VAGINAL BIRTH AFTER A PREVIOUS CAESAREAN SECTION IS POSSIBLE

1 August 2020 0 By DR. U.J. Agim

CAN I HAVE A NORMAL DELIVERY?

“What is a ‘normal delivery’ to you?” is the question that comes from me whenever a woman asks if she can have a normal delivery after a previous caesarean section. Their answers are always the same which is that, vaginal delivery is what a normal delivery is. Yes, it is possible to have a vaginal delivery after a caesarean section. The natural way of delivery is via the vaginal route, however, when that is not possible, the alternative is a caesarean section. Some hold on to the belief that a woman who has not had a vaginal delivery is not a real woman. For them, a test of real womanhood is to have experience of the pains of labour and vaginal delivery. This cultural misconception has caused a lot of harm to women both physical, psychological and even death for the ones who are not lucky enough. Apart from this misconception, their religious belief often influences their decision whenever the word caesarean section is mentioned. Some faith preachers associate other route of delivery with the devil, as believers are expected to have a ‘normal delivery’ like the ‘Hebrew’ women. As believers, this is supposed to be their inheritance. Poor socioeconomic status is also the reason why some couples view caesarean delivery with horror apart from the fear of possible complications from the operation.

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I have not come across a literature that said a particular route of delivery is normal while the other is abnormal, I am open to learning if you have come across any. We all know one is the natural route while the other is not. Maybe this is so to avoid the stigma that might be associated with what is termed to be abnormal, this will make it difficult if not impossible to persuade a woman to take the other route of delivery classed as abnormal. If you are talking about labour, yes, there is a normal and abnormal labour but this is not the talk for today.

There are only two routes of delivery, these could be the vaginal route or the abdominal route. The aim is always to have a vaginal delivery but this might not be the case at all time. Your healthcare provider will advise you appropriately on vaginal delivery if indicated. Delivery via the vaginal route during labour will depend on three factors; the strength of uterine contractions, the size of the baby and the adequacy of the birth canal. The vaginal route is the most preferred by most people for reasons stated above. Also, viewed as the safer and least expensive route of delivery. The vaginal delivery might also become an operative one and this is when instruments are used to assist the delivery such as forceps or vacuum. However, the vaginal route of delivery is not without its short and long term complications. In the short term; the baby might be in distress or delivered with birth injuries been unable to use one of it limbs, the woman’s cervix might be injured resulting in heavy bleeding that might necessitate blood transfusion, the vagina might also have injuries requiring stitching, there may be a pelvic floor damage. In the long term, women with a pelvic floor damage or repetitive small pelvic floor damages are at risk of developing pelvic organ prolapse (when the cervix or uterus is descending into the vagina).

The abdominal delivery route can also be called caesarean delivery or caesarean section (CS). This is when the abdomen and uterus is cut open during an operation to deliver the baby. This is the route of choice when the vaginal route is not going to be possible. Your healthcare provider will advise you when the need arises for a caesarean section if vaginal delivery will be dangerous to the mother and or the baby.  If the baby is too big, the birth canal is too narrow for the baby to pass, the presence of some disease of the birth canal or other reasons to avoid vaginal delivery, your healthcare provider will advise you for a caesarean section. Some women now request for caesarean section for social reasons when the baby is due and they are not in labour, often to enable them participate in an event which the pregnancy will prevent them from participating. Some also request for caesarean section for fear of labour pains. Caesarean section can prevent small pelvic injuries thereby protecting against pelvic organ prolapse. This protection is lost after menopause and the risk becomes almost similar for both routes of delivery, as the feminine hormones that play a role to prevent the prolapse are no longer produced during menopause. Just like any other surgery, caesarean section also has it complications which your healthcare provider will counsel you on before the operation.

Vaginal birth after a previous caesarean section is very possible. There are certain criteria you must meet before your healthcare provider will advise you to try vaginal delivery after a previous caesarean section. Read here for what you need to know about vaginal birth after caesarean section. The main purpose of this article is to educate those who have had a previous caesarean section and their healthcare provider is advising for a repeat in the index pregnancy from his professional point of view. Do not let religious or cultural misconception influence your decision against your doctor’s advice. Anything is possible in medicine but it is not wise to ignore your doctor’s advice, some did and lived to testify, some did and lived but too ashamed to testify while some did and are not alive instead, they added to the maternal mortality statistics.

SCENARIO 1

Some years back when I was an intern on duty, a woman entered the labour ward with labour pains. While the delivery couch was being prepared for her to lie on, she screamed and said the baby is coming. I asked when the labour pains started and she said about 10hours ago. Did you book for antenatal care? Yes, she said. I also got another yes when I asked if she had delivered a baby before. I was surprised why a booked patient with her experience will stay at home for a long time after the onset of labour. As soon as she laid on the delivery couch with her legs apart, I could already see the baby’s head protruding through the vagina and before anything could be done, she delivered a 4.1kg baby, however, I noticed a scar on her lower abdomen while delivering the placenta. After the mother and baby had settled, I went back to enquire about the scar. She told me she had had two previous deliveries, the first was delivered via the vaginal route, while the second was via a caesarean section because the baby was in distress during labour. She also said God has disappointed the doctor who advised her to have a repeat caesarean section because the scan showed the baby in the index pregnancy was big. So, that was why she stayed back to only come when she is far advanced in labour to avoid operation and also intentionally didn’t volunteer the history of a previous caesarean section.

SCENARIO 2

I was in the labour ward when a woman was rushed in bleeding from the vagina. She had a previous caesarean section about a year ago and was advised for a repeat caesarean section because of a short inter-pregnancy interval. She declined and instead went to a traditional birth attendant when she was in labour. She was only taken to the hospital when she started bleeding. After our clinical assessment, she was rushed to the theatre for an emergency operation for a ruptured uterus with a dead baby as the baby’s heart beat was not heard. The damage to the womb was extensive and we could not control the bleeding so, the womb had to be removed to save her. She had multiple blood transfusions and ended up in the intensive care unit.

The above scenarios are the lucky ones that made it, the first scenario will be widely publicised of course by the patient and some women will work with the information than what their healthcare providers will advise. I will like to state that having a caesarean section does not mean you cannot have a vaginal delivery. Read here to know the criteria for having a trial of labour after caesarean section and this would help you to make informed decisions.

I hope this article was helpful, do well to follow my blog for more informative articles on woman’s health.