The old adage ‘once a cesarean always a cesarean’ is no longer holding true for
more and more women giving birth in Singapore. Worldwide VBAC births are
increasing. (Vaginal Birth After Cesarean) As women become better educated in
the birthing process more are opting for a ‘trial of labour’ instead of
automatically scheduling a repeat cesarean.
Doula and childbirth educator Ginny Phang is witnessing first hand the increase
in women attempting VBAC. Almost 80% of Ginny’s doula clients and students are
planning a VBAC. “I’ve definitely seen an increase this year, I think women are
becoming more aware that a planned VBAC is very safe” says Ginny.
Is VBAC safe?
With appropriate care, 70 to 80 percent of women who labour for a VBAC will have
an uncomplicated vaginal birth. With a planned VBAC, the risk of uterine rupture
with one low transverse scar is 5 per 1,000.
Why chose VBAC?
There are many psychological ramifications of a caesarean birth. These continue
on, if this mode of delivery was unexpected and considered undesirable by the
mother, during the next pregnancy and birth. The loss of control, and the fear
associated with an earlier birth experience, may result in the need to maintain
control the next time. The amount of technology involved and the sterile
atmosphere may cause a need for a 'natural' labour and a reduction in
unnecessary interventions. When women choose a VBAC birth, they tend to be
making an extremely informed choice in doing so.
Local Obstetricians are seeing this increase also. Dr.Paul S.L Tseng Consultant
Obstetrician & Gynaecologist at TMC
“Yes, I am seeing more patients coming for VBAC, maybe because of word of mouth
patients come to hear that I am willing to help them try VBAC.
Questions about VBAC
Q: My doctor told me my pelvis is too small to vaginally deliver a baby over
eight pounds and I have to have another cesarean.. Is this true?
A: No, the pelvis and the baby's head are not fixed bone structures. During
labor the pelvis opens, allowing room for the baby, whose head molds to fit. The
pelvis will actually open up 33% larger than it's pre-pregnant size with a
squatting position. There are several factors that contribute to this. First a
hormone called relaxin is released during the latter part of pregnancy, which
soften the ligaments and cartilage surrounding the pelvis. Also different
positions assumed during labor will change the dimensions of the pelvis such as
walking, climbing stairs and squatting. This combined with the flexibility of
the baby's head gives ample room for babies to move through the pelvis. The
baby's head is made up of five plates that are connected with soft tissues that
allow it to mold during the birth process as the baby travels through the
pelvis. These bones return to their pre-birth state within hours of birth.
Q: I can't find a doctor willing to support a vaginal birth after cesarean.
A: Finding a doctor to be supportive can be difficult. Take the time to make an
appointment and go in a see several doctors. Ask questions and listen to their
answers.
Q: Doesn't a vaginal birth cause problems like pelvic floor "damage"?
A: Lead researcher Dr. Alastair MacLennan in an interview with Reuters Health
states, "80% of the problems a woman having a vaginal delivery has, also happen
to a woman having a Cesarean section." Most often it is the interventions like
episiotomies, vacuum and forceps deliveries that contribute to urinary and fecal
incontinence, uterine prolapse, and pelvic floor damage rather than the vaginal
birth itself. Women who have had cesarean deliveries also experience urinary and
fecal incontinence and other concerns due to the surgery or simply as a result
of the hormones of pregnancy and/or the drugs used during the delivery.
Q: Wouldn't a cesarean be safer than a vaginal birth after a cesarean?
A: A cesarean section is major abdominal surgery with all that entails. The
surgery itself, as opposed to medical problems that might lead to a cesarean
increases the risk of maternal death, hysterectomy, hemorrhage, infection, blood
clots, damage to blood vessels, urinary bladder and other organs, postpartum
depression, post traumatic stress syndrome, and rehospitalization for
complications. Potential chronic complications from scar tissue adhesions
include pelvic pain, bowel problems, and pain during sexual intercourse. Scar
tissue makes subsequent cesareans more difficult to perform, increasing the risk
of injury to other organs as well as placenta previa, placenta accreta,
infertility, ectopic pregnancy, uterine rupture in subsequent pregnancies and
the risk of chronic problems from adhesions. There are also risks to the baby
such as respiratory distress syndrome, prematurity, lower birth weights,
jaundice, lower APGAR scores (APGAR is the means of assessing the health status
of a newborn), and finally in 1 to 9 percent of cases the baby is scarred or
even maimed by the scalpel.
Q: When is a cesarean absolutely
necessary?
-
Transverse lie
-
Prolapsed cord
-
Abrupted Placenta
-
Uterine rupture
-
Complete placenta previa at term
-
Large uterine tumor which blocks the cervix
-
Initial outbreak of active herpes at the onset of labor
-
Eclampsia or severe preeclampsia with failed induction of labor
-
True fetal distress confirmed with a fetal scalp sampling or biophysical profile
-
True cephalopelvic disproportion (CPD- baby too large for pelvis). This is extremely rare and only associated with a pelvic deformity
(or an incorrectly healed pelvic break)
Since we know that vaginal deliveries are almost always safer for the mother,
and usually as safe for the baby, and that VBAC attempts are successful in about
80% of cases, why do some women still choose to have a repeat cesarean rather
than try for a vaginal delivery? In some cases it is fear of pain during labor
(although many patients report that the pain from recuperation from a cesarean
section is worse than labor pain), in others it is a "fear of the unknown,"
while for some women there is a convenience in scheduling the exact date of
their baby's birth.
Finally, a number of women do not wish to take the risk, no matter how rare, of
uterine rupture. No matter what the reason, since there is a small risk with an
attempt at vaginal delivery and a risk with repeat cesarean patients should make
the best choice for themselves, based on their specific medical history and
individual situation.
For more information on VBAC in Singapore contact Ginny Phang at
ginny@fourtrimesters.com
Resources:
http://www.ican-online.org
http://www.vbac.com
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13 Nov 2004 -
Having Baby in Singapore
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Vaginal Birth After Cesarean
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