Dear Doctor,

I’m 36 years old and pregnant with my second child, and I have the option of trying for a vaginal birth after cesarean (VBAC). I’m having a really hard time with the decision, and I haven’t been able to talk to anyone who’s been through this. My first born is 27 months old now.  Is this wise? I would really want to but I’m scared. 

Maria

Dear Maria

Usually 60 to 80 per cent of women have to undergo a C-section after a previous C-section. A caesarean section (C-section) is usually done either in emergency if there is an imminent danger to the mother or baby. These situations include a very high blood pressure of the mother, cord prolapsed; where the fetal cord tends to be across the neck of the baby or outside, fetal distress, non progression of labour, abnormal presentation of the baby like transverse lie or breech, etcetera. A C-section may be planned beforehand if on routine antenatal check up a situation is diagnosed which may pose a risk for mother or baby if normal labour is allowed. These are a cephalopelvic disproportion (where baby is bigger in size than the pelvic cavity of mother and obstructed labour is anticipated (abnormal position of placenta) hence, difficult labour and heavy bleeding expected during labour. If the mother has some infection like genital herpes, where the baby is likely to be infected during vaginal delivery, a C-section is preferred over vaginal delivery. In a precious pregnancy, as first pregnancy in an elderly woman, some obstetricians prefer to do a C-section more so if there is some other risk factor posing a health risk for the mother or baby. After a C-section, vaginal delivery in a subsequent pregnancy carries risk of tear of the scar of the previous C-section scar. Uterine perforation can also occur during uterine contractions, which can be fatal. The risk enhances with the midline vertical upper uterine scar of the previous C-section, as compared to lower abdomen transverse scar. Hence many times it is best avoided.

However a vaginal birth after C-section (VBAC)  can be tried if the previous C-section was for an indication that is not likely to relapse or has not relapsed, such as a breech presentation or  non progression of labour. Other risk factors are also taken into account like the age of the mother, her body weight, absence of high blood pressure or uncontrolled diabetes, no previous history of intrauterine fetal death or still birth,  normal fetal growth, baby of normal weight, etcetera. Ultimately, it is the choice of the obstetrician to consider a normal vaginal birth after a C-section or plan another C-section. If a normal vaginal birth is planned, one keeps an anesthetist and entire team ready for an emergency C-section if things go wrong at the last minute.

 Dr Rachna is a specialist in internal medicine at Ruhengeri Hospital.

rachna212002@yahoo.co.uk