Category: Variations of Pregnancy

VBAC

Posted on by development

Deciding how to give birth after a previous caesarean section.

 

If you have had a caesarean section before, your midwife or Doctor will talk to you about your options for giving birth now you are pregnant again.

Let’s look at some of the research about the options on so you can make the best choice for yourself and your family.

 

***Key Points***

A vaginal birth is a safe choice for many birthing parents who have had a C-section previously.

Some who plan vaginal birth after caesarean section (VBAC) will birth their baby vaginally, some will end up having another C-section, some will decide the best option for them is a planned Caesarean section prior to labour.

***Key Points***

 

***Definitions***

VBAC – vaginal birth after caesarean. It is the term used when a woman gives birth vaginally, having had a caesarean section in a previous birth. Vaginal birth includes spontaneous  vaginal delivery and a birth assisted by forceps or ventouse.

ERCS – Elective Repeat Caesarean Section. This is a choice to have a planned elective caesarean section at a planned date and time.

***Definitions***

***Benefits of a VBAC***

Benefits of planning a Vaginal birth

  • You avoid the potential complications of major abdominal surgery
  • You are more likely to have skin to skin contact with your baby immediately following birth
  • You are less likely to have difficulties breastfeeding. With vaginal birth, levels of prolactin and oxytocin (hormones that help you make milk and bond with your baby) are higher when compared with levels after C-section.
  • Your baby is less likely to be admitted to a nursery or neonatal intensive care unit (NICU) for breathing difficulties.
  • You have a shorter hospital stay and a faster recovery and less pain at 2 months and 6 months after birth.
  • When your baby is born vaginally, they come in contact with ‘good bacteria’. We need further research to understand the benefits of this but we know your baby is less likely to develop asthma or allergy related illnesses. It is thought this is because the good bacteria are good for the immune system of the baby.
  • You are less likely to experience postnatal depression. A large in 2020 study showed lower rates of depression both short term (two weeks after birth) and long term (six months after birth) in women who had a vaginal birth compared with those who had a C-section.
  • You are more likely to reflect on your birth as a positive experience.
  • You are more likely to have a positive birth experience. In one large Canadian study, clients who had a VBAC rated their experiences more positively than those who had a repeat C-section. You are less likely to have postpartum depression.

***Benefits of a VBAC***

***Benefits of a ERCS***

Benefits of ERCS

  • You are less likely to experience uterine rupture (see Risks section below).
  • You can avoid the risk of an emergency caesarean section (see Risks section below).
  • You are slightly less likely to experience urinary incontinence likely to experience pelvic organ prolapse after you have your baby. Urinary incontinence and pelvic organ prolapse are both treatable conditions.
  • You have the ability to plan your Caesarean section on a known date, which may be a benefit if you have other children to consider.

***Benefits of a ERCS***

***Risks of a VBAC***

What are some risks of VBAC and C-section? Studies tell us that both VBAC and planned C-section are very safe. However, having a baby always involves some risk of complications, no matter which kind of birth you have.

Risks of VBAC

Uterine rupture

Uterine rupture occurs when the wall of the uterus tears or splits during pregnancy or labour. If this were to happen, the split would likely be along the scar tissue of the previous Caesarean section.

Uterine rupture requires emergency surgery. Uterine rupture happens in about 0.5% of all VBAC labours.

This means that one uterine rupture would be expected to occur for every 200 birthing parents who plan to have a VBAC (which means a 99.5% chance this will not happen).

The need for an emergency C-section:

Even if you plan VBAC, you may need to have a Caesarean section. If this occurs after the onset of labour this is called an emergency caesarean section.

This happens to about one in four women who plan a VBAC, approximately 25-28%

Having a Caesarean section after labour has begun is associated with more risks than a Caesarean section planned electively before labour.

***Risks of a VBAC***

***Risks of a ERCS***

RISKS of a ERCS

Risks associated with having major surgery

As with any major surgery this comes with risks. These include fever, infection, injuries to the bowel or bladder, or blood clots.

Although the risks remain low, they are higher than after a vaginal birth.

Potential issues with the placenta in future pregnancies

The scar on the uterus from a caesarean section can cause difficulties with how the placenta attaches itself to the uterus in future pregnancies.

These include conditions such as placenta previa and placenta accrete.

These conditions can cause serious bleeding and in rare occasions may result in death. The risk of placenta problems increases with each additional caesarean section

Neonatal breathing difficulties:

If your baby is born vaginally, they are squeezed as they come through the birth canal.

This has the effect of squeezing the fluid from the babies’ lungs.

When a baby is born by caesarean section this does not occur and they are more likely to have trouble breathing right after birth compared with those who are born vaginally.

Most of the time, these symptoms are mild and most babies recover quickly.

There is a higher incidence of babies with breathing problems requiring admission to a special nursery or neonatal intensive care unit (NICU) for observation or treatment.

This may mean that you are separated from your baby

 

Other

Having a caesarean section impacts your fertility and has the potential to make it more difficult conceiving future pregnancies.

More likely to require CS for future births

Decreased rates of breastfeeding

***Risks of a ERCS***

***VBAC is not advisable***

 VBAC is normally an option for most women but it is not advisable when

  • You have a pregnancy complication such as placenta praevia
  • you have had three or more previous caesarean section births
  • your uterus has ruptured during a previous labour
  • your previous caesarean section was a ‘classical’, incision involving the upper part of the uterus

***VBAC is not advisable***

***What is the likelihood of a vaginal birth?***

What are my chances of having a VBAC?

Research tells us after one caesarean section, about three out of four women with a straightforward pregnancy who go into labour naturally will give birth vaginally.

Your chances of having a VBAC are enhanced if:

  • You have had a vaginal birth in a previous pregnancy
  • The reason for your last C-section does not occur again eg you baby is not breech again for this pregnancy
  • Your labour starts on its own and you do not need to be induced to start labour
  • Your labour progresses typically
  • Continuity of care from a known midwife is shown to increase the likelihood of VBAC rates

Your chances of having a VBAC are reduced if:

  • You have had more than one C-section.
  • Your BMI (body mass index) is over 25.
  • You are 35 years of age or older.
  • You are given drugs to induce (start) or augment (strengthen or speed up) your labour.

***What is the likelihood of a vaginal birth?***

***Planning a caesarean section***

If I plan to have  a ERCS – when should this be planned for?

If you decide the best decision for you and your baby is to have a planned caesarean section the best option for your baby is to book that for after 39 weeks pregnant.

This allows your baby the optimal time to mature prior to birth and reduces the likelihood your baby will require an admission to NICU.

***Planning a caesarean section***

***What are my options for pain relief***

What are my options for pain relief in labour?

It is possible to have an epidural during a VBAC labour. Discuss the risks and benefits with your midwife.

You may want to try other methods of pain relief such as massage, water immersion or nitrous oxide. These methods allow you to move and be active in labour.

There are no contraindications to water immersion for planned VBAC, using telemetry monitoring in labour.

***What are my options for pain relief***

***Induction of labour and VBAC***

Induction of labour?

If you are planning VBAC, going past your due date and being induced (having your labour started for you) are all options.

These options should be disussed with your health care provider

If you are induced, your chances of vaginal delivery are lowered and your chances of uterine rupture are increased.

An accurate due date is especially important if you are planning VBAC.

***Induction of labour and VBAC***

***What if I have more than one caesarean section?***

What if I have had more than one C-section?

It is still possible to have a VBAC after more than one C-section.

Research tells us that your chances of having a vaginal delivery are lower and your chances of uterine rupture are higher if you have had two previous C-sections.

There is very little research into VBAC after three or more C-sections.

***What if I have more than one caesarean section?***

***Deciding what is best for you and your baby***

 

How can I decide what’s best for me and my baby?

First discuss all the risks and benefits with your Midwife and an experienced Obstetrician. Do you have any unanswered questions, is there anything you do not understand.

Do you understand the reason for your previous caesarean section.

No think about your previous birth experience – how does it make you feel? What are your hopes for this birth?

***Deciding what is best for you and your baby***

Resources

Queensland Clinical Guidelines. Vaginal birth after caesarean (VBAC). Guideline No. MN20.12-V5-R25. Queensland Health. 2020. Available from: http://www.health.qld.gov.au/qcg

https://www.ontariomidwives.ca/sites/default/files/2021-06/Deciding-how-to-give-birth-after-caesarean-section-English.pdf

RANZCOG

 

 

Pre-Eclampsia

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Pre-eclampsia is a serious complication of pregnancy that causes you to have high blood pressure and protein in your urine. It can make you unwell and can affect your baby’s growth and wellbeing.

***Key Points***

Pre-eclampsia is a serious condition that may develop any time after 20 weeks of pregnancy until a few days after the birth.

Some people may not experience any symptoms but commonly it is diagnosed by:

  • High blood pressure,
  • Protein in the urine,
  • Sudden swelling in face, hands and feet
  • Sometimes problems with vision such as blurred vision, seeing spots or flashes.

***Key Points***

***Pre-eclampsia***

Pre-eclampsia affects between 2-8 pregnancies in 100 pregnancies with varying degrees of seriousness.

It is often mild and normally has very little effect on pregnancy. However, it is important to know if you have the condition because, in a small number of cases, it can develop into a more serious illness.

Around one in 200 women (0.5%) develop severe pre-eclampsia during pregnancy. The symptoms tend to occur later on in pregnancy but can also occur for the first time only after birth.

It can escalate in severity quickly and can affect the circulation to the baby, impacting your baby’s growth. If it develops into something more serious it may affect other organs of the body such as the liver (called HELLP syndrome) or cause seizures in the mother (called eclampsia).***Pre-eclampsia***

If you have developed pre-eclampsia it may be treated using medication, to lower your blood pressure.

If your condition worsens they care team may suggest the baby be born as soon as possible. If you have pre-eclampsia there is a higher chance that your baby will be born prematurely.

***Pre-eclampsia – risk factors***

There are some risk factors for pre-eclampsia including:

  • if it is your first pregnancy
  • if there has been more than 10 years since you were pregnant
  • if there is a family history
  • if you are a teenager or in your 40s
  • you have a high BMI
  • or you are pregnant with twins or triplets

***Pre-eclampsia – risk factors***

***Pre-eclampsia – symptoms***

See your Midwife or doctor if you experience any of the following

  • Severe headache that doesn’t go away with simple painkillers
  • Problems with vision, such as blurring or flashing before the eyes
  • Severe pain just below the ribs
  • Rapidly increasing swelling of the face, hands or feet
  • Feeling very unwell

Your Midwife or doctor will check your blood pressure and test your urine.

***Pre-eclampsia – symptoms***

***What happens in pregnancy?***

If you have pre-eclampsia it is considered a very high risk pregnancy, you and your baby will be very closely monitored throughout pregnancy, during birth and in the postnatal period.

There is a higher chance of requiring interventions such as induction of labour or caesarean section. The only way to rpevent serious complications is for your baby to be born. You are unique and the exact timing depends on your situation and how many weeks pregnant you are.

If your baby will be very premature they will administer a medication to help the lungs mature. You may have a longer stay in hospital after the baby is born.

***What happens in pregnancy?***

Low Platelets in Pregnancy

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Cholestasis

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Low Lying PLacenta

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The impact of Fibroids in pregnancy and how this may

Pregnancy Induced Hypertension

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High blood pressure is also called hypertension. Measuring your blood pressure at your first antenatal visit and throughout pregnancy is recommended for all pregnant women.

***Key Points***

In pregnancy it can develop because of the pregnancy or you may already have high blood pressure before you became pregnant.

It may occur after 20 weeks gestation and be a one-off event, or be part of a more complex condition such as preeclampsia.

Treatment includes rest, monitoring your blood pressure and the your baby’s growth and wellbeing. If your blood pressure doesn’t settle then you may need to start on medication or your baby may need to be born early.

***Key Points***

***Monitoring your blood pressure***

Your blood pressure is monitored throughout your pregnancy at each antenatal visit. Pregnancy induced hypertension [PIH] is usually diagnosed after 20 week’s gestation, it is usually a blood pressure greater than 140 over 90. However this should be assessed on an individual basis by your midwife or doctor.

It can also be a sign of a more serious condition called pre-eclampsia.

There may be a higher chance of you developing high blood pressure during pregnancy if you have had pre-eclampsia before, you are aged over 40, have another illness such as diabetes, you are pregnant with twins or you have a high body mass index [BMI].

***Monitoring your blood pressure***

***High blood pressure***

PIH is one of a few types of high blood pressure, the others are: chronic hypertension (when you had high blood pressure before the pregnancy); and pre-eclampsia (a serious condition that can affect other organs in the body).

If you experience headaches, blurred vision, seeing spots, swelling in your legs, feet, face and hands, and pain in your upper abdomen it is advised that you seek medical advice as soon as possible.

It is suggested that you maintain a nutritious diet and exercise to maintain a healthy weight and if you smoke to give up smoking. If there are concerns about your blood pressure your care provider may suggest a medication to help manage it.***High blood pressure***

During your antenatal visits the midwife of doctor will monitor your blood pressure. High blood pressure may impact on the function of your placenta and its ability to provide your baby with oxygenated blood and nutrients.

Resources

Health Direct – pre-eclampsia or pregnancy induced hypertension [PIH]

Pregnancy Birth Baby – high blood pressure in pregnancy

Department of Health – blood pressure

Underlying Medical Conditions

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If you have an existing medical condition you should consult with your specialist about planning for pregnancy.

Your medical condition may impact on your pregnancy, labour and birth and postnatal experience, your specialist team will collaborate with your maternity care team in order to provide you with the most appropriate care.

***Key Points***

Some women experience medical conditions that may have an impact on their pregnancy care choices.

These may include: asthma [or respiratory disease], diabetes, cardiac disease, epilepsy, problems due to previous injury including car accidents or birth, high blood pressure or previous surgery [this list is not inclusive of every medical condition that may impact on your pregnancy, birth and postnatal period].

Most importantly your specialist and maternity care providers collaborate in order to provide you with the most appropriate care to your needs.

In the majority of cases your pregnancy will be considered high risk as you will need more careful monitoring of your health and your baby’s.

Some symptoms may get worse due to the pregnancy and you may need changes to your medication or your treatment options may change.

***Key Points***

***Asthma***

If you have asthma before pregnancy it should not cause any problems if you manage it well. Most asthma medications are safe during pregnancy and it is usually better for you and your baby to take the medication rather than have your symptoms get worse if you don’t take medication. It is advisable to talk with your treating doctor about medications and pregnancy. For about one third of women their asthma will not change during pregnancy, for another one third their asthma will improve and for the other third they will notice their asthma getting worse during pregnancy. There is a chance that women with very bad asthma may develop high blood pressure or pre-eclampsia during pregnancy. If your asthma is not managed well there is a chance that your baby may be born early or have a low birth weight.

***Asthma***

***Diabetes***

Diabetes – it is important to manage your diabetes well if you are planning pregnancy or just found out you are pregnant. You will have a specialist team caring for you to help manage your diabetes and to carefully monitor your pregnancy. Keeping your blood sugars stable during pregnancy is important for the health of you and your baby.

There is a chance that you could develop eye or kidney problems during the pregnancy if your sugars are not well maintained. You also have a higher chance of developing pre-eclampsia which is a serious complication of pregnancy that may also affect your baby and cause a pre-term birth.

Your baby may have a higher chance of being born with some complications including – weighing more than average, being stillborn or having an abnormality, or developing diabetes later in life. Your doctor may recommend an induction of labour due to the effects of the diabetes on you and your baby. Both you and your baby will be monitored after the birth to check your sugar levels.

***Diabetes***

***Cardiac disease***

Cardiac disease – if you have pre-existing cardiac disease it is recommended that you speak with your treating doctor about your plans to get pregnant. Pregnancy increases your blood volume by about 30%-50% and during labour and birth increased pressure is placed on the heart and blood flow through the body.

Due to these added pressures, if you have cardiac disease it is recommended that you have an assessment by a cardiologist as part of your pregnancy care planning. You might develop high blood pressure during the pregnancy or if you have an epidural it might cause low blood pressure, throughout pregnancy, labour and birth there are constant changes to your blood pressure, heart rate and cardiac output.

This means that you may not have had problems before pregnancy but pregnancy may cause you to experience exacerbated symptoms.

***Cardiac disease***

***Epilepsy***

Epilepsy – as with other pre-existing conditions, careful management of your epilepsy you’re your specialist care team is important. Your medications may need to be changed or modified, aiming for the lowest dose to prevent seizures. About 95% of women with epilepsy have a successful pregnancy.

A detailed ultrasound is recommended at 18-20 weeks to specifically assess the heart, kidneys and presence neural tube defects. You will be more closely monitored during your pregnancy and labour and birth. The importance of rest and good quality sleep is particularly important during pregnancy.

Your baby will be more closely monitored after the birth, breastfeeding is encouraged but make sure you talk to your doctor or midwife about the type of medicine you are taking.

When you are home it is suggested that you feed your baby sitting on the floor, bath your baby when someone else is around, try not to carry your baby around too much and have an automatic brake on your pram.

***Epilepsy***

***High blood pressure***

High blood pressure – also known as chronic hypertension [also if high blood pressure was found before 20 weeks of pregnancy it will be called chronic hypertension] usually a blood pressure reading of more than or equal to 140/90 [140 over 90].

You may already be receiving treatment for your high blood pressure and will be taking medication to manage it. Your doctor or midwife will encourage a healthy life-style, including eating healthy, nutritious food, participating in regular exercise, maintaining a healthy weight and if you smoke to try to give up.

You will be more closely monitored during pregnancy and labour for signs that you may be developing pre-eclampsia. There is a higher chance of developing complications such as a placental abruption, pre-eclampsia, pre-term birth, low birth weight, perinatal death and gestational diabetes.

***High blood pressure***

***Pre-existing injury***

Pre-existing injury/surgery – you may have had an accident, injury or surgery that may impact on your choices during pregnancy or labour and birth. Things such as injury or surgery to the pelvis or spine may influence options for birth or pain relief during labour, or may affect your ability to be mobile during labour.

Breast surgery may influence your choices regarding feeding your baby. It is important to talk to your doctor about how this might affect your choices during pregnancy, labour and birth and the postnatal period.

***Pre-existing injury***

Resources

Department of Health WA – pre-existing conditions that can affect pregnancy

Family Education – managing pre-existing illness in pregnancy

Health Direct – Asthma and pregnancy

Diabetes Australia – pregnancy

Heart Foundation – heart disease and pregnancy

SA Health – guidelines epilepsy and pregnancy management

RACGP – epilepsy and pregnancy

Epilepsy Foundation – pregnancy planning

Department of Health – blood pressure

Multiple Births

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When you are pregnant with more than one baby – either twins, triplets or more, it is referred to as a multiple birth.

This occurs in about 2-3% of pregnancies across Australia and about 98% of that number are twins.

***Key Points***

  • Your pregnancy is considered higher risk if you are pregnant with twins or triplets, however your pregnancy and birth can still be a positive experience.
  • Most women with multiple pregnancies will ahve a healthy pregnancy and will give birth to healthy babies, however women pregnant with twins or triplets or more are more likely to experience pregnancy complications such as anaemia, bleeding, high blood pressure or premature labour.
  • They occur 2-3 more time more frequently in twin pregnancies and higher in triplet pregnancies.
  • Gather information, resources and support to navigate through this experience. This is an exciting time for you and your family and work towards a positive birth experience and early parenthood.

***Key Points***

***Discovering its more than one!***

The confirmation that you are expecting twins or triplets can be a shock and you may feel an array of emotions form excitement to overwhelm.

Twins or triplets are confirmed on ultrasound and your health professional wil be able to twll you how many baby’s, how many placenta’s and how many amniotic sacs there are at around 10-12 weeks gestation.

If you are pregnant with twins, your care provider will want to find out what type of twins you are having. Twins are either fraternal, which means two eggs have been fertilised by two sperm or they can be identical, which is when one fertilised egg splits and forms two babies. Identical twins may each have their own placenta, share a placenta and be separated by the inner membrane or they share a placenta and are not separated by an inner membrane.

If the babies are sharing a placenta it means that they are also sharing the supply of oxygenated blood and removal of deoxygenated blood and waste products. If the supply is not equal between the two babies some complications may occur. Which is why twin pregnancies need to be more closely monitored.

Triplets, or more babies are usually a combination of twins and a single baby. Most commonly they are identical twins with one other baby, but can be fraternal. These pregnancies are more complex than others so will need more frequent monitoring and specialist care.

***Discovering its more than one!***

***Your antenatal care***

If you’re pregnant with twins, triplets or more, then you’ll need a higher level of care to monitor you and your babies’ progress.

That means more appointments and tests during your pregnancy. The usual tests include ultrasound, blood, urine tests. When you are carrying multiples, you will most likely have more ultrasounds than a singleton pregnancy to monitor the growth of your babies.

Expecting twins or triplets increases your chance that your placenta may not work as well as we expect. This can affect your babies’ growth and wellbeing during pregnancy. This may mean one or both of your baby’s is smaller than expected and will be closely monitoried throughout pregnancy.

Giving birth prematurely (before 37 weeks) is more common if you have a multiple pregnancy and can either be because you go into labour early or because your healthcare team recommend that the babies are born early due to concern about your baby’s.

Depending on how early they have been born, they might need to spend time in the Special care nursery or neonatal intensive care unit. Wherever possible your babies will be kept together however depending on their individual needs they may need to be cared for separately.

You may feel more unwell during pregnancy with twins or other multiples, there is a higher chance that you may develop diabetes or high blood pressure.

It is important to care for yourself during pregnancy, but especially when you are pregnant with more than one baby

  • Eat nutritional foods and drink plenty of water
  • Stay active with gentle exercise
  • Pelvic floor exercises are essential
  • Look after your emotional wellbeing

***Your antenatal care***

***Birthing options***

Your care giver will talk to you about your wishes for the birth. You Midwife and Doctor will start to discuss your birth plan from around 24 weeks pregnant. There are a number of options that impact the decisions regarding your birth as to whether you plan for a vaginal birth or  caesrean section.

This will include the position in which you babies are lying, how well they are growing and your personal preference about birth.

Both vaginal birth of twins and caesarean section have risks and benefits depending on your individual circumstances. you Midwife and doctor will discuss these options with you to enable you to make an informed decision.

***Birthing options***

***Prepare for Parenting***

Having twins or triplets will be challenging but oh so rewarding!

  • Join your local Australian Multiple Birth Association group
  • Seek out local breastfeeding support in pregnancy
  • Don’t go it alone – seeks and accept help!

***Prepare for Parenting***

Resources

Australia’s Mothers and Babies – mothers who have multiple births and their babies

Better Health Channel – twins and multiple births

Pregnancy Birth Baby – types of multiple pregnancy

Australian Multiple Birth Association

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