When she was pregnant with her son, Dhilan, two years ago, Kumari Revi’s gynae discouraged her from giving birth naturally because of her history with spina bifida.
Says Kumari, “I was hoping to have a vaginal birth, but after accessing my medical history, my gynae discouraged me from doing so. I was told that if I had a vaginal birth I could risk being paralysed for the rest of my life.”
When Kumari, 35, was born, doctors discovered that she had a birth defect caused by the incomplete closing of the backbone and the membranes around the spinal cord. She subsequently underwent four major surgeries to correct her condition ― which can limit a person’s ability to walk, be active and mobil ― and now leads a healthy life.
Although Kumari and her husband sought a second opinion from two other doctors, they all said the same thing ― it was too high of a risk to take. Since it was Hobson’s choice, Kumari delivered Dhilan, now 2, via Caesarean section under general anaesthesia.
What happens during a C-section?
While most women yearn to have a natural vaginal delivery despite hearing horror stories and fearing pain and discomfort, this option might not always be in the cards for them.
Thanks to medical advancements, women can opt for a Caesarean or C-section delivery. During a C-section, your gynae will make incisions in your abdomen and uterus, so that he or she can lift your baby out from your belly, as opposed to you pushing it out from your vagina.
A C-section may be performed if the mother has existing health issues or if labour is not progressing. Some couples also opt for a Caesarean for social reasons, such as wanting to give birth on a specific date, timing it with a desired horoscope reading, or working it around the father-to-be’s work or travel schedule.
Some women are also not willing to risk the possible side-effects of a vaginal delivery, such as stress urinary incontinence or pelvic organ prolapse. In the latter, the bladder drops from its normal place in your lower belly and pushes against the wall of your vagina.
“I was told that if I had a vaginal birth I could risk being paralysed for the rest of my life.”
Before a C-section is carried out, the aim is for the baby to reach full term, which is 37 weeks. “The Caesarean is usually done at the start of the 38th week, as long as waiting that long does not compromise the mother or foetus’s health,” notes SmartParents expert ob-gyn Dr Christopher Chong. “Any earlier will depend on the condition of the mother and foetus, but the general guide is to get past 34 weeks, so that the organs will be more mature.”
A woman’s decision to have a C-section is not only a personal one, it’s always backed by a medical professional. Here are the top 10 reasons why a C-section may be necessary.
1. Expecting multiples
When you have two or more babies growing inside of you, chances are, they are fighting for space, food and oxygen in order to thrive. Things get especially tricky towards the end of the pregnancy when the body may not be able to accommodate multiple babies. “Often, there will be an unequal growth in the babies, and this very often leads to premature labour,” explains Dr Chong.
If you are expecting twins, you can still try to have a vaginal birth as long as both babies are head down and there are no other health conditions. However, if one or both of the babies are presenting bottom down, a Caesarean might be necessary, so as not to put all three lives at risk. Also, if the mother is carrying identical twins who are sharing the same placenta, Dr Chong will schedule the delivery at about 32 weeks, otherwise the risks to the foetuses will be too high. Triplets or larger groups of multiples are always born via C-section.
2. Vaginal birth after Caesarean (VBAC)
If your first baby was born via a Caesarean, and you’re keen to have a vaginal birth in your second pregnancy, you may risk rupturing your previous scar. However, most doctors in Singapore are willing to do a VBAC if their patient is willing to take this risk. But if the patient has had two C-sections, a vaginal delivery will no longer be an option in her third pregnancy as the risks are too high, according to Dr Chong.
This condition is usually picked up when the expectant mum has high blood pressure (BP), which usually shows up in the second trimester. Doctors will strive to manage her BP, so that she can still try delivering vaginally if she wishes to. But if she cannot control her BP, it can prevent the placenta from receiving enough blood, such that the baby will not get sufficient oxygen. “It could also lead to eclampsia, the throwing of fits, in which case, the mum and baby can die,” points out Dr Chong. Doctors, who will monitor the situation closely, will decide when it’s time to deliver the baby via a C-section.
Did you know that if you’re small in size, you may require a C-section?
4. Placenta problems
The placenta, an organ that attaches to the wall of the uterus and the baby’s umbilical cord, provides oxygen and nutrients to the growing baby, as well as removes waste products from the baby’s blood. While it has a vital role in pregnancy, the placenta can sometimes also pose as health risk. Should the placenta separate from the womb suddenly, causing oxygen to be cut off, you will need an emergency C-section, says Dr Chong. Placenta praevia is another placenta-related emergency that might require you to deliver with surgical intervention. “It’s when the placenta is lying lower than normal, blocking the passage of the foetus. This can lead to torrential bleeding and end up killing both mum and baby,” Dr Chong explains.
5. Position of foetus
You baby usually gets into the anterior position ― head-down towards the cervix ― towards the end of the pregnancy. This is perfect for a vaginal delivery as bubba will fit snugly into the curve of your pelvis. However, sometimes he might be in a posterior position, when his butt is facing the birth canal. If you are unable to help him turn by the time you go into labour, you could risk baby being stuck halfway through the birth canal and dying, warns Dr Chong. In this instance, a C-section is the safer option.
Existing health conditions could hinder your ability to have a vaginal birth. Some examples include certain heart conditions that could strain your ticker during labour, or severe high blood pressure.
6. Narrow pelvis or large babies
Large babies (4kg and heavier) may be hard to deliver vaginally, especially if it’s your first time and your pelvic area is naturally tighter. You could try giving birth vaginally, but you could end up requiring an emergency C-section.
In the case of cephalopelvic disproportion (CPD), a condition when the mother’s pelvis is too narrow for the foetus, the baby’s head may be too large, which could prevent it from sliding through the birth canal smoothly. Again, the mum-to-be could try giving birth vaginally, but this poses life-threatening risks.
“A patient of mine, who was small-sized with a narrow pelvic bone, wanted a normal delivery even though the C-section option was discussed,” recalls Dr Chong. “She had a vacuum delivery and tore through her anus. Faeces came through her vagina and she went on have four major surgeries before this was rectified. The next pregnancy, she opted for C-section.”
7. Failure to dilate
Once you go into labour, the cervix (or the door to the birth canal) should start opening slowly and allow bubba to exit. However, sometimes even with the most intense labour pains, the cervix might not open fully to 10cm ― even though the mum has been in labour for 10 hours or more. Other times, dilation may stall, where labour pains disappear in the middle of an active labour. As long as the cervix isn’t fully opened, vaginal delivery cannot take place, notes Dr Chong. Since taking too long to achieve full dilation may put the foetus in distress, an emergency C-section will be necessary in both instances.
8. Cord prolapse
It’s quite a rare occurrence, but a cord prolapse ― when the cord drops through the cervix into the vagina, ahead of the baby ― can cut off the blood supply to the cord. “If the baby is not delivered quickly via Caesarean, foetal brain damage and death can occur,” Dr Chong warns.
“Fibroids at the cervix blocks the foetus from coming through and many babies may also not end up in head presentation as a result,” notes Dr Chong. As this condition is usually caught during pregnancy, the gynae will help you manage, so that baby grows well and mummy remains in good health. Still, an elective C-section is usually the answer to ensure a safe delivery.
10. Existing health conditions
Just like Kumari, existing health conditions could hinder your ability to have a vaginal birth. Some examples include damaged pelvic bones (maybe from a previous accident), certain heart conditions that could strain your ticker during labour, or severe high blood pressure. A C-section may also be needed if you’ve had any previous surgery in your pelvic area.
Dr Christopher Ching is an obstetrician-gynaecologist who practises at Chris Chong Women & Urogynae Clinic at Gleneagles Medical Centre.
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