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VBAC in Singapore

The old adage ‘once a cesarean always a cesarean’ is no longer holding true for more and more women giving birth in Singapore. Worldwide VBAC births are increasing. (Vaginal Birth After Cesarean) As women become better educated in the birthing process more are opting for a ‘trial of labour’ instead of automatically scheduling a repeat cesarean.

Doula and childbirth educator Ginny Phang is witnessing first hand the increase in women attempting VBAC. Almost 80% of Ginny’s doula clients and students are planning a VBAC. “I’ve definitely seen an increase this year, I think women are becoming more aware that a planned VBAC is very safe” says Ginny.

Is VBAC safe?

With appropriate care, 70 to 80 percent of women who labour for a VBAC will have an uncomplicated vaginal birth. With a planned VBAC, the risk of uterine rupture with one low transverse scar is 5 per 1,000.

Why chose VBAC?

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

Local Obstetricians are seeing this increase also. Dr.Paul S.L Tseng Consultant Obstetrician & Gynaecologist at TMC

“Yes, I am seeing more patients coming for VBAC, maybe because of word of mouth patients come to hear that I am willing to help them try VBAC.

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, allowing room for the baby, whose head molds to fit. The pelvis will actually open up 33% larger than it's pre-pregnant size with a squatting position. There are several factors that contribute to this. First a hormone called relaxin is released during the latter part of pregnancy, which soften the ligaments and cartilage surrounding the pelvis. Also different positions assumed during labor will change the dimensions of the pelvis such as walking, climbing stairs and squatting. This combined with the flexibility of the baby's head gives ample room for babies to move through the pelvis. The baby's head is made up of five plates that are connected with soft tissues that allow it to mold during the birth process as the baby travels through the pelvis. These bones 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 doctor to be supportive can be difficult. Take the time to make an appointment and go in a 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 states, "80% of the problems a woman having a vaginal delivery has, also happen to a woman having a Cesarean section." Most often it is the interventions like episiotomies, vacuum and forceps deliveries that contribute to urinary and fecal incontinence, uterine prolapse, and pelvic floor damage rather than the vaginal birth itself. Women who have had cesarean deliveries also experience urinary and fecal incontinence and other concerns due to the surgery or simply as a result of the hormones of pregnancy and/or the drugs used during the delivery.

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

A: A cesarean section is major abdominal surgery with all that entails. The surgery itself, as opposed to medical problems that might lead to a cesarean 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 risks to the baby such as respiratory distress syndrome, prematurity, lower birth weights, jaundice, lower APGAR scores (APGAR is the means of assessing the health status of a newborn), and finally in 1 to 9 percent of cases the baby is scarred or even maimed by the scalpel.

Q: When is a cesarean absolutely necessary?

A:

• Complete placenta previa at term.
• Transverse lie
• Prolapsed cord.
• Abrupted Placenta.
• Eclampsia or severe preeclampsia with failed induction of labor.
• Large uterine tumor which blocks the cervix
• True fetal distress confirmed with a fetal scalp sampling or biophysical profile
• True cephalopelvic disproportion (CPD- baby too large for pelvis). This is extremely rare and only associated with a pelvic deformity (or an incorrectly healed pelvic break).
• Initial outbreak of active herpes at the onset of labor.
• Uterine rupture

Since we know 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 cesarean rather than try for a vaginal delivery? In some cases it is fear of pain during labor (although many patients report that the pain from recuperation from a cesarean section is worse than labor pain), in others it is a "fear of the unknown," while for some women 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, since there is a small risk with an attempt at vaginal delivery and a risk with repeat cesarean patients should make the best choice for themselves, based on their specific medical history and individual situation.

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

Resources:
www.vbac.com

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

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