Dr Girija Wagh, Obstetrician, Gynecologist, IVF expertMD, FICOG, DIP ENDO, FICS
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Am I going to have a vaginal / normal delivery or a cesarean section / abnormal delivery ???
Let us know the facts and aim, plan for a safe delivery !! Safe both, for the baby and the mum.
What actually is a normal delivery ?
In medicine, we define a normal delivery which essentially starts naturally after reaching 37 weeks and before 40 weeks of duration and delivers a single live baby by the head through the natural vaginal route within a stipulated time and complications such as injury to the passage, undue prolongation of the process or excessive bleeding. Assistance offered such as episiotomy, medications or techniques used to shorten the delivery are components of normal delivery.
In reality, it is a process which results in safe outcome both for the baby and the mother.
Are all vaginal deliveries then normal deliveries ?
Not essentially so. Sometimes the woman may be delivered by the use of forceps ( special equipment used to deliver the baby ) or ventouse ( the equipment uses a vacuum cup and pressure to deliver the baby ) or it could be a twin delivery, or the baby may deliver by its face or buttocks instead of the head. All these variations are not essentially classified as a normal delivery. These processes even if achieved via the natural vaginal route need assistance and expertise and are associated with not so normal outcomes.
What is a cesarean delivery ?
The baby is delivered through a surgical cut taken in the lower area of the tummy and by opening the womb (uterus). The procedure is done under proper aseptic precautions and with anaesthesia so that infections and pain can be relieved.
Why is cesarean delivery performed ?
Certain conditions necessitate a cesarean delivery for safety and to avoid complications. Common baby indications are abnormal position such as baby presenting by buttocks instead of the head or a horizontally lying baby, large baby, small baby, weak baby, baby which has got stuck or is jeopardised or more than one baby or premature baby.
Mother indications are obese mothers, mothers suffering from diabetes, severely raised blood pressure, previous cesarean section or any uterine surgery, previous death of the baby during delivery, mother who has undergone repair surgeries for the birth canal, pelvic deformities, fibroids etc:
Some life-threatening situations such as lower placed placenta, bleeding from the birth canal or stuck placenta, obstructed labour, mother with seizures or breathing difficulties may need the mother to be delivered by cesarean section.
Do doctors do deliberate cesarean sections ?
This is an unfortunate perception in today’s society that doctors do purposeful cesarean sections either to earn more money or because they lack the expertise. The doctors are well aware of the morbidity associated with an operative intervention and an ethically practising doctor will never deliver a mother deliberately by cesarean delivery. Today’s vaginal delivery is comparable to a cesarean delivery, in terms of expenditure, infrastructure, time and importantly the outcome.
Are cesarean sections safe ?
Today with the advent of modern anaesthesia and surgical techniques, intra-operative monitoring systems, stitching materials, antimicrobials, access to blood banks, infrastructure, observation of safety protocols has made cesarean sections safe than they were in the past.
Are vaginal deliveries always safe ?
Not essentially so. Yes, vaginal route the natural route to deliver as the birth passage is meant for delivery. But excessive prolongation of delivery, very large baby, mother delivering for the first time, failure of progress, baby getting stuck can be the risks which can crop up when embarking on a vaginal delivery route. Also, injury to the birth canal and nearby structures can occur and are not essentially predetermined.
Which is the best method of delivery ?
The best method is the one which achieves safety for all, the mother, the baby and the doctor. Your doctor can guide you based on your pre-existing condition, previous delivery track record, status during the course of pregnancy and emergence of any situation during the course of delivery. So there is nothing like best. It is important that it is safe
Do cesarean sections have long term consequences ?
Cesarean sections do have some amount of morbidity attached to it such as an abdominal cut, cut on the womb , possibility of infection , difficulties in mobility initially and longterm issues are next to negligible but possibility of adhesions ( fibrotic bands making structures stick to each other ) are there in future if the woman needs to undergo pelvic surgery such as a hysterectomy ( removal of the womb) .
Is it always “once a cesarean always a cesarean” ?
No . This decision of a repeat cesarean section is based on what has been the initial reason for the cesarean section done for the first time and some such other issues. If your doctor rules out all these contraindications you can be offered a trial of a vaginal delivery and 50% of the times in such a situation women can deliver vaginally.
What according to you are the situations where delivery itself can be associated with increased morbidity?
Obesity, large baby or very small baby, preterm deliveries, twin pregnancies, breech or transverse lie, previous surgeries, mothers who have other co morbid conditions such as diabetes, raised blood pressure or any other febrile illnesses.
Some actual experiences
Mrs S ( 29 years ) was a low-risk mother who had an optimum pregnancy course and it was decided that she will undergo a natural birth. All the requisite counselling sessions, checklists were well in place. The only issue was the baby head was still floating but with an assurance that it will get engaged during the course of delivery this was just kept in mind. Eventually around 38 + 6 weeks she reported in labour and was identified in established labour. Both the mother and the baby conditions were normal and the patient was hospitalised for observation and care. Most of us obstetricians believe in an age-old dictum of ‘watch full expectancy and masterly inactivity’ which means “Observe the patient and give her, her own due time to deliver vaginally”, taking into account the fact that delivery is a perfectly natural process. The woman progressed with pains and the womb started opening. However, the head refused to descend further into the birth canal. After a while, the fetal heart rate dropped and we took a decision for a cesarean section as the baby heart was not reassuring. Intra-operatively it was observed that the cord inside had entangled all around the baby body and also had a true knot. Now, these are things which are not identified before delivery. The procedure was uneventful and all three the doctor, the baby and the mother are safe.
Mrs P ( 35 years ) has undergone 3 miscarriages and now has been suffering from severe hypertension and diabetes onset during pregnancy. She has a background history of PCOS and also is obese ( pre-pregnancy BMI 33).She has now reached 34 weeks and the baby is suffering from growth restriction as well. She delivered with a cesarean section and needed to be observed in high dependency unit for 72 hours immediate post delivery for severe hypertension and diabetes.The baby needed NICU for 2 days. Its been a month now both are safe.
Mrs K had an IVF conception and her previous delivery was a normal delivery. She was perfectly healthy during the entire course of pregnancy. A very chirpy, happy and a content mother looking forward to a natural birth. She attended all the visits regularly and followed the instructions by the book. She had just crossed 37 weeks pregnancy and reported on phone that she has some queasy tightening in the tummy. I gave her the necessary instructions and she reported to the facility wherein she had entered the beginning of labour. She was observed closely as per the protocol, she chose not to take the epidural and delivered after 5- 6 hours of admission a healthy Bonney baby.
So what should I expect and how should I plan my delivery ?
First consult your doctor and discuss about the course. Choose a facility which has a competent doctor, good infrastructure and which follows all the safety protocols. It will help you in making the right decision. Most ethical clinicians have their own self-audits and facility audits.
Should I ask about the cesarean section rates to a facility ?
We will deal with the rising cesarean rates and related issues such as facility cesarean section rates etc in our next issue coming week . . .
HAPPY WEEKEND AND GOOD READING
Dr. Girija Wagh, MD (Obstetrics & Gynaecology), FICOG, FICP, Diploma (Endoscopy, Infertility), Fellowship of Indian College of Ob-Gynec, Women health care specialist, Academician, Acclaimed Orator & Researcher, B. J. Medical 1990-1992, Topper University Of Pune 1992
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