By Dr Mama-Asu Peprah
Did you have a caesarean section previously but want to try for a vaginal birth this time (VBAC)?
You can try for a vaginal birth provided the following criteria are met:
- You had only one previous Caesarean section that was simple with no complications.
- You are pregnant with ONE baby (i.e no multiples).
- Baby’s HEAD is coming first/ head down position.
- Baby weighs less than 3.5kg.
- You deliver in a setting that is suitably staffed and equipped for continuous monitoring and immediate caesarean section.
- You have a health professional who is comfortable to take care of you in labour.
Now what is the problem with trying vaginal birth after caesarean section?
It’s the risk of your previous scar bursting open (scar rupture) from the force of your contractions and pushing. This is a reality. But this risk is small. If the scar ruptures, it’s instantaneous and devastating. I have seen Mothers who have lost their lives and unfortunately babies have died too.
Ok so enough of the scary stuff. The reality too, is that VBAC is a perfectly safe way to go provided the above conditions are met.
So, what are realities of VBAC in the South African setting?
- You are more likely to be successful if you deliver in government than in private.
This is because due to the patient load to doctor ratio – there just isn’t enough resources to do a Caesar on all women. In fact, women are strongly advised to do a VBAC in state. It also works because there are doctors on site 24/7 so if there is an emergency, you can be assessed and treated quickly. We all know the challenges of the government sector from long waiting queues and patient burden.
The problem with private is that your obstetrician is not on site especially after hours. Therefore, it becomes a very labour intensive (excuse the pun) exercise and it’s even more difficult if we also have to attend to other patients at the same time. Sometimes we rely on the nursing staff to update us and alert us if there is any problem- and that risk is just too great. We pick the more controllable option of strongly encouraging an elective caesarean section.
2. The second truth is that you are more likely to be successful if you go into labour naturally and during the day; This is because all hands are on board . Everyone is at work, people are fresh and energetic so the chances of detecting a problem is better and you will be attended to more quickly too.
Who can definitely not try for caesarean section:
- Someone who has had more than one previous Caesarean section
- If you had a previous Caesar but it was a classical incision (this means an up and down cut was made on the uterus rather than a transverse cut) the risk of rupture in such cases is very high.
- Baby who weighs more than 3.5kg.
- Abnormal presentation (breech, transverse or oblique).
- Abnormal position of the placenta.
- Delivering at a hospital that does not have the means to properly monitor you and does not have emergency c section services 24/7.
- Previous myomectomy (fibroid surgery).
So, what are you odds of having a successful vaginal delivery?
- If you have had one previous Caesar and have never had a vaginal delivery your chances of having a successful VBAC is 72-75%.
- If you have one previous Caesar and have had at least one successful vaginal delivery your chances of having a successful VBAC increases 85%.
- Your success rate decreases to 40% if:
- You have never experienced labour before and have never had a successful previous vaginal delivery (ie you had an elective caesarean section before).
- Your BMI is more than 30 (obese).
- The reason for your caesarean section was slow labour/ big baby.
- You are over the age over 40 years old.
Now, you have gone through everything and you meet the criteria. You go into labour at home and arrive at the hospital, here is what to expect:
- You will need a urinary catheter. This helps us monitor if your scar is opening up and about to burst. Often you can see blood in the urine catheter.
- You will not be allowed to eat or drink anything. So, make sure you eat before you arrive in Hospital.
- You will have an intravenous line put up. This is in case we have an emergency and need quick action. Also, because you are starved, the drip will provide you with the extra electrolytes and energy that you will need.
- You will have a CTG put on you and the baby’s heartbeat will be monitored continuously.
- You will be admitted to Hospital with 24 theatre service, monitored strictly and examined frequently to ensure that you and your baby are fine.
Now the ways to cope and navigate VBAC is discussed in our antenatal workshop – the Real Antenatal.
Wishing you all the best on birth and hope to meet you soon.
Disclaimer
This is not medical advice rather information. Please discuss with your healthcare provider about the best and feasible options for you. The opinions expressed are that of myself, Dr Peprah, and my experience and does not reflect the practice and/or opinion of other obstetricians.
Reference
- Birth after Previous Caesarean Birth (Green-top Guideline No. 45)
