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VBAC in Singapore

The old adage ‘once a caesarean, always a caesarean’ is no longer holding true for more and more women giving birth in Singapore. Worldwide vaginal birth after caesarean (VBAC) procedures are increasing. As women become better educated in the birthing process, more are opting for a ‘trial of labour’ instead of automatically scheduling a repeat caesarean.

Doula and childbirth educator Ginny Phang has witnessed firsthand the increase in women attempting VBAC. Almost 80% of Ginny’s doula clients and students who have had a caesarean are planning a VBAC. “I think women are becoming more aware that a planned VBAC is very safe,” says Ginny.

Is VBAC safe?

With appropriate care, 70-80% of women who undergo a VBAC will have an uncomplicated vaginal birth. The risk of uterine rupture with one low transverse scar is 1 in 200.

Why chose VBAC?

There are many psychological ramifications associated with a caesarean birth which may continue into the next pregnancy, if this mode of delivery was unexpected and considered undesirable by the mother. The loss of control and fear associated with an earlier birth experience may result in the need to maintain control the next time. The amount of technology involved and hospital sterile atmosphere may engender 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.

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 to allow room for the baby whose head molds to fit the opening. The pelvis can actually open up to be 33% larger in a squatting position than its pre-labor size. There are several factors that contribute to this phenomenon. First, a hormone called relaxin is released during the latter part of pregnancy, which loosens the ligaments and cartilage surrounding the pelvis. Different positions assumed during labor such as walking, climbing stairs and squatting will also change the dimensions of the pelvis. A baby's head is made up of five plates connected with soft tissues that allow it to adjust as needed during the birth process as the baby travels through the pelvis. These bones typically 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 supportive doctor can be difficult. Take the time to 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 stated that, "80% of the problems experienced by a woman delivering vaginally can also happen to a woman delivering through a caesarean section." Interventions such as episiotomies, vacuum and forceps deliveries are often the decisive factors contributing to complications, rather than the vaginal birth itself. Some problems such as urinary and fecal incontinence are common across both methods of delivery due to the hormones of pregnancy or specific drugs used during delivery.

Q: Wouldn't a caesarean be safer than a vaginal birth after a caesarean?

A: Cesarean sections are considered major abdominal surgery with all of the consequent risk. The surgery itself 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 increased risks to the baby such as respiratory distress syndrome, prematurity, lower birth weight, jaundice, lower APGAR scores (a standard metric used to assess the health of a newborn), and finally in 1-9% of cases the baby may be scarred or even maimed by the scalpel.

Q: When is a caesarean absolutely necessary?

A: Under the following circumstances:

  • Complete placenta praevia at term (placenta covering the cervix)
  • Transverse lie (baby sideways in the uterus compared the cervix)
  • A prolapsed umbillical cord
  • Abruptio placenta (detachment of the placenta from the uterus wall prior to delivery)
  • Eclampsia or severe preeclampsia accompanying failed induction of labor.
  • A large uterine tumor which blocks the cervix
  • True fetal distress, confirmed with a fetal scalp sampling or biophysical profile
  • True cephalopelvic disproportion (baby too large for pelvis). This is extremely rare and only associated with a pelvic deformity or incorrectly healed pelvic break.
  • Initial outbreak of active herpes at the onset of labor.
  • Uterine rupture

Since it is given 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 caesarean rather than attempt a vaginal delivery? In some cases, for fear of pain during labor (although many patients report that the pain of a cesarean section is worse than labor), for others, a fear of the unknown, while for others still 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, patients should make the best choice for themselves, based on their specific medical history and individual situation.

For more information on having a VBAC procedure in Singapore, contact Ginny Phang at ginny@fourtrimesters.com.

For additional reading and information on VBAC, please visit www.vbac.com.

If you have any further questions about medical concerns in Indonesia, see the Ask the Experts.

We trust this information will assist you in making correct choices regarding your health and welfare. However, it is not intended to be a substitute for personalized advice from your medical adviser.

Our thanks to Tracy Donegan for sharing this information wth the community!