The birth of a child is supernatural spiritual event. – Lailah Gifty Akita,
A miracle is really the only way to describe motherhood and giving birth. – Jennie Flnch
A miracle is really the only way to describe motherhood and giving birth. – Jennie Flnch
SYNOPSIS
A baby may be delivered by a vaginal or a cesarean delivery. But in a given situation, one procedure may be safer for the mother and the baby than the other procedure.
Advantages of the vaginal delivery are that the mother feels it is natural, the recovery period is shorter and she can breastfeed earlier. Disadvantages are that it is a gruelling event and has a higher risk of urinary incontinence; and that the baby may be injured during delivery.
A cesarean may be required in certain situations such as low-lying placenta or breech baby. Mother has longer recovery period; and risk of excessive blood loss and bowel or bladder injury. Baby may have breathing problem and childhood ashthama and obesity.
A successful. VBAC (vaginal birth after a cesarean) is possible. However, there is a small risk of rupture of the uterus. Therefore, suitable doctor and hospital are required.
INTRODUCTION
Between cesarean and vaginal delivery, choose the one which has the least chance of causing injury or morbidity to the baby and the mother. Both procedures have risks. But in a given situation, risks in one procedure are greater than in the other. Aim is to minimize the risk.
For an informed discussion with the therapist, for choosing the optimum delivery method in a given situation, and for giving an informed consent, the expecting mother and her family need to know the pros and cons of the two methods of delivery.
This paper summarizes the pros and cons of the two methods for the mother and for the baby.
INCIDENCE
According to WHO, maternal and new-born deaths decrease as the cesarean rate rises up to 10-15% of the number of deliveries. Higher cesarean rate does not further reduce maternal or neonatal mortality. We may interpret that to mean that in 10-15% cases cesarean is called for; but in 85% of the cases, that is majority of the cases, vaginal delivery is possible. In a few other studies, the death rate continues to reduce till 19% of caesarean rate.
The average caesarean rate in India is 18%. However among the 20% richest population, the rate is 30%. In the United States caesarean rate is about 32% (2017). Clearly, among the rich, more caesareans are being done than are medically needed: rich women choose caesarean rather than vaginal delivery.
VAGINAL DELIVERY
A Mother finds vaginal delivery a more natural experience, feels she is giving birth the way nature intended her to. The other advantages are:
• a shorter hospital stay (24 – 48 hours) and recovery time compared with a cesarean.
• avoid major surgery and its associated risks, such as severe bleeding, scarring, infections, reactions to anesthesia and longer-lasting pain.
• earlier contact with the new-born, hold her baby and begin breastfeeding sooner after she delivers
• avoid major surgery and its associated risks, such as severe bleeding, scarring, infections, reactions to anesthesia and longer-lasting pain.
• earlier contact with the new-born, hold her baby and begin breastfeeding sooner after she delivers
The disadvantages for the mother are;
• labor is a physically gruelling process and is hard work.
• a risk that the skin and tissues around the vagina can stretch and tear while the fetus moves through the birth canal. If stretching and tearing is severe, a woman may need stitches or this could cause weakness or injury to pelvic muscles that control her urine and bowel function.
• higher risk of bowel or urinary incontinence; more prone to leak urine when they cough, sneeze or laugh.
• may experience lingering pain in the perineum, the area between her vagina and anus.
• increased risk of:
o anxiety and stress during pregnancy
o sexual problems post-delivery
o increased risk of post partum depression
• a risk that the skin and tissues around the vagina can stretch and tear while the fetus moves through the birth canal. If stretching and tearing is severe, a woman may need stitches or this could cause weakness or injury to pelvic muscles that control her urine and bowel function.
• higher risk of bowel or urinary incontinence; more prone to leak urine when they cough, sneeze or laugh.
• may experience lingering pain in the perineum, the area between her vagina and anus.
• increased risk of:
o anxiety and stress during pregnancy
o sexual problems post-delivery
o increased risk of post partum depression
For the Baby the advantages are:
• muscles involved in birthing may squeeze out fluid in a new-born’s lungs, making breathing problems at birth less likely.
• good bacteria received as the new-born travels through the birth canal may boost its immune systems and protect its intestinal tracts.
• good bacteria received as the new-born travels through the birth canal may boost its immune systems and protect its intestinal tracts.
For the Baby the disadvantage is that in long labor, or if the new-born is large, it may get injured during the birthing, resulting in a bruised scalp or a fractured collarbone.
CESAREAN
In certain medical situations, vaginal delivery may be too risky. Therefore a cesarean may be planned. Typical risky situations are:
• twins or other multiples
• a very large baby in a mother with a small pelvis
• baby not in a heads-down position and efforts to turn the baby into this position before birth were unsuccessful.
• medical conditions such as diabetes or high blood pressure
• an infection, such as HIV or genital herpes, that she could pass along to her baby during birth
• problems with the placenta during pregnancy
• a very large baby in a mother with a small pelvis
• baby not in a heads-down position and efforts to turn the baby into this position before birth were unsuccessful.
• medical conditions such as diabetes or high blood pressure
• an infection, such as HIV or genital herpes, that she could pass along to her baby during birth
• problems with the placenta during pregnancy
Sometimes an unplanned, or emergency cesarean, may become necessary because the health of the mother, the baby, or both, is in jeopardy. This may happen because of a problem during pregnancy; or after a woman has gone into labor: if labor is happening too slowly or if the baby is not getting enough oxygen (fetal distress).
Sometimes a mother may request for an elective cesarean because she wants to plan her delivery; or because she previously had a complicated vaginal delivery.
In certain situations cesarean is lifesaving. But opening up a woman’s abdomen and removing the baby from her uterus is a major surgery. The risks are:
• often leads to repeat C-sections in future pregnancies,
• longer hospital-stay, two to four days on average.
• longer recovery period, often at least two months; more pain and discomfort in the abdomen as the skin and nerves surrounding the surgical scar need time to heal.
• increased physical complaints such as pain or infection at the site of the incision and longer-lasting soreness.
• increased risk of:
o blood loss and a greater risk of infection, bowel or bladder injury or a blood clot forming during the operation.
o future pregnancy complications, such as placental abnormalities and uterine rupture, which is when the uterus tears along the scar line from a previous cesarean. The risk for placenta problems increases with every cesarean a woman undergoes.
o death during surgery: three time more likely in a cesarean than in a vaginal birth, due mostly to blood clots, infections and complications from anesthesia.
o miscarriage and stillbirth in pregnancy after cesarean.
• longer hospital-stay, two to four days on average.
• longer recovery period, often at least two months; more pain and discomfort in the abdomen as the skin and nerves surrounding the surgical scar need time to heal.
• increased physical complaints such as pain or infection at the site of the incision and longer-lasting soreness.
• increased risk of:
o blood loss and a greater risk of infection, bowel or bladder injury or a blood clot forming during the operation.
o future pregnancy complications, such as placental abnormalities and uterine rupture, which is when the uterus tears along the scar line from a previous cesarean. The risk for placenta problems increases with every cesarean a woman undergoes.
o death during surgery: three time more likely in a cesarean than in a vaginal birth, due mostly to blood clots, infections and complications from anesthesia.
o miscarriage and stillbirth in pregnancy after cesarean.
Baby born by cesarean is at a higher risk of:
• stillbirth
• higher mortality rate than vaginal delivery baby
• more likely to be admitted to the NICU for breathing problems
• higher rate of childhood (up to the age of 12) asthama
• a greater risk of becoming obese as children and as adults (perhaps because women who are obese or have pregnancy-related diabetes are more likely to have a C-section)
• lesser immune system
• higher mortality rate than vaginal delivery baby
• more likely to be admitted to the NICU for breathing problems
• higher rate of childhood (up to the age of 12) asthama
• a greater risk of becoming obese as children and as adults (perhaps because women who are obese or have pregnancy-related diabetes are more likely to have a C-section)
• lesser immune system
VBAC
VBAC (vaginal birth after cesarean) is possible under certain conditions. But VBAC is not safe for every woman and can even be life threatening to her. Before attempting a trial of labor after cesarean (TOLAC), remember that the following are contraindications:
• obesity (body mass index 30 or higher; weight over 200 pounds)
• pre-eclampsia (high blood pressure during pregnancy)
• age (usually older than 35)
• previous caesarean was in the last 19 months
• fetus is very large
• the reason for the initial caesarean is recurrent (for example, very small maternal pelvic dimensions). In this case, TOLAC may be dangerous to both mother and baby.
• more than two previous caesareans
• scar is a vertical cut, that is, it goes from top to bottom (high risk it will rupture and harm the baby and the mother and will call for a cesarean)
• additional uterine scars, anomalies, or ruptures
• pre-eclampsia (high blood pressure during pregnancy)
• age (usually older than 35)
• previous caesarean was in the last 19 months
• fetus is very large
• the reason for the initial caesarean is recurrent (for example, very small maternal pelvic dimensions). In this case, TOLAC may be dangerous to both mother and baby.
• more than two previous caesareans
• scar is a vertical cut, that is, it goes from top to bottom (high risk it will rupture and harm the baby and the mother and will call for a cesarean)
• additional uterine scars, anomalies, or ruptures
If scar is low and a transverse cut, that is, goes from side to side, then TOLAC may be attempted.
According to ACOG (The American College of Obstetricians and Gynecologists):
• 3-4 out of 5, ie, 60-80% women can have successful VBAC
• transverse cut, risk of rupture, is 0.2 to 1.5%, ie 1 in 500
• VBAC is safer than repeat caesarean
• more than one previous caesarean does not pose any additional risk in VBAC
• genital herpes is acceptable, unless a visible lesion
• no evidence that a large baby requires cesarean. Squatting increases outlet of the pelvis by 10%
• transverse cut, risk of rupture, is 0.2 to 1.5%, ie 1 in 500
• VBAC is safer than repeat caesarean
• more than one previous caesarean does not pose any additional risk in VBAC
• genital herpes is acceptable, unless a visible lesion
• no evidence that a large baby requires cesarean. Squatting increases outlet of the pelvis by 10%
Rupture of the uterus is the principal risk of VBAC. The risk is small: less than 1% VBAAC result in rupture. But it is dangerous if it happens. Go for VBAC only if you are prepared to take that risk.
Also be sure to choose a pregnancy doctor in delhi and a hospital who can handle the rupture and do a cesarean if needed.
You may wish to attempt a VBAC because if it is successful, you will avoid the disadvantages of a Cesarean.
History
The second Mauryan Samrat (emperor) of India, Bindusara, was born c. 320 BCE by caesarean. His mother accidentally consumed poison and died when she was close to delivering him. Chanakya, his father Chandragupta’s teacher and adviser, cut open the belly of the queen and took out the baby Bindusara, thus saving the baby’s life.
That Julius Caesar was born by caesarean, hence the name caesarean for the procedure, is a myth. Though caesareans were performed in Roman times and Jewish woman are said to have survived such operation. But caesareans usually led to the death of the mother and were usually performed only when woman was dead or supposed to be beyond help. In Great Britain and Ireland, the caesarean-mortality rate in 1865 was 85%.
