Vaginal Birth After Caesarian(VBAC) – The Travelling Midwife

Marli is 1,8m tall, slim and has a good bone structure.  Marli  felt intrinsically that she was capable of giving birth normally to a healthy baby. Her own mother had given birth vaginally to three big babies at 42 weeks of pregnancy. Marli’s obstetrician had told her that the “baby’s head was too large, he had not engaged or dropped into the pelvis, because her hips were too small”. At the time, Marli said she was not well informed and felt anxious about the baby’s wellbeing, so she agreed to the surgery. Subsequently, Marli’s first baby, Neil, was born by caesarian section at 41+weeks (10 days) and weighed 3,8kg. Mother and baby were separated after birth, as is protocol in South African private hospitals, and this was something Marli regretted. She struggled to breastfeed her son initially, although  after much pain and persistence, succeeded, and continued breastfeeding for more than a year.

There are a few issues raised here:

Firstly, the proof of the pudding is in the eating, in other words, you cannot know whether your hips are ‘too small’ for the baby until you have been in labour for a reasonable number of hours. Studies that tried to predict outcomes in pregnancy using pelvimetry (X-ray measurements and ultrasounds) were not accurate in predicting  fetal/pelvic size ratio. Hip joints are flexible at the end of a pregnancy and expand during birth to allow the passage of a baby’s head, especially when the mother adopts upright positions for labour and birth. The baby’s head is also able to mould to the shape of the mother’s pelvis to a degree.

Secondly, many babies do not descend into the pelvis until the actual labour begins. Caucasian women have a higher incidence of engagement of the vertex(the baby’s head) in the pelvis at 36 weeks, with first time pregnancies (primigravida) only.  African women’s babies tend not to descend into the pelvis until labour begins.  We (midwifery and medical students) were taught that, as a rule, the vertex descends into the pelvis at 36weeks, but, remember the Bell Curve? – 60% of babies or women will follow the norm while 40%  will be ‘outliers’.

Thirdly, physiological traits may be passed from mother to daughter. A mother’s trait to carry a baby till 42 weeks may be passed on to her daughter so that when she is pregnant she may also carry her babies till 42 weeks. This could be a problem if a mother wants a VBAC, because most doctors will schedule the caesarian for 40-41weeks. This puts pressure on a mother to perform and we know that labour is not controlled by the conscious mind.

Scheduling a caesarian for 41-plus weeks when the mother is a ‘VBAC’ client, though, may well be warranted.  After the due date, a placenta matures and optimal placental function may decrease. The baby has more time to grow and the head may grow larger than necessary for a safe birth. Ideally a VBAC mother should go into labour spontaneously on or a few days either side of her expected date of birth, but some women will carry beyond the threshold an obstetrician or midwife feel they can safely allow. I do know of one woman who, after three previous caesarian sections, gave birth naturally to her fourth baby just short of 43 weeks. Ultrasound doppler monitoring of the placental flow and regular graphic recordings of the baby’s heart rate can reassure you and your obstetrician to allow more time after the due date.

Marli first came to see me when she was 23 weeks pregnant, referred by a facebook friend. I agreed to assist her and recommended she use a different obstetrician, Dr Douglas Dumbrill, as back-up obstetrician at the Vincent Pallotti Hospital.  As we chatted I explained the prerequisites for a natural birth.  Normal health is a good starting point, a healthy, low sugar diet (diabetic diet)and regular exercise are essential, avoiding stress and ensuring sufficient rest and relaxation periods inbetween periods of activity. Sufficient high quality protein and oils, particularly the omega oils help to sustain the elasticity of bodily tissues and maintain the healing of  scar tissue. Marli had a good support system, her husband supporting her choices and her mother helping to care for her active toddler Neil when Marli needed a break.

Approximately 70% of women who are eligible and elect to attempt a VBAC  give birth naturally. While the risk of uterine rupture is less than 1,0%, the risk is higher to the baby than to the mother, and although most uterine ruptures are not catastrophic,  this is unpredicatable.  A dehiscence of the uterine scar is when the scar tissue thins out without bleeding profusely, and usually the labour is erratic and does not progress. Contractions may slow down altogether. These signs are indicative of incordinate uterine function. In my view it is the body’s way of communicating that something is amiss. This is why induction for a VBAC trial of labour is not recommended, as induction will override the body’s natural responses during labour and mask potential problems. A rupture of the uterus, on the other hand, is sudden and will immediately affect the pulse rate of the mother, and the baby’s heart rate. Many VBAC studies used data which included women who were induced or given pitocin to speed up the rate of cervical dilatation. This would not be  a true reflection of  a VBAC success rate in my opinion.

It is also critical in my opinion to have one caregiver/birth attendant who knows the patient well and can respond to small changes in her and her baby’s bodily signals. Fetal heart rate monitoring during labour is recommended and the monitor can usually be attached while the mother is in upright positions as well as semi-reclining positions. Monitors themselves need to be ‘monitored’ – they need to be regularly calibrated and the wires and probes must not be damaged. Monitors and graphs need to be watched to ensure they are recording accurate readings. This can interfere with the ‘flow’ of labour, but a midwife will help by following you with the monitor, holding it by hand if necessary. Some women feel that these interventions distract them interfere with the natural birth process and choose to give birth at home (HBAC).

Lets get back to Marli!

Marli made lifestyle changes and started attending gym regularly with her husband. She adapted her dietary behaviour, eliminating refined food and sugar from her diet and eating frequent, small, high-protein healthy meals. Marli gained about 8kg during the pregnancy and her baby continued to grow well. The 40 week marker came and Marli came to see me, eager to get things moving! Dr Dumbrill gave her 1 week’s grace over her due date, after which she was booked for a repeat ceasarian section.We used every natural technique in the book to encourage labour that week and on Monday the 4th of July, early in the morning, Marli went into labour spontaneously.

By the time we arrived at Vincent Pallotti Hospital (http://www.lifehealthcare.co.za/hospitals/displayhospital.aspx?nHospitalId=16), Marli was almost in transition, the stage of labour just prior to giving birth. We monitored the baby while she lay on her side, and then in upright positions, standing next to the bed. She walked to the toilet and back a few times, tried warm water but found it too hot and soon started to feel strong urges to bear down. Doppler fetal heart measurements were taken inbetween monitoring and the baby’s heartrate was stable. I also inserted an intravenous needle with a small heplock so that if emergency fluids were  needed they could be given without delay. Dr Dumbrill popped in to check on how things were going and saw that the birth was imminent.

Aldo was alert and responsive immediately after birth and was welcomed with joy into his family as he began his earthly journey of life. Once Marli and her newborn were settled it was time for a photographic session and congratulations from family and friends. Her father and paren’t in-law arrived with Neil, her firstborn son, who wasn’t sure about his new brother Aldo! Neil managed to pose for a few pics and happily went back to ‘Ouma’, Marli’s mother, who had imparted calm and confidence during the labour.

Well done to Pieter and Marli and Aldo on their successful VBAC!