HIGH RISK PREGNANCY

Did you know that if you meet the criteria for a trial of labour (vaginal birth after caesarean section), you might not need a repeat caesarean section? After a woman undergoes delivery via a caesarean section, at discharge, she is reminded of the reason why the operation was done and also told that her subsequent pregnancies are high risk because of the operation. She will be advised to book for antenatal care in a health facility that has the capacity to carry out caesarean section, also to space her pregnancy to give adequate time for her body to return to the pre-pregnancy state. It is important to volunteer information on the fact that you have had a previous caesarean section during your pre-conception counselling and care, at booking for antenatal care and during any emergency situation while pregnant. The aim of vaginal birth after caesarean section is to reduce the overall rate of caesarean section.

At the 36^th week of antenatal care, your healthcare provider will carry out a clinical examination on you. These will involve measuring the length of the womb which gives an estimate of the baby’s weight. A clinical pelvimetry might be done to measure the dimension of the birth canal if it is wide enough for the baby to pass through, or a radiologic pelvimetry using either X-ray, computer tomography scan(CT-Scan) or magnetic Resonance Imaging (MRI) might be done. Pelvimetry helps to identify whether there is a disproportion between the baby’s head and the mother’s pelvis thereby preventing obstructed labour. A scan will be requested to measure the thickness of the previous scar and estimate the weight of the baby. With the information from your examination findings, medical history and history of previous deliveries, your healthcare provider will advise you on the option of delivery (vaginal or caesarean delivery).

CRITERIA THAT FAVOUR VAGINAL BIRTH AFTER CAESAREAN SECTION

The following criteria involving the unborn baby favour a trial of labour after a caesarean section at term and include;

• the baby’s head should be at the lower part of the womb,
• the weight of the baby should be ≤3.5kg,
•  there should be a single baby in the womb.

The following criteria involving the mother favour a trial of labour

• If labour starts spontaneously.
• Previous vaginal delivery before caesarean section.
• Vaginal delivery after the caesarean section.
• If the thickness of the previous scar on the womb seen via an ultrasound scan is ≥3.5mm.
• If the indication for the previous caesarean section is no longer present in the index pregnancy.
• The previous incision on the womb during the previous operation made transversely on the lower part of the uterus.

If the above criteria are met, then trial of labour can be the option of delivery. However, meeting the above criteria does not guaranty a successful trial. The labour will be monitored closely for signs of uterine rupture which is the most feared complication of trial of labour after caesarean section.  Such signs are excessive pain even though the woman is not contracting, the presence of vagina bleeding, low blood pressure and high pulse rate. When vaginal delivery cannot be achieved that is, a failed trial of labour, a repeat caesarean section is carried out.

CRITERIA THAT DO NOT FAVOUR VAGINAL DELIVERY AFTER CAESAREAN SECTION

They include any condition that vaginal delivery is not advised or contra-indicated such as;

• When the placenta covers the cervix.
• presence of two or more babies in the womb
• When the interval between the last delivery and the conception of the index pregnancy is less than 14 months.
• Maternal short stature.
• Contracted pelvis.
• Diseased pelvis example rickety pelvis.

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