Caesarean section vs. Vaginal Delivery

When C, a 33 year old mum and her husband came into my consultation room, they looked anxious and tense.

“What is the matter?” I asked

“Doc, you know I just delivered my baby 6 months ago by C- section. I am pregnant again. We don’t mind having a second baby but this is too soon. My friend tells me that I should wait for at least 2 years; otherwise the scar in my womb might burst. My husband and I are very worried. Should we terminate the pregnancy?” C said

A vaginal ultrasound scan revealed that C was indeed 9 weeks pregnant and the baby was actively moving in her womb. I reassured her that the wound in her uterus had healed well and there was no medical reason to abort the baby.

“Can I have a normal delivery this time?” she asked.” I was a bit upset that I could not deliver normally in the last pregnancy and that an emergency C-section had to be done because of fetal distress”. 

A Caesarean section (C-section) is the delivery of a baby by an incision in the uterus. During much of the last century, a woman who had a previous Caesarean section would almost have a planned repeat C-section and not a vaginal delivery for any subsequent births. 

Doctors were concerned that the scar from the previous incision in the uterus could rupture during labour, causing serious consequences to the mother and child. The blood vessels in the uterine wall might tear resulting in massive bleeding. An emergency operation would have to be done to save the mother’s life. In the process, the damaged uterus might have to be removed, ending hope for subsequent pregnancies.

The effect of uterine rupture to the baby can be catastrophic. The baby would be expelled from the uterine wound resulting in instant death. Even if he or she is saved by an emergency operation, there is a risk of permanent brain damage. Because of all these concerns, the conventional wisdom is: “Once a caesar, always a caesar”.

In recent times, however, medical studies have established the safety of vaginal delivery after a previous C-section. In Singapore, almost all the c-sections are done in the lower part of the uterus (lower segment caesarean section), the wound usually heals well and the risk of rupture during labour is very low (less than 1 per cent).

Besides, there are advantages of a successful vaginal birth. Complications such as infection and blood loss are less common. Recovery is faster with a shorter hospital stay. Energy and stamina return more quickly. Many mums, like C, would like to participate in the birth process and experience a vaginal delivery. They can hold and breast-feed the baby sooner. A successful vaginal birth can also have a positive impact on future pregnancies. While repeat C-sections get more complicated each time, repeat vaginal deliveries tend to become progressively easier. 

However, not all women with a previous c-section are suitable for normal delivery. They include women with:

• Big babies

• Babies in an abnormal position such as breech or horizontal position

• Serious maternal problems such as diabetes or high blood pressure

• Multiple pregnancies

• Abnormal placental positions such as placenta preavia (low lying placenta)

• Previous uterine operations such as fibroid removal 

As C had none of the above conditions, I encouraged her to try for a vaginal birth, which she gladly accepted. She went into spontaneous labour at term and had a successful vaginal delivery. She had since delivered another baby naturally.