VBAC

I really want a natural delivery for my second kid but I am afraid there might be some complications. In order to find out if it is really true that "once a c-sect, always a c-sect", I did some research:

1. Natural birth after C-section: Is it really safe ?

10-Feb-2011 (Thu) Mind Your Body, The Straits Times

By Lea Wee Doctors here may advise women against it, but recent findings suggest uterine rupture risk is small. Madam Joanne Koh had a caesarean section eight years ago. When she found she was pregnant again last year, she wanted to try a vaginal delivery, but her doctor advised her not to. The 32-year-old office manager said: 'He said the old scar may tear.' So she had another caesarean section. Last week, Mind Your Body reported how caesarean birth rates are rising because of women who, like Madam Koh, find themselves having such births for a second or third time, whether or not they intended to in the first place. A third of all women giving birth at the KK Women's and Children's Hospital do it through caesarean sections. Doctors estimate as many as six to eight out of every 10 women who have had one caesarean section in Singapore will end up with another. In the United States, the figure is as high as nine in 10. But the conventional wisdom of 'once caesarean, always caesarean' is now being challenged by both the American and British colleges of obstetrics and gynaecology. They think women who have had one prior low transverse incision, the most common type of incision used in caesarean sections nowadays, are suitable for Vaginal Birth After Caesarean (Vbac). Last July, the Americans further relaxed their guidelines to say that most women with two such caesarean incisions as well as those pregnant with twins are also suitable for vaginal deliveries. Doctors here are cautious There are no corresponding guidelines in Singapore but three out of five doctors MYB spoke to say they would discourage women who have had two caesarean sections or those pregnant with twins to try for a vaginal birth unless they fulfil certain conditions, such as they have had a vaginal delivery. But all agreed that women with one former caesarean birth could indeed try a vaginal delivery. This is especially so if the first caesarean section was done for a condition that is unlikely to recur - such as a breech baby - and the baby was not larger than normal, said obstetrician gynaecologist Chong Yap Seng from the National University Hospital. Doctors here are cautious about Vbac because of the risk of the old scar rupturing during labour. If that happened, the woman would need an emergency caesarean section and the baby may die from the lack of oxygen or have brain damage. The mother may also die from massive bleeding. The chances of massive bleeding and death in the woman during an elective caesarean section is much lower, said obstetrician gynaecologist Benjamin Tham from the Thomson Medical Centre. Lukewarm attitude Doctors say many women do not want to take the risk, once they are told there could be a chance of a rupture and harm to the baby. But even those who are willing to take the admittedly-low risk may be faced with a reluctant doctor. Housewife Tham Yin May said she had to search online for a doctor willing to let her go for a Vbac after her own doctor discouraged her from doing so (see story below). One reason for the lukewarm attitude of doctors here towards Vbac could be the fear of legal repercussions if something goes wrong. Dr Benjamin Tham said some women may accept the risk of uterine rupture when it is first explained to them, but when something happens to the baby, they will blame the doctor for allowing them to go ahead with the Vbac. Some doctors may also prefer elective caesarean sections because they are convenient and predictable. In contrast, a vaginal delivery after the woman had a caesarean section is unpredictable and the patient needs to be monitored continuously throughout labour, said Dr Paul Tseng of TLC Gynaecology Practice. He has come across two cases of uterine rupture in his 15 years in private practice. The United States guidelines say the risk of uterine rupture is less than 1 per cent in women who have had one caesarean section and that 60 to 80per cent of vaginal deliveries in this group are successfully completed. The risk of rupture is twice as high in those who have had two caesarean sections and for this group, only half the vaginal deliveries are successful. But these figures are not from controlled studies so it is hard to conclude how reliable they are, said Dr Benjamin Tham. No reliable data yet Doctors say up till now, there has been no reliable data to show that a vaginal delivery after a caesarean section is safer than another caesarean section. However, a recent study in the medical journal Lancet may provide some answers. It found that women who undergo caesarean sections for non-medical reasons are three times more likely to have problems like bleeding compared to those who give birth unaided. The US guidelines also said that compared to those who had a successful Vbac, mothers who underwent elective caesarean sections appear to have a higher risk of infection and the potentially fatal condition of pulmonary thromboembolism, a condition where a blood clot gets lodged in the lungs. But this also has to be balanced against women who begin labour and then need an emergency caesarean section. They have the highest risk of all. In conclusion, there is no easy answer as to whether a woman should have a vaginal delivery after one or two caesarean births. Said Dr Chong: 'The doctors' duty is to help the patient find out what is best for her.' And what many women want is a vaginal birth, regardless of its risk. Said Dr Tseng: 'It could be a psychological need which should not be ignored.' Businesswoman Thasneem Begum, 30, wants a vaginal birth for her twins in March. 'Having experienced a vaginal birth for my first child and an emergency caesarean section for my second one, I must say a vaginal delivery makes me feel more complete as a woman.' This is the second in a series on women and childbirth Up to 8 in every 10 women here who have had one caesarean section will end up with another

2. KKH Article

What Is VBAC?

VBAC is the acronym for "Vaginal Birth After Caesarean section".

If I Had One Pervious Caesarean Section Birth, Can I Go Through A Subsequent Vaginal Birth?

Women who have had one previous uncomplicated lower segment caesarean section (LSCS) and no other adverse obstetric feature in the current pregnancy are suitable candidates for VBAC. Generally, the relevant factors to determine suitability for VBAC are as follows :

    The previous caesarean section

        Type of incision: This refers to the manner in which the uterus was incised during the delivery in the last pregnancy.

        "Classical section" refers to a vertical incision on the upper part of the uterus. Women who a previous classical caesarean section should not opt for VBAC as there is a higher risk of uterine rupture or tear.

        "Lower segment caesarean section" refers to a horizontal incision on the lower part of the uterus. This method is associated with a lower risk of uterine rupture and women with this type of incision may opt for VBAC.

        Reason for previous caesarean section: If the reason for the previous caesarean section is a recurring one such as contracted pelvis (i.e. where the pelvis is too small to allow the passage of baby due to some form of obstruction), then VBAC is unsuitable.

        Complications during the previous caesarean section: If the previous caesarean section was complicated by unexpected tears in the uterus, the obstetrician may advise the need for repeat caesarean section in the subsequent pregnancy. VBAC should not be considered in such a case.

    Current pregnancy: Certain conditions such as low-lying placenta or abnormal presentation of the baby in the present pregnancy may prevent a safe vaginal delivery.

    Other medical / surgical problems: Certain medical conditions such as certain heart diseases or severe hypertension would prevent a woman from enduring the physical stress of a vaginal delivery. Previous operation on the uterus to remove fibroids may result in weakening of the muscle wall of the uterus and increase the likelihood of uterus rupture during labour. In such cases, VBAC may not be suitable.

What Is The Chance Of A Successful VBAC?

The chance of a successful VBAC is between 60% and 70%. It is generally higher for women who have had previous successful vaginal deliveries. The chance of success may be lower if the reason for the previous caesarean section was due to cephalopelvic disproportion (i.e. where the baby is relatively too big to pass through the maternal pelvis).

What Are The Advantages Of VBAC As Compared With Elective Caesarean Section Delivery?

A successful vaginal birth is beneficial to the mother as it is generally associated with less bleeding, less blood transfusion, less infection, faster recovery with shorter hospital stay and less post-delivery pain and complications.

Successful VBAC has also no proven adverse effect on the baby. In terms of cost, a successful VBAC is cheaper than caeserean section birth.

What Are The Complications Associated With VBAC?

The primary concern associated with VBAC is the risk of uterine rupture or tear. The incidence of uterine rupture is quoted as:

    Less than 1% after one previous lower segment caesarean section

    1 - 5 % after two previous lower segment caesarean sections

    4 - 9% after a classical uterine scar

The risk of rupture is also increased in induction. Uterine rupture can be life-threatening for both the mother and child. It may also result in the need for surgical removal of the womb (hysterectomy) for the mother as well as neurological impairment of the child (cerebral palsy).

In addition, if the trial of labor fails and the mother needs an emergency caesarean section, there will be higher risk of complications for the mother as compared to an elective caesarean section or a successful VBAC. The costs of a failed VBAC would also be higher.

What Are The Precautions My Obstetrician Will Exercise To Minimise Complication Associated With VBAC?

Before the decision for VBAC can be made, the obstetrician would:

    Review the medical records for the previous pregnancy to assess the reason for the last caesarean section and the operation procedure to determine if there were any complications during the operation and the possible need for repeat caesarean section.

    Assess the current pregnancy to see if the patient is suitable for vaginal delivery. Relevant factors include the location of placenta, baby's presentation and the adequacy of the maternal pelvis relative to the baby's size.

    Discuss with you the suitability for VBAC and the associated risks and benefits.

    If desired and found to be suitable for VBAC, you will be allowed a short trial of labor. During labour, your baby will be continuously monitored to ensure his well-being. The need for induction or augmentation of labour is left to the obstetrician's discretion based on his assessment of the situation. An emergency caesarean section would be performed if there are signs of fetal distress or if the labour is not progressing as well as expected.

Can I Opt For Epidural Relief If I Have Decided To Go Through VBAC?

Epidural is commonly used in labour to provide effective pain relief. It is safe and not associated with late detection of uterine rupture.

In addition, if trial of labour fails, epidural can be continued as a form of anaesthesia for emergency caesarean section to be carried out. Therefore, epidural can be chosen as a good form of pain relief while undergoing VBAC.

Apart from epidural, there are other options for pain relief such as breathing exercises, back massage, entonox gas, pethidine injection etc.

Can I Make My Own Decision For Or Against VBAC?

A decision for or against VBAC should be a joint decision between you and your obstetrician after having taken into consideration the pros and cons of VBAC in your situation.

I also managed to contact Eunice via Singapore Motherhood forum and she shared her experience and I must say it has been very encouraging. However, I still have to bear in mind that I need to discuss with my gynae (whoever it is then) and make a decision based on my situation at that point in time.

Base on my findings and my conversation with her, it seems that there are very few doctors in Singapore who are supportive and confident of VBAC. So far, there are only two: Dr Paul Tseng and Dr Lai Fon-Min.

Let's see how it goes.