compared with vaginal birth, cesarean section
increases a woman's risk for a number of physical problems. These range from less
common but potentially life-threatening problems, including hemorrhage (severe

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 bleeding), blood clots, and bowel obstruction (due to scarring and adhesions from the
surgery), to much more common problems such as longer-lasting and more severe pain and
infection. Even after recovery from surgery, scarring and adhesion tissue increase risk
for ongoing pelvic pain and for twisted bowel.
• Hospital stays: If a woman has a c-section, she is more likely to stay in the hospital
longer and to be re-hospitalized.
• Emotional well-being: A woman who has a c-section may be at greater risk for
poorer overall mental health and some emotional problems. She is also more likely to rate
her birth experience poorer than a woman who has had a vaginal birth.
• Mother-baby relationship: A woman who has a c-section is more likely to have less
early contact with her baby and initial negative feelings about her baby.
• Breastfeeding: Recovery from surgery poses challenges for getting breastfeeding
under way, and a baby who was born by c-section is less likely to be breastfed and get the
benefits of breastfeeding.
• Impact on babies: Babies born by c-section are more likely to:
o be cut during the surgery (usually minor)
o have breathing difficulties around the time of birth
o experience asthma in childhood and in adulthood.
• Impact on any future babies: A cesarean section in this pregnancy increases risk
for babies in future pregnancies. Some research finds that babies who develop in a
scarred uterus are more likely to:
o be born too early (preterm)
o weigh less than they should (low birth weight)
o have a physical abnormality or injury to their brain or spinal cord
o die before or shortly after the birth

What are some concerns about risks of vaginal birth compared with c-section?
C-section offers advantages in a few areas, primarily during the recovery period after birth.
(Some practices used with vaginal birth, such as episiotomy, are associated with pelvic floor
problems. It is wrong to conclude at this time that vaginal birth itself causes such problems.
See the Pregnancy Topic Preventing Pelvic Floor Dysfunction.

• A woman who has a vaginal birth is more likely to:

o have a painful vaginal area in the weeks after birth
o leak urine (urinary incontinence) (about 3 women per hundred still have a
problem 1 year after birth)

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 o leak gas, or more rarely, feces (bowel incontinence) (about 3 women per
hundred still have a problem 1 year after birth)
• Babies born vaginally have been shown to be at higher risk for a nerve
injury affecting the shoulder, arm, or hand (brachial plexus injury) (usually temporary).

What are some ways that a planned c-section may differ from an unplanned c-section?
A planned c-section offers some advantages over an unplanned c-section that occurs after
labor is under way. For example, there is a lower risk of surgical injuries and of infections.
The emotional impact of a cesarean that is planned in advance appears to be similar to or
somewhat worse than a vaginal birth. By contrast, unplanned cesareans can take a greater
emotional toll. In addition, a woman planning repeat cesarean surgery would almost certainly
be less likely to experience difficulty breastfeeding if she had breastfed before or to have
negative feelings for her baby compared with a first-time mother having an unplanned
cesarean. Nonetheless, a planned cesarean still involves the risks associated with major
surgery. And both planned and unplanned cesareans result in a uterine scar, which increases
risk for serious concerns for mothers and babies in future pregnancies, and for adhesion-
relation problems in mothers at any time.

To learn more about these differences, see

• Best Evidence: C-Section for a summary of research comparing cesarean and vaginal
birth.
• Preventing Pelvic Floor Dysfunction for in depth information about the relationship
between giving birth and a woman's pelvic floor health
• details below about effects of giving birth when a woman's uterus has a scar from a
previous cesarean

MORE DETAILED INFORMATION ABOUT SCAR-RELATED RISKS NOTED ABOVE

Click below on HIGH, MODERATE, etc. to understand difference in level of risk between
care options.

What is the added likelihood that the scar will give way (uterine rupture) during
a VBAC labor?
Best research suggests that an extra 27 women experience a ruptured uterus in every
10,000 VBAC labors, compared with planned c-section deliveries. Thus, nearly 400 women
would need to experience surgical birth to prevent one instance of uterine rupture during
VBAC labors. While the scar giving way usually requires an urgent cesarean, loss of the baby
is much less common (see next paragraph).
Added likelihood for a woman with a known low-transverse (horizontal)
scar: MODERATE for scar rupture compared with planned repeat c-section.

15
What is the added likelihood that the baby will die as a result of the scar giving way
(uterine rupture) during a VBAC labor?
Best research suggests that about 1.4 extra babies die due to problems with the scar in
every 10,000 VBAC labors, compared with planned c-section deliveries. Thus, over 7,000
women would need to experience risks of surgical birth to prevent the death of 1 baby from
scar problems during VBAC.
Added likelihood for a woman with a known low-transverse (horizontal) scar: LOW for death
of the baby around the time of birth compared with repeat c-section.

What is the added likelihood of the scar giving way (uterine rupture) with any of these
factors:
type of uterine scar not known
low vertical uterine incision at prior c-section (may have been used if c-section took
place earlier in pregnancy before growth in lower part of the uterus)
baby estimated to be large, weighing over 4,000 grams (8 lb 13 oz) or
pregnancy extends past 40 weeks?
Some caregivers recommend planned repeat c-section with these factors on the grounds
that VBAC is riskier, but the research does not support that belief. More detailed
information on these issues can be found in Options: VBAC or Repeat C-Section.
No added likelihood for scar rupture in a woman with unknown type of uterine scar, prior low
vertical uterine incision, baby estimated to weigh more than 4,000 grams, or pregnancy
extending past 40 weeks, in comparison with women planning VBAC without these factors.

What is the added likelihood of the scar giving way (uterine rupture) with twin
pregnancy or the use of external cephalic version (turning a baby in a buttocks-
or feet-first (breech) position to a head-first position by manipulating the
woman's belly)?
While studies have not found an excess incidence of scar rupture in these situations, not
enough women have been studied to rule out an increase. More detailed information on these
issues can be found in Options: VBAC or Repeat C-Section.
No currently known added likelihood for scar rupture in a woman with a twin pregnancy or a
woman experiencing external version, in comparison with women planning VBAC without
these factors.

What is the added likelihood that a woman planning VBAC will require
a hysterectomy compared with a woman planning repeat c-section?
Most studies find an excess of hysterectomies (surgical removal of the uterus) among
women planning repeat c-section. However, this could be because those studies may have
included cases where the c-section was planned for reasons that could increase the risk of
complications during surgery such as the placenta overlaying the cervix (placenta previa). A
study that took care to exclude women having planned repeat cesareans for medical reasons
found no difference in the percentages of women having hysterectomies.

16
No apparent added likelihood for hysterectomy for a woman planning VBAC compared with a
woman planning repeat c-section.

What is the added likelihood that a woman will require a hysterectomy as a result of
the scar giving way (uterine rupture) during a VBAC labor?
Best research suggests that about 3.4 extra women have a scar-
related hysterectomy (surgical removal of uterus) occurs in every 10,000 VBAC labors,
compared with planned c-section deliveries. Thus, nearly 3,000 women would need to
experience surgical birth to prevent one instance of hysterectomy due to scar problems
during VBAC labors.
Added likelihood for a woman with a known low-transverse (horizontal) scar: LOW for
hysterectomy as a result of uterine rupture compared with repeat cesarean.

What is the added likelihood that a woman will develop an infection after a planned
cesarean?
Surgery always introduces the risk of infection. Even though some women who plan VBAC will
have repeat c-sections, most will not. This puts women planning VBAC at lower risk of having
an infection than women planning repeat c-sections.
Added likelihood for a woman planning repeat cesarean: MODERATE for developing a wound
or internal infection compared with planned VBAC.

What are some concerns about effects of accumulating uterine scars on future
pregnancies and births?
The likelihood of the following problems grows as the number of previous cesareans (and c-
section scars) grows:

• placenta previa: a woman whose uterus has a cesarean scar is more likely than a
woman with an unscarred uterus to have a future placenta attach near or over the opening
to her cervix; this increases her risk for serious bleeding, shock, blood transfusion, blood
clots, planned or emergency delivery, emergency removal of her uterus
(hysterectomy), placenta accreta (see next), and other complications.
Added likelihood for a woman with a previous cesarean: MODERATE for placenta previa
in a future pregnancy after having one cesarean; HIGH for placenta previa in a future
pregnancy after having more than one cesarean
• placenta accreta: a woman whose uterus has a cesarean scar is more likely than a
woman with an unscarred uterus to have a future placenta grow through the uterine lining
and into or through the muscle of the uterus; this increases her risk for uterine
rupture (see below), serious bleeding, shock, blood transfusion, emergency surgery,
emergency removal of her uterus (hysterectomy), and other complications.
Added likelihood for a woman with at least one previous cesarean: MODERATE for
placenta accreta in a future pregnancy, with increasing risk as the number of previous
cesareans grows

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 • rupture of the uterus: a woman whose uterus has a cesarean scar is more likely
than a woman with an unscarred uterus to have the uterine wall give way in a future
pregnancy or labor, especially at the site of the scar; this increases her risk for severe
bleeding, shock, blood transfusion, blood clots, planned or emergency cesarean delivery,
emergency removal of the uterus (hysterectomy), and other complications; whether a
woman plans a repeat cesarean or a VBAC (vaginal birth after cesarean), she is at greater
risk for a ruptured uterus than a woman with no previous cesarean.
Added likelihood for a woman with a previous cesarean: MODERATE for rupture of the
uterus, with increasing risk for two or more cesareans

Questions About Impact of Repeated Cesareans

We did not find research to clarify whether some scar-related risks in future pregnancies
increase as the number of previous cesareans increases. The following risks for mothers are
worse after one cesarean and may or may not grow as the number of c-section scars grow:
fertility problems, ectopic pregnancy (not within the uterus), and placental
abruption (placenta detaches before birth). The following risks for babies are worse after
one cesarean and may or may not grow as the number of c-section scars grows: being born
too early (preterm), being born too small (low birthweight), having a physical abnormality or
injury to the brain or spinal cord, and dying before birth (stillbirth) or shortly after birth.

Scarring and adhesion tissue often increase as the the number of cesareans increases,
creating greater and greater challenges for anyfuture surgical procedures in the area. We
did not find information to clarify whether the likelihood of the following adhesion-related
problems grows as the number of cesareans grows: ongoing pelvic pain and risk for twisted
and blocked bowel in women.

References
Guise J-M, Berlin M, McDonagh M, Osterweil P, Chan B, Helfand M. Safety of vaginal birth
after cesarean: a systematic review. Obstet Gynecol 2004;103:420-9.

Guise J-M, McDonagh MS, Osterweil P, Nygren P, Chan BKS, Helfand M. Systematic review
of the incidence and consequences of uterine rupture in women with previous caesarean
section. BMJ 2004;329:159-65.

Hashima JN, Eden KB, Osterweil P, Nygren P, Guise J-M. Predicting vaginal birth after
cesarean delivery: a review of prognostic factors and screening tools. Am J Obstet
Gynecol 2004;190:547-55.

Lieberman E. Risk factors for uterine rupture during a trial of labor after cesarean. Clin
Obstet Gynecol 2001;44:609-21. [Alone among references, this article is not a systematic
review; it is included, however, as a well done review that addresses important questions for
women facing the VBAC/repeat c-section decision.]

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Childbirth Connection. Comparing risks of cesarean and vaginal birth to mothers, babies, and
future reproductive capacity: a systematic review. New York: Childbirth Connection, April
2004. [The following study documents are available as PDF files from the Childbirth
Connection website: description of methods and sources (including full bibiliography), list of
main questions and outcomes (a table of contents for evidence tables), first file of evidence
tables, and second file of evidence tables.]

Tips & Tools: VBAC or Repeat C-Section

How should I move forward after deciding to plan either a VBAC or a repeat c-
section?

WHEN PLANNING VBAC, what are some tips that can help avoid problems with the
scar in my uterus in labor?

Are there some practices used in VBAC labors that I might want to avoid?

If my goal is VBAC, how can I increase the likelihood of giving birth vaginally?

What are some tips I can use to reduce my risk of having an unnecessary repeat
cesarean?

What if I have unresolved emotional issues?

What if I can't find a hospital and caregiver who will support my wish for VBAC?

WHEN HAVING A REPEAT C-SECTION, what are some tips for having a safer
delivery?

What are some tips for having a satisfying cesarean birth experience?

How should I move forward after deciding to plan either a VBAC or a repeat c-
section?
Planned repeat cesarean may be the safest choice in a small number of situations, but for
most mother-baby pairs, the overall risks of surgical delivery outweigh VBAC ("vee-back"
or vaginal birth after cesarean) risks. If you do not have a clear and compelling need for a
repeat cesarean, planning VBAC is far safer for you and any future pregnancies and babies.
Thinking just of your baby in the current pregnancy, some rare but serious risks
of VBAC need to be weighed against a number of more common risks of c-section.
Planned VBAC is also likely to be the most emotional satisfying option for you.

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If your birth plan is for VBAC, there are no guarantees that you will avoid another cesarean.
However, you can take steps to increase your chances for having a safe and satisfying
vaginal birth. Most of these steps are strongly supported by good research. Advance
preparation in pregnancy can make all the difference. Careful choice of a doctor or midwife
and birth setting that support and encourage VBAC and a trained or experienced companion
who will be available to provide continuous labor support may be the most important things
you can do. The Q&As that follow give detailed guidance about these and other tips to
include in your pregnancy and birth plans.

While overall risks favor vaginal birth, you may have a repeat cesarean delivery for various
reasons. There may be special considerations in your individual case, or some risks may be
especially important to you and override others. Or your options may be limited by what is
available in your community or through your health plan. Finally, no one can know what labor
may bring. For these reasons, this section concludes with tips for having a safer and more
satisfying cesarean birth.

WHEN PLANNING VBAC, what are some tips that can help avoid problems with the
scar in my uterus in labor?
Try to:
• Wait at least 9 months before trying to conceive again: While the difference is
small (1 more woman in every 100), research suggests that you are less likely to have a
problem with the scar opening in labor with a birth-to-birth interval of 18 months or more
compared with a shorter time period.
• Avoid induction of labor, whenever possible: Experts disagree about some common
reasons given for induction (for example, the pregnancy has gone beyond 41 weeks), and
others are not supported by research (for example, induction for suspected big baby).
Some inductions may be recommended for non-medical reasons, such as your convenience
or that of your caregivers. Because induction agents may increase risk of scar rupture
and do increase the likelihood that the labor will end with a c-section, it is best to limit
induction to situations where there is a clear, compelling, and well-supported reason.
Should the question of induction arise, discuss the trade-offs with your caregiver of
awaiting labor, having the induction, or scheduling a c-section. In many cases, awaiting
labor is the safest option. (See making informed decisions for tips on how to discuss your
options with your caregivers.)
• If you are having labor induction, avoid cervical ripening agents: Available
research on the role of cervical ripening agents is hard to interpret but suggests caution.
Dinoprostone, also called prostaglandin E2, the agent found inPrepidil and Cervidil, may
increase the likelihood of scar rupture, especially in combination with
synthetic oxytocin(Pitocin or "Pit"). Misoprostol, also called prostaglandin E1, the agent
found in Cytotec, may increase the chance of scar rupture. Please note: although a
recent independent review concluded that evidence about impact of labor inductionon
VBAC labors is unclear at this time, the manufacturer of Cytotec includes a warning on
the official Food and Drug Administration (FDA) "label" that use of this product

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 for induction increases risk for uterine rupture, which is higher for women with a
previous cesarean (see references for Searle and Guise, McDonagh and colleagues).
• Avoid use of synthetic oxytocin (Pitocin or "Pit") early in labor: Available
research suggests caution about synthetic oxytocin in early labor. However,
synthetic oxytocin given once labor is well underway doesn't seem to cause a problem.
This may be because more forceful contractions over a longer period are needed to get
labor going than to help it along once it is in progress.

Are there some practices used in VBAC labors that I might want to avoid?
There appears to be no research showing benefits for using the following practices in VBAC
labor, and all either reduce the chances of vaginal birth or increase discomfort. Should they
be recommended in your case, you may wish to discuss the trade-offs with your caregivers.
(See making informed decisions for tips on discussing options with caregivers.):

• internal monitoring of contraction pressures (as opposed to internal monitoring of

the baby's heart rate): The theory is that should the scar give way, internal contraction
monitoring will pick up a drop in contraction pressure, but studies have not found this to
be the case. Meanwhile, internal monitoring increases the risk of uterine infection and
limits mobility.
• prohibition of eating and drinking in labor: The fear is that in the event of
general anesthesia, the woman may risk serious infection by vomiting and inhaling the
vomit into her lungs. But cesareans are rarely performed under general anesthesia. When
general anesthesia is used, a tube is inserted to protect the airway. If hospital staff are
unwilling to permit solid food, a compromise is frequent sips of clear fluids, which are
rapidly absorbed into the bloodstream.
• routine intravenous (IV) drip: If the hospital will not agree to forgo an IV line, a
good compromise is a heparin orsaline lock. The IV needle is inserted with a short piece
of attached tubing, and heparin or saline keep the needle from clogging. In an emergency,
an IV bag can be connected immediately.
• routine internal examination of the uterine scar after vaginal birth: This is
extremely painful for a woman who doesn't have an epidural, it could introduce infection,
and it could convert a small, harmless gap in the scar into a problem.

If my goal is VBAC, how can I increase the likelihood of giving birth vaginally?
(For additional ideas, see tips for lowering your chances of having an avoidable cesarean
within Tips & Tools: C-Section.)

• Choose a doctor or midwife who favors VBAC: Unfortunately, with changing

cultural views of c-section, VBAC and vaginal birth, and fears of legal claims and lawsuits,

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caregivers who offer you the option of VBAC are becoming more difficult to find. Discuss
your goals and preferences with potential caregivers, and find out how they will work with
you to meet your objectives. If their response does not satisfy you, and you have other
options, seek a better match.

A pro-VBAC caregiver:
o believes that women should labor unless there is a new reason for cesarean
or a compelling reason not to labor. Even in these cases, the caregiver respects a
woman's right to make the ultimate decision.
o does not have policies that discourage VBAC but are not supported by
sound research. Examples of unnecessary barriers would be caregivers who refuse
VBAC for women thought to be having a big baby, for women with "gestational
diabetes," or when the pregnancy goes past 40 weeks. (To learn more about what such
policies might be, see Options: VBAC or Repeat C-Section.)
o has a VBAC rate (proportion having a vaginal birth among those who plan
VBAC) of 70% or more. Dozens of studies involving tens of thousands of women have
shown that a VBAC rate this high or higher is an achievable goal.
• Hire a doula (trained labor support specialist): Because your prior labor ended in
a cesarean (or if you haven't experienced labor), and there is growing bias against VBAC,
you and your partner may feel heightened anxiety and doubts during a VBAC labor. The
continuous presence of a trained, experienced woman can help you deal with this. She will
know ways to help you relax, ease pain, and promote progress.
• Work with your caregivers to delay hospital admission until your cervix is
beginning to open: Women who are admitted to the hospital before their uterine
contractions are well-established are less likely to have VBAC.
• Avoid labor induction procedures, when possible: when caregivers use drugs or
other techniques to try to start labor artificially, a woman's risk for c-section goes up
• Commit yourself to vaginal birth: If you ask for a cesarean in a weak moment, your
request is likely to be granted.
• Avoid epidural and spinal analgesia: Although these generally provide excellent
pain relief, they have many drawbacks. One in particular is important to VBAC labors: a
common side effect is slowing of the baby's heart rate. As a drop in the fetal heart rate
is also the most reliable symptom that the uterine scar has given way and is causing
problems, this side effect could lead your caregivers to push for an urgent c-section. If
you wish to avoid this "regional" analgesia, be sure to learn about the wide variety of
comfort measures and other strategies, including continuous labor support, that can help
you cope effectively with labor pain. (See Options: Labor Pain for more information on
epidurals and other methods of coping with labor pain.)

One factor that need not enter into the epidural decision is the concern that having an
epidural could mask the pain of the scar giving way. Pain has not been shown to be a

22
 reliable symptom. Experts agree that women should not be denied an epidural for this
reason.

What are some tips I can use to reduce my risk of having an unnecessary repeat
cesarean?
You can:
• If a c-section is proposed and you're not in an emergency situation: Ask about
(1) why it's being recommended, (2) the benefits and risks of surgery, (3) other possible
solutions to the problem, including just waiting longer, and (4) the benefits and risks of
those. If you aren't in labor at the time the issue arises, you should have time to do your
own research and talk things over with your partner and caregivers before making a
decision. (See making informed decisions for more information on this topic and Options:
VBAC or Repeat C-Section for information on reasons that may given for a c-section.)
• If your baby is in a buttocks- or feet-first position (breech): Very few
caregivers will agree to vaginal birth with abreech baby. Ask your caregiver about having
an external cephalic version (a doctor turns the baby to a head-first position by
manipulating your belly) if your baby is still breech when you reach "term" (about the
37th week of pregnancy). You may need to search to find a caregiver who has skills and
experience with this technique. We do not have much research on external version in
women with prior cesareans, but what little we have has not found extra problems. See
more on breech position and external version on the Cesarean Section page in Resources
A-Z.

What if I have unresolved emotional issues?

Some women who have had an extremely difficult or frightening prior birth experience or
other traumatic experiences such as sexual abuse find that thinking about labor brings up
such strong emotions that it interferes with their ability to make decisions. Unresolved
issues can interfere with the smooth progress of labor as well. If you feel that you have
unresolved emotional issues, you will want to work through them so that they don't get in
your way when planning for or experiencing your next birth. Keeping a journal, talking
through the troubling events and your concerns with a friend or relative who is a good
listener, or getting peer support from other women with similar experiences may help with
this. Getting professional counseling from a competent mental health professional who is
well-informed about maternity issues proves very helpful in resolving extremely deep fear
and anxiety for many women.

Consider, too, what you will need during this birth to feel safe and well-cared for. If you
were dissatisfied with your previous care, you will want to pinpoint the sources of your
dissatisfaction and plan to do things differently this time.

What if I can't find a hospital and caregiver who will support my wish for VBAC?

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If you feel strongly about having a VBAC and do not have access to VBAC care in your
community, you may wish to consider relocating at the end of your pregnancy to stay with a
friend or relative in a community where such care is available.

It may be possible in some communities to find a practitioner willing to take on a VBAC client
who wishes to give birth outside of the hospital at home or in a birth center. You should
know, however, that while many birth center and home birth practitioners have had good
success with helping women who plan VBAC achieve vaginal birth, a national study of VBAC in
birth centers concluded that risks of laboring with a scarred uterus warrant hospital care.

WHEN HAVING A REPEAT C-SECTION, what are some tips for having a safer
delivery?
If you plan a repeat c-section, you will want to know how to plan the safest possible birth
experience.

• Schedule the c-section after the 38th week of pregnancy if there is no urgent
reason to deliver the baby sooner: Babies born before the 39th week of pregnancy are
more likely to have breathing problems.
• Use epidural or spinal anesthesia: Regional anesthesia (you are numbed from your
ribs down) is safer for you and your baby than general anesthesia (being "put to sleep").
• Request antibiotics at the time of the cesarean: Antibiotics reduce the chance
of infection. You do not need them afterwards unless you develop an infection.
• Ask for your uterus to be closed in two layers of stitching (double-layer
uterine suturing): In recent years, many doctors have begun closing the uterus with one
layer of stitches instead of two. Some studies suggest that this may lead to the scar
giving way more often during a future labor. Research that established that there was a
very low likelihood of the scar opening during labor was done when double-layer stitching
was the norm. Until this controversy is resolved, it may be wise to request the older
technique.
• Request care after the surgery to reduce the chance of blood clots: Depending
on how likely you are to have this problem, preventive care may include getting you up and
walking soon after the operation, having you wear elastic support stockings, or giving you
medication for this purpose.

What are some tips for having a satisfying cesarean birth experience?
Having a birth experience that is as much like a satisfying vaginal birth as possible and
having good pain control after the surgery are keys to a satisfying cesarean birth
experience. Discuss these options beforehand even if your birth plan is for VBAC. If an
unexpected problem arises at the end of pregnancy or during labor, it may be much more
difficult or impossible to obtain them.

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Some of these options may be readily available; others may require some effort on your
part. Still others may not be available at all. In that case, you will have to decide whether
they are important enough to you to seek care elsewhere. You may wish to choose a doctor
and/or hospital based on your preferences.

• Participate fully in decisions about the birth: The difficulty or ease of the birth
and whether the baby was born vaginally or by cesarean have little to do with how women
feel about the birth. Women are most likely to feel satisfied with their births when they
feel a sense of accomplishment and personal control and when they have a good
relationship with caregivers. A good relationship includes such elements as being treated
with kindness and respect, getting good information, and having the opportunity to
participate in decisions about care.
• Have an epidural or spinal anesthesia (regional anesthesia): Epidural or spinal
anesthesia allows you to be awake and aware to greet your baby and to hold and
breastfeed your baby in the recovery area.
• Have the bladder catheter inserted after the epidural or spinal is
administered: Then you will be numb for this somewhat uncomfortable procedure.
• Keep your partner and any labor companions with you throughout: You can
benefit from the support of your partner and any other labor companions during what
may be an anxious and stressful time. This is particularly true during preparation for
surgery and administration of the epidural or spinal anesthesia, which many women find
more stressful than the surgery itself. Your partner and support team will also have the
opportunity to share in moment of birth and to greet the baby.
• Keep your baby with you after the birth, in skin-to-skin contact: Unless your
baby has problems at the birth that require care in the nursery — and few babies do —
there is no reason not to keep your baby with you so that you and your partner can enjoy
and begin to get to know your baby, and you and your baby can get breastfeeding off to a
good start. Skin-to-skin contact can contribute to breastfeeding success and your early
relationship.
• Work with your caregivers to carry out your preferences: For example, you may
wish to:
o videotape the birth or the time just after the birth
o play the music of your choice
o not have your arms strapped down
o have the drape that screens your view of the surgery placed low enough
that the baby can be laid on your chest; if your arms are free, you can hold and touch
your baby.
o have a doctor or nurse explain what is happening throughout
o have the drape lowered or have a mirror at the time of the delivery (your
belly will be covered so you will see your baby lifted out of an opening in the sheet)

25
 o announce or have your partner announce the sex of the baby or be the first
to speak to the baby (versus a member of the care team doing these things)
o take the placenta home (some people bury the placenta and plant a tree or
bush over the site; if of interest, bring a sealable container to contain the blood and
ease the staff in this time of HIV/AIDS)
• Have a narcotic (opioid) medication injected into the epidural tube at the end
of the operation: This provides sufficient pain relief for you to feel comfortable enough
to hold and breastfeed your baby in the first hours after the surgery.
• Have your baby and your labor companions with you in the recovery
area: Holding and breastfeeding your baby soon after delivery helps both you and your
baby get started on the right foot and may avoid problems with breastfeeding.
• Have your partner able to be with your baby in the nursery: This includes the
newborn intensive care nursery. If your baby must be separated from you because of
concerns about the baby's health, it will be comforting to know that your partner can
provide a reassuring presence and can bring you word of your baby's condition.
• Control your pain medication: A new alternative is patient-controlled analgesia
(PCA). With this technique, you can give yourself a small dose of medication through
the intravenous (IV) line when you need it by pushing a button. A lockout mechanism keeps
you from going beyond a preset dose. Since narcotics can make you feel sleepy and
nauseous, you may wish to combine narcotic with non-narcotic pain medications. This can
reduce or even eliminate your need for narcotics.
• Begin drinking and eating again when you feel ready: Access to food and drink
when you feel ready will help you feel more normal and can avoid hunger and thirst.
• Get help with breastfeeding: Breastfeeding can be more difficult right after
surgery and while your incision is healing. A knowledgeable person can help you find ways
to be more comfortable during breastfeeding sessions. Your partner or others can help
with switching sides, burping, and diaper changing.
• Get plenty of help at home: You will be recovering from major surgery with all
that entails in terms of how you may feel, as well as restrictions on lifting and driving. At
the same time, unlike the usual experience of recovering surgical patients, you will have
the demands of caring for a newborn and one or more older children. The VBAC or Repeat
C-Section Resources page can lead you to detailed help with cesarean recovery.

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