Posted by: Kurnia | April 6, 2009

Vaginal Birth After Caesarean (VBAC)

Apakah putra/putri Anda lahir melalui proses operasi Caesar?

Apakah kemudian proses operasi tersebut menimbulkan trauma tersendiri bagi Anda, sehingga berniat untuk melahirkan secara normal bila hamil kembali?

Apakah mungkin melahirkan normal setelah caesar?

Berdasarkan Mayoclinic, hal tersebut dimungkinkan dengan mempertimbangkan beberapa hal.

Silahkan pelajari dan diskusikan mengenai kemungkinan melahirkan Normal setelah Caesar kepada DSOG anda.

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You’ve already had a baby by Caesarean section (C-section). Your doctor says you have a choice with your next baby. You can try a vaginal delivery or schedule a repeat C-section.

Years ago, a C-section ended any hope of future vaginal deliveries. But today, thanks largely to changes in surgical technique, vaginal birth after C-section (VBAC) is possible in many cases. In fact, 60 percent to 80 percent of women who try VBAC have a successful vaginal delivery.

VBAC isn’t right for everyone, though. Sometimes a pregnancy complication prevents the possibility of a successful VBAC. Many local hospitals don’t offer VBAC because they don’t have the staff or resources to handle emergency C-sections.

In this guide, you’ll explore your options. When is VBAC a safe choice? When should VBAC be avoided? What are the benefits of VBAC? What are the risks? You’ll also consider common questions about VBAC, answered by a Mayo Clinic specialist in obstetrics and gynecology. After reviewing the guide, you’ll be better prepared to make a decision about whether VBAC is right for you.

Delivery options

After a C-section, many women are candidates for VBAC. Your doctor will review your medical history to help you decide whether VBAC or repeat C-section is appropriate for you and your baby. Here are factors your doctor will consider.

What type of uterine incision was used for the prior C-section?

Scars left from certain types of incisions have an increased risk of tearing during labor and delivery — a rare but serious risk of VBAC. You can’t tell what kind of uterine incision you’ve had just by looking at the scar on your belly. Instead, check with your doctor or review your medical records.

  • Low transverse incision. This is the most common uterine incision. It’s made sideways across the lower part of the uterus. A low transverse incision usually bleeds less than an incision made higher on the uterus. It also forms stronger scars and presents less danger of rupture during subsequent labors — between a 0.2 percent to 1.5 percent chance. If you’ve had one or even two of these incisions, you may be a candidate for VBAC.
  • Low vertical incision. This type of incision is made low on the uterus, where the uterine wall is thinner. A low vertical incision may be used to deliver a baby situated in an awkward position or when there’s concern that the incision may need to be extended. A low vertical incision presents a higher risk of subsequent uterine rupture — 1 percent to 7 percent. If you’ve had a low vertical incision that doesn’t extend into the upper uterus, you may still be a candidate for VBAC. However, it’s sometimes difficult to determine if the scar is low enough to minimize the risk of uterine rupture.
  • Classical incision. This type of incision, also called a high vertical incision, was once used for all C-sections. However, it carries the highest risk of bleeding during labor and of subsequent uterine rupture — 4 percent to 9 percent. It’s now used only in emergency situations. VBAC isn’t recommended for women who’ve had a classical uterine incision.
  • T-shaped, inverted T-shaped or J-shaped incision. These incisions are used only in emergencies or when problems develop. They’re not planned. If you have any of these scars, VBAC isn’t an option. The risk of uterine rupture is too great.
  • If your type of previous uterine incision can’t be determined, your doctor may recommend a repeat C-section.

    Have you had previous vaginal deliveries?

    A vaginal delivery at least once before or after your prior C-section increases your chances for a successful VBAC.

    What prompted the prior C-section?

    If your prior C-section was done for a reason that isn’t present during your current pregnancy — such as infection or a problem with the placenta — your chance of a successful vaginal delivery is similar to that of a woman who’s never had a C-section.

    If your C-section was done because the baby didn’t descend through the birth canal, the chances of a successful vaginal delivery decrease — but you don’t necessarily need to rule out VBAC. Your next baby may enter the pelvis in a more favorable position. Or your current pregnancy may have changed your pelvic dimensions.

    If you had your prior C-section because your cervix didn’t dilate enough to allow your baby to pass through the vagina, your chance of a successful VBAC is less favorable.

    How many C-sections have you had?

    If you’ve had two or more C-sections and no vaginal deliveries, you face a higher risk of complications from VBAC — including uterine rupture. If you’ve had two or more C-sections, your doctor may support VBAC only if you’ve also had at least one successful vaginal delivery.

    Have you had a uterine rupture?

    If you had a uterine rupture during a previous pregnancy, you’re not a candidate for VBAC.

    Are you delivering multiples?

    If you’re delivering twins and both babies are positioned headfirst, VBAC may be a safe option. But because twin births are more complicated, many women and their doctors choose repeat C-section for twins. If you’re pregnant with triplets or other multiples, VBAC generally isn’t an option.

    Do you have any health conditions that might affect a vaginal delivery?

    If you have diabetes, heart disease, high blood pressure or active genital herpes, vaginal delivery may be risky for you and your baby. Asthma and anemia may increase the risks associated with vaginal delivery as well, depending on the severity of your symptoms.

    Will you deliver the baby in a facility equipped to handle an emergency C-section?

    If complications arise, an emergency C-section may be the only option. A home delivery isn’t appropriate for VBAC. Many local hospitals don’t offer VBAC because they don’t have the staff or resources to handle emergency C-sections. If you choose a facility farther from home, traveling while you’re in labor may pose substantial risks.

VBAC: The basics

Sixty percent to 80 percent of women who attempt VBAC have successful vaginal deliveries. Although your doctor can’t predict how much pressure labor will place on the scar tissue from your prior C-section or whether you’ll have a successful VBAC, various factors influence the odds.

The chances of a successful VBAC are higher if:

  • You have only one prior low transverse uterine scar
  • You and your baby are healthy and your pregnancy is progressing normally
  • The reason you had your prior C-section isn’t a factor this time
  • Your labor begins spontaneously between the 37th and 40th week of pregnancy
  • You’ve had a previous successful vaginal delivery

Likewise, some factors may decrease your chances for success — but they don’t necessarily prevent you from trying VBAC. The chances of a successful VBAC are lower if:

  • You’re older than 40. After age 40, the chances of a successful vaginal delivery decrease — whether you’ve delivered other babies vaginally or are attempting VBAC.
  • You’re past your due date. Although the risk of uterine rupture remains the same, successful VBAC is less likely if your pregnancy continues past 40 weeks.
  • You have an unusually large baby. If your baby weighs too much, he or she may not safely pass through the birth canal during a vaginal birth. The risk of uterine rupture increases only if you haven’t had a previous vaginal delivery.

When an unplanned C-section might be necessary

Sometimes complications of pregnancy or delivery require a C-section, even if you had your heart set on a vaginal delivery. Be prepared for a C-section if:

  • There’s a problem with the placenta. Placenta previa occurs when the placenta lies low in the uterus, sometimes blocking the birth canal. This can cause severe vaginal bleeding. Placental abruption occurs when the placenta separates from the uterus before birth. Left untreated, placental abruption puts both mother and baby in jeopardy.
  • You develop preeclampsia. This complication is defined by high blood pressure and excess protein in the urine after the 20th week of pregnancy. Preeclampsia doesn’t preclude you from trying VBAC if labor begins naturally, but this condition can require an early delivery — which is often best done by repeat C-section.
  • Your baby is in the wrong position. By the time labor begins, most babies have settled into a position that allows them to be delivered headfirst through the birth canal. But that doesn’t always happen. If your baby is positioned to enter your pelvis feet or buttocks first (breech presentation) or the baby is lying sideways across your pelvis (transverse lie), you’ll need a C-section.
  • Your labor fails to progress. VBAC isn’t possible if your cervix doesn’t dilate completely or if your baby doesn’t move down the birth canal. Prolonged or obstructed labor increases the risk of uterine rupture.
  • There’s a problem with the umbilical cord. Sometimes the umbilical cord passes into the birth canal ahead of the baby. If this happens, the baby will compress the cord during contractions. An emergency C-section is needed to prevent oxygen deprivation to the baby.
  • Your baby doesn’t tolerate labor. If your baby’s heart rate doesn’t remain within a safe range during labor, you may need a repeat C-section.

Benefits

VBAC has various benefits:

  • Safety. A successful VBAC is safer than a planned C-section. You’re less likely to get an infection, have serious blood loss or experience complications from the anesthesia with a VBAC than with a repeat C-section. However, if the VBAC fails, the baby must be delivered by emergency C-section — which may have slightly more risks than a planned C-section.
  • Shorter recovery time. You’ll likely spend one less day in the hospital after a VBAC than you would after a repeat C-section. Your energy and stamina will return more quickly as well.
  • More participation in the birth. For some women, VBAC is more emotionally satisfying than a repeat C-section.
  • Earlier bonding with your baby. If you have a successful VBAC, you may get to hold your baby sooner than you would after a repeat C-section. If you plan to breast-feed, you can start while you’re still in the birthing room.
  • Cost. A successful VBAC costs less than a planned repeat C-section. However, an attempted VBAC that ends in an unplanned C-section costs more than a planned repeat C-section.

Risks

As with any birth, problems can occur during VBAC:

  • Failed attempt at labor. Labor ends in a repeat C-section for 20 percent to 40 percent of women who attempt VBAC, often because the baby doesn’t tolerate labor.
  • Uterine infection. If you must have a repeat C-section after labor has begun, you face a slightly higher risk of C-section complications — such as a uterine infection — than if you had a planned repeat C-section.
  • Uterine rupture. Rarely, the uterus may tear open along the scar line from a prior C-section. If your uterus ruptures — either before or during labor — an emergency C-section is needed to prevent life-threatening complications, including blood loss, infection and brain damage for the baby. When you deliver your baby in a hospital equipped to handle such emergencies, rarely is your baby at risk. If the rupture occurs late in labor, an emergency operation may be needed to repair the tear and control the bleeding. For less than 1 percent of women who have a uterine rupture, the uterus must be removed (hysterectomy) to stop the bleeding. If your uterus is removed, you’d be unable to get pregnant again.

For some women, pelvic floor problems also are a concern. The weight and pressure of pregnancy can weaken the pelvic floor muscles that support your uterus, and vaginal delivery may stretch the pelvic floor muscles even farther. This can lead to urinary incontinence. However, any urinary incontinence after childbirth often goes away on its own as the pelvic muscles recover.

More on uterine rupture

Although uterine rupture is rare, it’s a valid concern. In fact, fear of uterine rupture is the reason VBAC wasn’t done for decades. To put the risk in perspective, consider the odds of uterine rupture for women who have various types of uterine scars.

If you have this type of uterine incision: The risk of uterine rupture is:
A low transverse uterine incision 0.2 percent to 1.5 percent — or less than two out of 100 women
A low vertical uterine incision 1 percent to 7 percent, depending on how far the incision extends into the upper uterus — or one to seven out of 100 women
An up-and-down (classical) uterine incision 4 percent to 9 percent — or four to nine out of 100 women

In addition to the type of uterine incision, other factors may increase the risk of uterine rupture during VBAC, including:

  • Single-layer suturing. If your prior C-section incision was closed with one layer of stitches instead of two, the scar may not be as strong. Most C-section incisions are closed with two layers.
  • Short time since prior C-section. Women who attempt VBAC less than 18 to 24 months after having a C-section have a two to three times greater risk of uterine rupture. The longer the interval between deliveries, the lower the risk of rupture.
  • Labor-inducing drugs. Inducing labor with medication may increase the risk of uterine rupture. If your doctor decides that it’s best for your baby to be delivered before labor begins naturally, he or she will probably recommend a repeat C-section.

What to expect

If you choose to try VBAC, your prenatal care will be just like the care you’d receive during any other healthy pregnancy. When you go into labor, you’ll follow the same process as any woman expecting to deliver vaginally. This is called a trial of labor.

Here’s what to expect:

  • Early hospitalization. Your doctor will ask you to report to the hospital promptly if your water breaks or when you begin feeling contractions. Laboring at home with a prior C-section scar isn’t recommended.
  • Pain control. If you choose medication, you’ll have various options. VBAC success rates are the same for women who receive an epidural as for those who choose other forms of pain control.
  • Continuous electronic monitoring. The medical team will keep a close eye on your baby’s heart rate and will check on you often to make sure that labor is progressing normally. A fetal monitor may be attached to your baby’s scalp.
  • Less tolerance of abnormal labor patterns. A prolonged or difficult labor increases the risk of uterine rupture. Medication to stimulate contractions may pose the same risk. If your labor isn’t progressing well, you may need a repeat C-section.

Pros and cons

Unless your doctor says VBAC isn’t an option, the choice is yours. Consider this summary of pros and cons.

Pros Cons
A successful VBAC is generally safer for you and your baby than is a repeat C-section. When VBAC succeeds, you’re less likely to get an infection, have serious blood loss or experience complications from the anesthesia. VBAC may not succeed. Twenty percent to 40 percent of women who attempt VBAC fail to deliver vaginally. They require an unplanned C-section, which has a slightly higher risk of complications than does a planned C-section.
Recovery is typically quicker, both in the hospital and at home. You have less pain after the birth. Your energy and stamina return more quickly. Though it rarely happens, uterine rupture is more likely in a VBAC delivery.
You may find VBAC to be more emotionally satisfying than a C-section. You can’t schedule a VBAC as you can a repeat C-section.
If you’re planning a larger family, VBAC may be a better option with each subsequent delivery. Repeat C-sections get more complicated each time, while repeat VBACs tend to become progressively easier.
A successful VBAC costs less than a planned C-section does.

Repeat C-section: The basics

Like VBAC, a repeat C-section has its own distinct benefits. Among them:

  • You can choose a convenient time to have the C-section. This can be helpful when arranging child care for your other children or planning your maternity leave.
  • A C-section usually takes considerably less time than labor and vaginal delivery. Plus, you don’t experience labor pain.
  • In some cases, a repeat C-section may be safer for you and your baby than a VBAC.

Risks

Repeat C-sections are safe, but the risk of complications is slightly higher because the procedure poses more surgical challenges than does the initial C-section.

Potential risks for the mother include:

  • Infection. Infection of the uterus or nearby organs — such as the bladder or kidneys — is more likely after a C-section than after a vaginal birth.
  • Blood loss. You may lose twice as much blood during a C-section as you would during a vaginal birth. Sometimes the blood loss is heavy enough to require a transfusion.
  • Problems with the placenta. The more C-sections you’ve had, the greater the risk of developing placenta accreta — when the placenta implants too deeply and firmly to the uterine wall. Placenta accreta can cause excessive bleeding during delivery, which sometimes can be stopped only by removing the uterus (hysterectomy).
  • Weakened uterine wall. The incision may leave a weak spot in the uterine wall. This may cause problems with future attempts at vaginal birth.
  • Damage to surrounding organs. During a C-section, damage to surrounding organs is possible. When it happens, the damage is usually slight and repaired immediately.

Potential risks for the baby include:

  • Premature birth. When you plan to deliver a baby on a particular date, it’s important to accurately determine your baby’s age. Babies delivered prematurely may have a low birth weight and difficulty breathing.
  • Breathing problems. The fluid in a baby’s lungs is normally squeezed out by the pressure of moving through the birth canal. This doesn’t happen during a C-section. If your baby’s lungs are too wet, he or she may need extra oxygen after birth. The problem typically goes away within a few hours to a few days.
  • Effects of anesthesia. Anesthesia can decrease the baby’s oxygen supply or depress the baby’s breathing. If necessary, medications can be given to the baby after birth to counteract these effects.
  • Surgical cuts. Rarely, accidental nicks to the baby can occur during delivery.

What to expect

As you may remember from your prior C-section, epidural and spinal anesthetics block pain — but not the ability to feel motion. You’ll likely feel some tugging as the baby is taken out of your uterus. If you have general anesthesia for an emergency C-section, you won’t be aware of the procedure.

Once the baby is delivered, the doctor will clamp and cut the umbilical cord. While other members of the medical team assess your baby, the doctor will remove the placenta from your uterus and close the incisions layer by layer. You may be separated from your baby during this process, or a loved one or a member of the medical team may hold the baby close to you.

The hospital stay after a planned or unplanned C-section is typically three days, compared with two days after a VBAC. Recovery at home also is longer after a C-section. The first week after the birth, you’ll likely have less energy, feel more discomfort and need more sleep than you would if you’d had a VBAC. You’ll need to restrict your activity for four to six weeks after the delivery.

If you had a long and difficult labor before your first C-section, a repeat C-section may be less physically taxing — but the healing process will take at least as long. If you develop complications, recovery may take longer.

Pros and cons

Repeat C-sections appeal to many women. As you’re making your decision, remember the pros and cons of a repeat C-section.

Pros Cons
You choose the time of delivery. Your hospital stay will probably be longer than if you’d had a VBAC.
A C-section usually takes considerably less time than does labor and a vaginal delivery. Pain and fatigue linger longer after a C-section.
In some cases, a C-section may be safer for you and your baby. You may wait longer to bond with your baby and begin breast-feeding.
Complications are rare. A repeat C-section makes it riskier to attempt VBAC for your next baby.
You don’t have to experience the pain of labor. C-section poses rare — but real — risks to your baby, such as premature birth and breathing problems.
The risk of needing a hysterectomy to stop bleeding after delivery increases with the number of repeat C-sections.
A C-section costs more than a successful VBAC does.

Things to consider

As you decide whether to try VBAC or have a repeat C-section, review the pros and cons of each option. Let your emotions guide your final decision, too.

How strong is your desire to deliver your baby vaginally? Some women feel a deep sense of personal fulfillment or emotional satisfaction after a vaginal birth. Others simply want to have a healthy baby.

How intense are your fears? It’s natural to worry about uterine rupture or simply going through labor. But sometimes doubts and fears override the benefits VBAC may offer. Reservations about your likelihood of success might interfere with your ability to give VBAC the required physical and emotional effort.

The decision is yours

If you and your doctor think that VBAC is right for you, don’t be afraid to try it. Here’s help boosting the odds of a positive experience:

  • Discuss your fears and expectations. Your doctor can help you understand the risks of VBAC in your case. Make sure he or she has your complete medical history, including records of your previous C-section and any other uterine procedures.
  • Learn about VBAC. Take a childbirth class on VBAC. Include your partner or another loved one, if possible.
  • Make sure your health care provider will be available throughout your labor. Close monitoring can decrease the risk of complications.
  • Plan to deliver the baby at a well-equipped hospital. Look for one that has continuous fetal monitoring, a surgical team that can be assembled quickly, and the ability to administer anesthetics and blood transfusions 24 hours a day.
  • Allow labor to begin naturally, if you can. Drugs to induce labor can make contractions stronger and more frequent, which may contribute to the risk of uterine rupture — especially if the cervix is tightly closed and not ready for labor.
  • Take good care of yourself. Think positively, eat healthy foods, exercise regularly and get plenty of rest. These good-for-you habits will help you prepare for a vaginal delivery.

Remember, your ultimate goal is a healthy baby and a healthy mom — regardless of how you get there.


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