Your Birth

Your Birth: Birth Options and Potential Complications

You have been through the first and second trimesters and have completed the tests you chose.  You are now in the 3rd trimester and you can see the light at the end of the tunnel.  Your delivery is the culmination of your pregnancy, resulting in a wonderful new life entering the world.  It can be both an exhilarating and tiring experience.  It's an emotional time- and a time you will always remember.  So many things you may be thinking of ...you, the baby, the family and future, and the delivery itself.  It's a very personal time, and the time you finally get to meet your baby.  


The birth of your baby should be right for you.  Vaginal birth or cesarean delivery (C section)? The experiences of others might help, but only you will know what is best for you.  The goal your choice and a positive experience, whether you have a vaginal birth or cesarean delivery.  Some women say they feel they were pressured into either vaginal birth or cesarean delivery, so it's worth considering both sides and deciding what is right for you.  Because it's so personal, and emotional, I have used many excerpts from other sources so the words are not mine, but from others.  The current page addresses 



  1. Vaginal birth after cesarean (VBAC)
  2. Breech
  3. Placenta previa


image252
image253

Birth options

Birth Options

There is a lot of debate and discussion about birth and issues surrounding birth, but 2 things are certain:


1.  You WILL give birth.


2.  You will delivery your baby by either vaginal birth or cesarean birth (C section). 


Vaginal birth can also be spontaneous (natural), with or without medication (typically an epidural) or induced; while cesarean birth can also be scheduled or unscheduled.  An unscheduled cesarean birth implies it was not your first choice but you chose it based on your own individual circumstances.  This page discusses these options with pluses and minuses.  

Vaginal Birth vs. C-section

Vaginal Birth

image254

Vaginal Birth Pluses

  • Natural
  • Quicker recovery
  • 'Badge of honor'  Self esteem 


Vaginal Birth Minuses

  • Waiting for onset of labor
  • Labor and pain of labor (but reduced or eliminated with epidural)
  • Could turn into unscheduled  or emergent C-section
  • Episotomy  According to NHS 1 in 7 chance
  • Chronic (>5 months) pain from episotomy 12%


Debatable points

  • Quicker skin to skin contact




C-Section

image255

C Section Pluses

  • Scheduled 
  • Eliminates unscheduled or emergent C section
  • Less chance of pelvic floor injury
  • Eliminates chance for episotomy (1 in 7 vaginal births)


C Section minuses

  • Postoperative recovery longer
  • Pain and or bleeding from scar long term (increased chance with number of c-sections and size of the scar)
  • Increased chance of newborn issues?  Ask for delayed cord clamping. 
  • Newborn respiratory distress.  Possibly. 


C Section minuses relative to subsequent pregnancies


  • Increases chance of C section in subsequent births
  • Increased chance of retained placenta and placenta accreta for subsequent pregnancies  (risk increases with number of c-sections)
  • Small chance of uterine scar rupture if vaginal labor of subsequent pregnancies. 
  • Small risk of c-section scar ectopic pregnancy


Debatable points.  Need to separate potential risks of c section from reasons for having the c section

Natural Vaginal Birth

Very well said.  Natural vaginal birth is the goal for ALL pregnant women.   

But not everyone is a candidate, and not all women choose it.  Also, some women might feel pushed into this option

Birth and Birth Options

Birth and Birth Options

 "Childbirth is a very personal thing. It's about weighing up the pros and cons for each individual. There are risks and benefits in whatever you do," she tells me. 

(This section taken from the Guardian)


Sher, 38, chose an elective caesarean. Not because she was too posh or too scared to push but because she decided it was the safest method. In fact, Sher makes decisions on delivery and surgery every day, and she understands the consequences more than most - she is a consultant obstetrician.  The official disapproval of elective C-sections means Sher daren't talk under her real name; Stephanie Sher is a pseudonym. 


 One London study published in the Lancet in 1996 reported that 31% of female obstetricians would personally prefer a caesarean birth. In the US, the figure is almost 50%. Many female surgeons and GPs quietly take this option too - though, as one told me, "to admit as much is still massively un-PC". 


 In April 2007, the then health secretary, Patricia Hewitt, launched her strategy for the future of maternity care. Maternity Matters trumpeted "choice", promising better access to "normal" deliveries via home births and midwife units. Her plans chimed with recent guidelines from the National Institute for Clinical Excellence (Nice) drawn up to reduce caesareans - currently 23% of all births - by advising obstetricians against granting them without medical justification. 


 It's important to remember that it is the obstetrician's and the surgeon's task to remedy the rarer complications and consequences of childbirth. Unlike midwives, who oversee successful, normal births every day, doctors bear witness to the worst-case scenarios. REF


Maternity experts across the board believe that a straightforward vaginal delivery is by far the best for both mother and baby. Most women agree: 63% of mothers see childbirth as a natural experience that should not be interfered with unless necessary. In "putting women at the centre of maternity provision", the government's strategy reflects the overwhelming consensus.

Nevertheless, among all the furor that surrounds the issue of childbirth, for Sher and her colleagues, one thing is clear: the government's promotion of delivery "choice" is a promise rarely kept. "There is nothing wrong with hoping for a natural event," Sher says, "and for everything to happen beautifully. But it just isn't like that for a large proportion of women."


 

Sher's greatest fear was not the pain of spontaneous labour. It was the prospect of emergency intervention, if the birth went wrong. According to the most recent NHS maternity statistics made available (2005-6), just under half (47%) of expectant mothers have a regular, uncomplicated "normal" labour. The rest have interventions ranging from induction, to forceps, to an emergency caesarean. In other words, when a woman tries for a normal birth and the best, safest kind of delivery, she has only a 50% chance of achieving it. For a significant number of others, the birth will be more complex.

With odds like this, it is not illogical to consider alternatives, particularly not if your line of work exposes you to the most extreme of cases. Many obstetricians find the second safest solution is a planned caesarean. The National Caesarean Section Audit (2001) revealed half of obstetricians think this is the safest delivery method for the baby - though not for the mother.



image256

Cesarean Delivery

Cesarean Deliveries

 The following is nearly verbatim from WhatToExpect.com  


Currently about 30% of babies are delivered by C-section — which means, all things being equal, you have about a 1 in 3 chance of having to go that route (closer to 1 in 4 in the UK). While any surgery is a proposition that should be taken seriously, with some mental and emotional preparation, you can feel empowered if a C-section seems in the cards. 

As @onestep.doula (Instagram) says: 'Most would agree that delivering vaginally is best and the recovery is better but that doesn't mean that having a cesarean means you or your body has failed at giving birth....Sometimes in order to have a healthy baby and mom a cesarean is required and they have save many lives!...My hope is that every mother who has gone through a cesarean birth or belly birth as we call it in the Doula world feels proud and powerful.'

 

Can I have an elective C-section?


The latest guidelines by the American College of Obstetricians and Gynecologists (ACOG) recommend that moms and their doctors always plan for a vaginal delivery unless a C-section is medically required. The group also suggests that other labor interventions be delayed or avoided completely if possible in women with low-risk pregnancies where Mom and baby are progressing normally.For women who decide to go through with an elective C-section, ACOG recommends scheduling the procedure no earlier than 39 weeks of pregnancy. The group asks that doctors remind women that the of risk of placenta previa, placenta accreta and hysterectomy increase with every cesarean delivery you have. Once you've already had a C-section, the group adds, you're more likely to require another in the future.Since cesareans are safe and can prevent the pain of labor, some women (particularly those who've had a C-section before) prefer them to vaginal deliveries and ask for them in advance. The rate is dropping, however, since there has been quite a push to lower C-section rates in the U.S.Obstetricians and other experts are encouraging more trials of labor to promote vaginal births after prior cesarean deliveries (VBAC) and more widespread use of vacuum and forceps during delivery to prevent unnecessary surgical deliveries.They're also suggesting that moms be given more time to labor and to push, and/or that doctors use Pitocin as needed to nudge labor along (assuming all is going well) before moving on to a C-section. Finally there's a growing recognition that while C-sections are very safe, they're still major surgery, which comes with greater risk.Experts agree: C-sections shouldn't be the delivery of choice, at least when there is a choice. Ultimately, the best time for your baby to make that grand entrance is when she's ready. And when an elective C-section is planned, there’s always the possibility that the baby will inadvertently be born too soon.Still wondering if you should ask your practitioner for an elective C-section? Before you raise the topic, ask yourself a few key questions:


  • Are you afraid of the pain of labor? Most women share your fear (how many people do you know who look forward to pain, after all?), but there are many effective pain-relief options for laboring womenundergoing a vaginal birth, including an epidural. 
  • Have you heard that vaginal birth causes urinary incontinence? While it's true that a vaginal birth can increase the risk of leaking, regular pelvic floor exercises (yup — it's those Kegels again) significantly reduce that risk.  
  • Do you want your delivery to fall on a convenient day? Keep in mind that a C-section is major abdominal surgery. That means that you'll have a longer recovery time and hospital stay (certainly not convenient or especially fun — unless you really enjoy hospital food). And you'll also be exposing yourself to the risks that surgery entails. 
  • Is there another baby in your future? Remember that opting for a C-section now may prevent you from delivering vaginally next time around — although VBACs are generally safe (especially for the 95 percent of women who receive low, horizontal incisions). C-sections also increase your risk for complications including placenta previa, placenta acreta and retained placenta in future pregnancies.


Reasons for a scheduled C-section


Your doctor may peg you for the procedure in advance of your due date. A few factors that might necessitate a C-section include:

  • Certain medical conditions. You have a medical condition like diabetes, high blood pressure or kidney disease that makes vaginal delivery dangerously stressful to your body (and a cesarean birth is a safer option).
  • Infections. If you’re HIV-positive or have an active genital herpes infection, a scheduled C-section is necessary because both viruses can be transmitted to your baby during delivery.
  • Your baby’s health. An illness or a congenital condition might make the already tricky journey through the birth canal even more treacherous for your baby.
  • A large baby. Sometimes your baby is considered too large (a condition called macrosomia) to move safely, if at all, through the birth canal.
  • Your weight. Being extremely overweight or obese significantly increases your chance of needing a C-section delivery, partly because of the other risk factors that often accompany obesity (like gestational diabetes), and partly because obese women tend to have longer labors (which, in turn, ups your risk of ending up on the operating table).
  • Your age. While being older doesn’t guarantee a cesarean by any means, the odds of having one increase with age. 
  • Breech position. When your baby is either feet-first or butt-first in a breech position and can't be turned, your practitioner might decide that a C-section is necessary.
  • Multiples. The likelihood of the procedure increases with the number of babies you’re carrying.
  • Placental problems. If the placenta is partly or completely blocking the cervical opening (placenta previa) or has separated from the uterine wall (placental abruption), a C-section is likely safer for you and your baby.
  • Other complications.  If you develop preeclampsia (pregnancy-induced high blood pressure) or eclampsia (a progression of preeclampsia that affects the central nervous system, causing seizures) and treatment isn't working, your practitioner might opt for a C-section to protect both of you.
  • Previous C-sections. More than one prior C section increases the risk of uterine rupture during labor.  While having a first cesarean raises your risk of subsequent procedures, vaginal birth after c-section or VBAC, is frequently successful and often recommended.


If your practitioner says that a C-section is necessary — or likely necessary — ask for a detailed explanation of the reasons and any possible alternatives.  See what happens during a C section. 

image257

Unplanned Cesarean Delivery

Unplanned Cesarean Delivery

Also from WhatToExpect.com

  If you’re a mom-to-be with your heart set on a vaginal birth, the news that your baby needs (or may need) to be delivered by cesarean section might feel disappointing. However, sometimes it's the safest, or rarely only, way to delivery 


Reasons for an unplanned C-section


Far more frequently, the need for a cesarean section isn't obvious until a woman is well into labor. A few of the most common reasons for an unscheduled or unplanned C-section include:


  • Labor doesn’t start. If your labor just can't seem to get moving in the first place (your cervix isn't dilating even though you're having contractions) — after 24 or 25 hours in a first-time mother and fewer for subsequent deliveries — your doctor might decide on surgery.


  • Labor stalls. You might sail right through the early stage of labor (dilation to 3 centimeters), only to grind to a halt. While it's possible that Pitocin or another labor stimulator could jump-start the contractions, if the problem is that your baby's head is too big to fit through your pelvis (which is the case about half the time) a cesarean birth is necessary.


  • Exhaustion or fetal distress. If your doctor determines that you’re becoming too exhausted, or if the fetal monitor is picking up signs of your baby in distress, he or she may opt for a cesarean.  


  • A prolapsed umbilical cord. If the umbilical cord slips into the birth canal before baby does, it will be compressed as your little one comes through, which could cut off her oxygen supply.


  • Uterine rupture. If your uterus tears, a C-section is required.


If you're still concerned, talk with your practitioner. Together, you can decide what's right for you and your baby. 

image258

Induction of Labor at 39 weeks

image259

INDUCTION OF LABOR AT 39 WEEKS

There is growing support for induction of labor after completion of the 39th week in both the U.S. and the UK


From Professor Lockwood (USA):


The cornerstone of obstetrics is the determination of when it is better for the mother and her fetus to effect delivery. Much attention over the past decade has been focused on avoiding truly elective deliveries prior to 39 weeks because of the risks of iatrogenic prematurity. Conversely, given the increase in perinatal mortality attendant post-term gestations, it has been the longstanding policy of the American College of Obstetricians and Gynecologists (ACOG) to consider induction of labor (IOL) between 41 0/7 and 41 6/7 weeks’ gestation and to recommend IOL after 42 0/7 weeks.


However, between 39 and 42 weeks, there are multiple risks to mother and fetus associated with continuing the pregnancy. Perinatal mortality rates nadir at 39 weeks as neonatal risks from prematurity fade and rates of stillbirth grow.2  Beyond 39 weeks, pregnancies are at increased risk of placental insufficiency, preeclampsia, and macrosomia, all of which are associated with increased cesarean delivery rates, not to mention increased maternal, perinatal, and neonatal mortality and/or morbidity. These findings all suggest that elective IOL at 39 weeks could reduce adverse pregnancy outcomes and lower cesarean delivery rates compared to expectant management. While older literature did not support this thesis, recent studies suggest that this is indeed the case.


Older studies were flawed

In 2009, Caughey and associates conducted a systematic review of nine randomized clinical trials of elective IOL at either < 41 or ≥ 41 weeks compared with expectant management and noted that overall, the latter was associated with an increased cesarean delivery rate (OR 1.22; 95% CI: 1.07-1.39) but among women < 41 weeks, no significant differences were noted.3However, the authors reported that the two studies conducted at < 41 weeks were of poor quality and not generalizable to current practice. Stock and associates conducted a large retrospective cohort study among 1.27 million Scottish women delivering between 1981 to 2007 with singleton gestations ≥ 37 weeks to compare cesarean delivery rates, perinatal mortality, and neonatal and maternal outcomes for those with elective IOL vs. expectant management.4They noted that at 39 weeks, elective IOL was associated with decreased perinatal mortality (0.06% versus 0.18%, P< 0.001; adj OR of 0.28; 99% CI: 0.12-0.67), with a minimal increase in cesarean delivery rates 9.3 versus 8.4% (adj OR: 1.08, 1.00-1.16). However, the problems with these older studies include non-standardized definitions of successful induction, variable induction methods, and heterogenous populations.


Recent studies

In 2016, Walker and colleagues reported on their small clinical trial among 618 nulliparous woman ≥ 35 years with singleton pregnancies randomized to elective IOL at 39 weeks versus expectant management until spontaneous labor or medically or obstetrically indicated delivery.   They observed no differences in cesarean rates (RR 0.99; 95%CI: 0.87-1.14) and no differences in operative vaginal delivery, infant deaths, or women’s experience of childbirth. The chief problem with this study was its lack of power, given the rarity of many of these adverse outcomes. 

To address the issue of sample size and rare outcomes, Sinkey and associates conducted a comparative effectiveness study using a sophisticated Monte Carlo micro-simulation model to compare elective IOL at 39 weeks with expectant management including delivery for standard medical or obstetrical indications, or at 41 weeks if undelivered.6  They based their decision support probabilities of potential maternal and perinatal outcomes on an exhaustive review of the literature and data derived from the Consortium on Safe Labor. They also conducted sensitivity analyses based on maternal preferences for optimizing maternal versus infant health using weighted utilities. The primary objective was to determine which management strategy posed less maternal and neonatal risk. Secondary outcomes were rates of cesarean deliveries, maternal morbidity and mortality, stillbirth, neonatal morbidity and mortality, and preferences regarding the importance of maternal and perinatal health. 

The authors found that elective IOL at 39 weeks resulted in lower cesarean delivery rates (13.9% versus 35.9%, P< 0.01) even among women with unfavorable cervices (8.0% versus 26.1%, < 0.01). Conversely, there was an increase in maternal morbidity in the expectant management group (21.2% versus 16.5%, P< 0.01) as well as more stillbirths (0.13% versus 0%, P< 0.0003), neonatal deaths (0.25% versus 0.12%, < 0.03), and neonatal morbidity (12.1% versus 9.4%, P< 0.01). These findings persisted after adjustment for maternal preferences. This decision model simulated a far larger population (> 100,000 women) than any clinical trial could hope to enroll. 


Even more recently, Grobman and colleagues conducted a large prospective multicenter trial among low-risk nulliparous women with a vertex presentation who in their 38th week were randomized to either elective IOL (n=3062) at 39 0/7 to 39 4/7 weeks or expectant management (n=3044) in the ARRIVE Trial (see below).    The results of the ARRIVE trial (A Randomized Trial of Induction Versus Expectant Management) add further evidence to the value of elective IOL at 39 weeks. 


Take-home message (still Professor Lockwood)


I don’t think we should be surprised by these recent studies. Term stillbirths are frequently related to placental insufficiency and cord accidents, which explains why stillbirths and neonatal morbidity stochastically increase with advancing gestational age. Simply not being in utero would reduce such risks. As for the lower cesarean delivery rates accompanying elective IOL, this may reflect a combination of:

  1. fewer cesarean deliveries for non-reassuring fetal testing again due to lower rates of placental insufficiency and cord compression; and 
  2. smaller infants, as fetal weight progressively increases with increasing gestational age. Macrosomia should also be less common among patients undergoing elective IOL at 39 weeks, reducing the risk of shoulder dystocia and its related morbidity. 

The Arrive Trial


The ARRIVE Trial


 Labor induction at 39 to 39 weeks 4 days resulted in a significantly lower frequency of cesarean delivery and hypertensive disorders of pregnancy than expectant management, even after post hoc adjustment for multiplicity.  The data suggest that 1 cesarean delivery may be avoided for every 28 deliveries among low-risk nulliparous women who plan to undergo elective induction of labor at 39 weeks.  Subgroup analysis found no differences in results based on maternal race, age, or body mass index nor any effect from initial Bishop score. 


Summary: Elective labor induction at 39 weeks of gestation did not result in a greater frequency of perinatal adverse outcomes than expectant management and resulted in fewer instances of cesarean delivery. These results suggest that policies aimed at the avoidance of elective labor induction among low-risk nulliparous women at 39 weeks of gestation are unlikely to reduce the rate of cesarean delivery on a population level; the trial provides information that can be incorporated into discussions that rely on principles of shared decision making. 



Induction of labor at 39 weeks: ACOG Statement

From Professor Lockwood:


In response to the ARRIVE study, ACOG has opined that “it is reasonable for obstetricians and health-care facilities to offer elective induction of labor to low-risk nulliparous women at 39 weeks gestation.”  The ACOG advisory prudently notes that the obstetrician should consider a woman’s preference, available resources and ensure an adequate trial of labor is provided. 

From my perspective, the decision to be electively delivered at 39 weeks is an intensely personal one for mothers, and their desires should be of paramount importance. However, if a low-risk nulliparous patient whose fetus is in a vertex presentation asks me “when is the safest time for me and my fetus to deliver”, I would feel obligated to describe the outcomes of these studies.  

image260

Complicated Pregnancy

This Patient Thought She had an Uneventful Pregnancy

 But she almost died in childbirth after signs of this dangerous complication were missed  


Sometimes, it's difficult to know whether the pregnancy was normal or not... until after the fact.  This woman almost died....after what she thought was an uneventful delivery.  In retrospect, signs of HELLP syndrome were missed. 


Take home message... Don't ignore warning signs.  

More About HELLP Syndrome and Preeclampsia

Find out more

Prevention of StillBirths

image261

Stillbirths

Stillbirths, especially near term stillbirths, are always tragic, devastating events for everyone involved.   Most stillbirths can be attributed to placental related complications.  However, up to 50% remain unexplained.  

More on stillbirths and potential prevention here, or clicking on the image. 

Professor Jason Gardosi from the Perinatal Institute

Lowering Risk of Stillbirth and Improving Outcomes

Highly recommend that everyone listen to the lecture by Professor Jason Gardosi from the Perinatal Institute by clicking on image or on

Lecture here  He shows the basis for the GAP program and how it has lowered the stillbirth rate.  Initiating the GAP protocol has resulted in 10 less stillbirths per week in the UK!  And Professor Gardosi believes we are half way there..'.there are still babies dying unnecessarily. '


Also,  watch slide show on GAP Assessment here.  

Click on Image to see More on Third Trimester Potential Complications

Potential 3rd Trimester Complications

Nearly all potential 3rd trimester complications can be explained as 'placental related'.  The placenta is designed to work until about 40 weeks, but not much more.  Sometimes the placenta is stressed prior to 40 weeks.  

Click here or on image to see other potential 3rd trimester complications. 

MAMA Academy

Say Hello to Heidi Eldridge, and her Story

  Read Heidi's story here


The pregnancy progressed normally, but Heidi developed gestational diabetes which affects  one in 10 women, who develop higher than normal levels of glucose in their blood. These pregnancies are classified as high risk, as complications include high birth weight babies, miscarriage and still birth. But, says Heidi, ''No one explained what it meant in practice. I had been assured there was nothing to worry about.’’

 Heidi had planned a leaving party from work for May 14, 2009, her 37th week of pregnancy, after a routine midwife appointment. But the midwife listened to Aidan and asked Heidi when she had last felt her baby kick. '’I couldn’t remember; I wasn’t keeping track. She told me to go straight to St Peter’s Hospital in Chertsey for a scan.’’

 ''At the time I was in blissful ignorance. I called Steve and was surprised that he insisted on coming with me.’’ At the hospital a sonographer was waiting. ''She said, 'I’m sorry, he’s gone.’ 

Having gone in thinking it was just a routine check and that there was nothing to really worry about, Heidi was engulfed by shock. Thinking maybe she was asleep and experiencing a nightmare, her first instinct was to 'pull at my eyelids believing I needed to open them, to wake up.’ At her side, Steve was trying to make sense of what was happening too and comfort his screaming wife. 


 We quickly learnt by talking to the doctors that his low birth weight showed he had been growth restricted, which could have been picked up earlier. If I’d have known to monitor his movements, that might have helped. There could have been a different outcome.’’ 


 

Having researched antenatal restricted growth extensively and found a programme called GAP (see below) which uses very accurate measurements of the mother’s bump to analyse the baby’s development, she campaigned for their local hospital St Peters to implement the programme.

Keen to empower other mums with key pregnancy information: knowing signs of infection, how to monitor movements, and when they should call their midwife for advice, she also launched the charity MAMA Academy which stands for mums and midwives awareness and equips midwives with current guidelines and research. 'We want to aid consistent maternity care across the country.’’


Her efforts and the efforts of GAP protocol have been very successful in both increasing awareness of the issue of stillbirth, but also in dramatically reducing the number of stillbirths in the UK by enlisting more trusts and units to embrace the GAP protocol. 


image262

Identification of Patients at Risk: The Gap Protocol

GAP Protocol

image263

See below for better detail of the GAP Protocol (Growth Assessment Protocol).  The GAP protocol helps identify 'high' or 'higher' risk patients who can benefit from closer monitoring

Decreasing Stillbirths

image264

The more trusts/Units following the GAP protocol (red line), the greater the drop in the stillbirth rate, suggesting that the GAP protocol is effective in identification of pregnancies at risk

image265

Identification of Patients at Risk: The GAP Protocol

The Key is Identification of Patients at Risk: The GAP Protocol

The GAP protocol (Growth Assessment Protocol) helps to identify higher risk patients who can benefit from closer monitoring.  Importantly, serial ultrasounds and Doppler studies   (to evaluate blood flow from the baby to the placenta, or from you to the placenta, or both).    are key in identification of patients at risk. This protocol can also help identify those patients with normal pregnancies who could consider natural childbirth options.  

Initiating the GAP protocol has resulted in 10 less stillbirths per week in the UK!


More About the GAP Protocol

Find out more

Other Delivery Issues

image266

Vaginal Birth After Cesarean

 

Vaginal Birth after Caesarean (VBAC)


From the Mayo Clinic


 

Many women are candidates for vaginal birth after cesarean (VBAC). In fact, research on women who attempt a trial of labor after cesarean (TOLAC) shows that about 60 to 80 percent have a successful vaginal delivery. Still, the choice to pursue VBAC or schedule a repeat C-section can be difficult. Here's insight on how to make the decision.


Why consider VBAC?


Compared with having another C-section, a vaginal delivery involves no surgery, none of the possible complications of surgery, a shorter hospital stay and a quicker return to normal daily activities. VBAC might also be appealing if you want to experience vaginal childbirth.

It's important to consider future pregnancies, too. If you're planning for more pregnancies, VBAC might help you avoid the risks of multiple cesarean deliveries, such as placental problems.


What are the risks of VBAC?


While VBAC is associated with fewer complications than an elective repeat C-section, a failed trial of labor after a C-section is associated with more complications, including, rarely, a uterine rupture. During a uterine rupture, the uterus tears open. An emergency C-section is needed to prevent complications, such as heavy bleeding for the mother and life-threatening injury to the baby. Sometimes, the uterus might need to be removed (hysterectomy) to stop the bleeding. If your uterus is removed, you won't be able to get pregnant again.


Can you put the risk of uterine rupture into perspective?


Uterine rupture is rare, happening in fewer than 1 percent of women who attempt a trial of labor after cesarean. If you're considering VBAC, make sure that the facility where you'll deliver the baby is ready to deal with a uterine rupture. You'll need staff immediately available to provide emergency care.


Who's eligible for VBAC?


VBAC eligibility depends on many factors. For example:

  • Have you had previous vaginal deliveries? A vaginal delivery at least once before or after your prior C-section increases the probability of a successful VBAC.


  • What type of uterine incision was used for the prior C-section? Most C-sections use a low transverse incision. Women who have had a low transverse or low vertical incision are usually VBAC candidates. If you've had a prior high vertical (classical) incision, VBAC isn't recommended because of the risk of uterine rupture


  • How many C-sections have you had? Some health care providers won't offer VBAC if you have had more than two prior C-sections


  • When was your last C-section? The risk of uterine rupture is higher if you attempt VBAC less than 18 months after having a C-section.


  • Do you have any health concerns that might affect a vaginal delivery? A C-section might be recommended if you have placental problems, your baby is in an abnormal position, or you're carrying triplets or higher order multiples.


  • Where will you deliver the baby? Plan to deliver at a facility equipped to handle an emergency C-section. A home delivery isn't appropriate for VBAC.


  • Will you need to be induced? Having labor induced or augmented decreases the likelihood of a successful VBAC.


  • Have you ever had a uterine rupture? If so, you're not a candidate for VBAC.


How does labor and delivery during VBAC differ from labor and delivery during a routine vaginal birth?


If you choose VBAC, when you go into labor you'll follow a process similar to that used for any vaginal delivery. However, your health care provider will likely recommend continuous monitoring of your baby's heart rate and be prepared to do a repeat C-section if needed.


What other advice do you offer women who are considering VBAC?


If you're considering VBAC, discuss the option, your concerns and expectations with your health care provider early in pregnancy. Make sure he or she has your complete medical history, including records of your previous C-section and any other uterine procedures. Your health care provider might calculate the likelihood that you'll have a successful VBAC. It's important to continue discussing the risks and benefits of VBAC throughout pregnancy, especially if certain risk factors arise.

Find out about the VBAC policy at the facility where you'll deliver your baby, but try to stay flexible. The circumstances of your labor could make VBAC a clear choice or, after counseling, you and your health care provider might decide that a repeat C-section would be best after all.



image267

Breech And External Version

 From Chelsea and Westminister Hospital


Most of the time it is only a matter of chance that a baby does not turn and remains in the breech (bottom down) position. In few situations certain factors make it difficult for a baby to turn during pregnancy. These might include the amount of fluid in the womb (either too much or too little), the position of the placenta or the presence of more than one baby. The majority of breech babies are born healthy but, for a small minority of babies, breech may be a sign of a problem with the baby and therefore all breech babies will have a newborn examination. 


 

What can be done?

If you are at 34 weeks and your baby is in breech position you can discuss options of:

  • Moxibustion
  • External cephalic version (ECV)
  • Choices for birth (vaginal breech delivery or Caesarean section), if your baby is still in a breech position after 39 weeks


What is moxibustion?


Moxibustion (a treatment method of traditional Chinese medicine) involves the burning of a herb (artemisia vulgaris) close to the skin to induce a warming sensation (Turner 1991). Moxibustion close to the acupuncture point Bladder 67 (BL67—Chinese name Zhiyin), located at the tip of your fifth toe, may correct breech presentation. Women with a breech presentation may seek treatment with moxibustion from 32–38 weeks. Published evidence suggests that moxibustion is effective in reducing the need for an external cephalic version (ECV). 

This technique involves holding moxa sticks (1.5cm in diameter and 20cm in length) or burning moxa cones on or over BL67 on both toes. The heat felt should be warm but not uncomfortable. Treatment regimens vary and there is no consensus on the best regimen, but moxibustion may be administered for 15–20 minutes daily for up to 10 days. There have been no reported side-effects for mothers or babies.

After trying moxibustion for 10 days you will be reviewed again either in the breech clinic or the day assessment unit at 36 weeks and the midwife will check the position of your baby. If your baby is still breech and you opt for an ECV, you will be shown a short video and an ECV appointment will be arranged for you.


What is ECV?

ECV or external cephalic version is technique used to try to turn your baby to a head-first position. ECV increases the likelihood of having a vaginal delivery. It is usually tried after 36 weeks and can be attempted right up until you give birth.


Does ECV always work?

ECV is successful in about 50% of women. Relaxing the muscles of the womb with medication during an ECV is likely to improve your chance of success. This medication does not affect your baby. If your baby does not turn, it is possible to have a second attempt on another day. Your midwife or obstetrician will advise you further if they think a second attempt is reasonable.


Is ECV safe for me and my baby?

ECV is generally safe and does not cause the labour to begin. The baby’s heartbeat will be monitored before and after the ECV. Complications can sometimes occur but this is very rare. About one in 200 (0.5%) of babies need to be delivered by emergency Caesarean section immediately after an ECV. This may be due to bleeding from the placenta and or changes in the baby’s heartbeat. Your baby’s heart rate will be monitored before, during and after the procedure to ensure s/he is not in distress. Your ECV will also be attempted on the labour ward where there is immediate access to facilities should you need delivery by emergency Caesarean section.


The ECV should not be carried out if:

  • you need a Caesarean section for other reasons
  • you have had vaginal bleeding during the previous seven days
  • the baby’s heart tracing (CTG) is abnormal
  • your womb is not a normal pear shape (some women have a womb which resembles a heart shape, known as bicornuate uterus)
  • your waters have broken before you go into labour
  • you are expecting twins or more (except if after delivering the first baby, the second baby is breech)

How is ECV performed?

A specialist midwife will carry out the ECV and an obstetrician will scan. Gentle pressure is applied on your abdomen which helps the baby to turn in the womb to lie head first. It will take no more than three attempts over a ten-minute period followed by fetal monitoring for one hour. Afterwards you can go home with a follow-up plan.


Sources and acknowledgements

This information is based on the recommendation of the Royal College of Obstetricians and Gynaecologists (RCOG). Useful links:

Breech babies are often delivered by cesarean delivery.  However, there are options.  

image268

Placenta Previa

 

Placenta previa happens in about 1 in 200 pregnancies. If you have placenta previa early in pregnancy, it usually isn’t a problem. However, it can cause serious bleeding and other complications later in pregnancy.

Normally, the placenta grows into the upper part of the uterus wall, away from the cervix. It stays there until your baby is born. During the last stage of labor,  the placenta separates from the wall, and your contractions help push it into the vagina (birth canal). This is also called the afterbirth.

If you have placenta previa, when the cervix begins to efface (thin out) and dilate (open up) for labor, blood vessels connecting the placenta to the uterus may tear. This can cause severe bleeding during labor and birth, putting you and your baby in danger.

 

Risk factors

Placenta previa is more common among women who:

  • Have had a baby
  • Have scars on the uterus, such as from previous surgery, including cesarean deliveries, uterine fibroid removal, and dilation and curettage
  • Had placenta previa with a previous pregnancy
  • Are carrying more than one fetus
  • Are age 35 or older
  • Are of a race other than white
  • Smoke


Complications


If you have placenta previa, your health care provider will monitor you and your baby to reduce the risk of these serious complications:


  • Bleeding. Severe, possibly life-threatening vaginal bleeding (hemorrhage) can occur during labor, delivery or in the first few hours after delivery.  Sometimes there is enough bleeding to require a blood transfusion.


  • Preterm birth. Severe bleeding may prompt an emergency C-section before your baby is full term.


  • Placenta accreta Placenta percreta.  These are forms of invasive placenta which grow deep into the uterus.  The placenta does not detach and deliver as usual.  Patients may have severe bleeding which can put the mother's life in danger.   This complication usually is usually the result of anterior placenta previa overlying the cesarean scar in women who have had prior cesarean deliveries. The risk for placenta accreta / percreat increases with the number of prior cesarean deliveries.  


Your Birth: My Take

Your Birth

Birth of your baby should be right for you.  The experiences of others might help, but only you will know what is best for you.  Taking control of your pregnancy and birth plan with normal vaginal delivery is possible for the majority of women.  For others, cesarean delivery is the best or only option and those women should feel equally proud of their achievement.   In either case, you too can  'Give Birth Like a Feminist'   However, also realize constraints and biases of your own healthcare system


Pregnancy doesn't always go perfectly but with early detection and help, you can delivery a normal baby.  The data from the GAP protocol indicates that women considered at risk benefit from closer monitoring with serial ultrasound scans, including Doppler studies (to evaluate blood flow from the baby to the placenta, or from you to the placenta, or both).   Don't ignore symptoms,  warning signs, or risk factors (see GAP protocol above) and keep regular checkups.  I would also still advise Vitamin D through breast feeding at least, while folate is not as important after the first trimester.


 It may not always be according to your original birth plan, but your midwife, obstetrician and other healthcare providers will always strive to help you have the delivery you'd like.  Let them help you in your journey, and say hello to your amazing new baby.  Any concerns or issues regarding birth will quickly disappear with the joy you feel with your new baby.  


image269

Downloads

Cesarean RCOG (pdf)

Download

GAP Fetal surveillance (pdf)

Download

White Newham Near term deliveries (pdf)

Download

Vitamin D for mother and child (pdf)

Download

choosing-to-have-a-c-section (pdf)

Download

Sillbirths Ireland (pdf)

Download

Vitamin D and preterm birth (pdf)

Download

Still birth RCOG (pdf)

Download

ARRIVE trial (pdf)

Download

Breech birth options (pdf)

Download

breech-baby-RCOG (pdf)

Download