BIRTH THREE WAYS
One woman who had three vastly different birth experiences takes us through her journey and shares her insights
For her first baby, Dorcas Mogoera, a 32-year-old mom of three boys under five years old, didn’t have a birth plan. “Although I wanted to have a natural birth, I basically just went with the flow,” she says. Ultimately, that “flow” involved a caesarean section following a labour that didn’t progress well, and Dorcas recalls the negative consequences. “I didn’t have skin-to-skin contact with my baby immediately after birth, as I was moved out of theatre and taken to the recovery room while my baby was checked by medical staff. My son then struggled to breastfeed. I spent the next three days in hospital in a lot of pain and I was still in a lot of pain when I got home. Then, I developed an infection 10 days later. My mom had to come help me out as I couldn’t do much for myself.” Dorcas’s second delivery, 19 months later, was markedly different, because she did in-depth research on her options. “My mom couldn’t come to help me this time around, and I didn’t want to deal with the pain following a C-section. Also, I wanted skin-to-skin contact with my baby immediately after birth. I decided I was going to have a natural birth,” she says. “I did a lot of research around vaginal birth after caesarean (VBAC) and discovered that there’s a much better rate of success if you have a doula.” Dorcas’s contractions started in the early hours of the morning, and she went to the hospital about eight hours later. Her gynaecologist, who manually broke her waters, wasn’t happy with the slow progression of the labour and urged her to have a C-section. But Dorcas and her doula urged him to wait, and eventually her labour got going. In the early hours of the evening, Dorcas delivered a healthy boy. She had a tear that the doctor stitched, and was discharged the next morning. Referring to her second birth experience, Dorcas says, “I didn’t like the fact that the gynae had broken my waters, or that I was forced to be on a monitor to track my baby’s heartbeat. I didn’t want an
epidural, and I didn’t like having to plead with medical professionals to give me a chance to give birth naturally. I didn’t want people to instil fear in me.” Which is why, when she found out she was pregnant for a third time, Dorcas decided to have a home birth with a midwife and a doula. “I wanted a calm and peaceful environment. I wanted to own my birth,” she recalls. In the event, her labour progressed so quickly that the midwife didn’t get to her house on time – and her husband was out buying groceries when their sturdy 4.3kg baby boy made his safe and healthy arrival into the world. “My doula supported me emotionally and physically,” Dorcas says of the experience, which she describes as “empowering”.
BIRTH BY C-SECTION
“Although the safest mode of delivery is a normal vaginal delivery, if this poses a danger to the well-being of the mother of the baby, a C-section is performed,” says Johannesburg gynaecologist Dr Monica Nkabinde. The C-section can either be elective (a planned procedure that’s decided on before the patient goes into labour) or emergency (when an unexpected event arises before or during labour that makes it necessary). “One of the reasons for doing an emergency C-section is if the labour isn’t progressing well, as in Dorcas’s case,” says Dr Nkabinde. Birth by C-section, which is usually done under regional (spinal) anaesthesia, comes with several possible immediate and long-term complications, including bleeding, infection and blood clots. “A caesarean delivery, while generally very safe, is associated with higher morbidity for the mother, compared with vaginal delivery,” Dr Nkabinde adds. The decision about whether or not to have a C-section should be made by the medical practitioner, rather than the patient, says Dr Nkabinde. “Some women choose to deliver their babies by C-section to protect their pelvic floor, for fear of pain, whether real or perceived, or because they have a close family member who had a bad outcome following a vaginal delivery. But, all these fears can be allayed with help from a counsellor,” she says.
VAGINAL BIRTH AFTER CAESAREAN
A VBAC is safe, says Cape Town obstetrician and gynaecologist Dr Philip Zinn, provided “it’s a singleton pregnancy, head down, normal size, healthy baby in a healthy woman with a previous uncomplicated lower-segment C-section”. He adds that the labour should start spontaneously and progress normally. The reason for the previous C-section is also important. “If it was for a nonrecurring reason, like breech presentation or a placental problem, then the chance of a VBAC succeeding is better,” Dr Zinn says. And the facility where the mother is delivering must be geared up to deal with VBACs. “The hospital must have the right theatre facilities and staff, including adequate staff and equipment to monitor mom and baby, and access to blood that may have to be given intravenously in case of rupture,” says Dr Josh Matambo, a gynaecologist at the Essence Women’s Centre in Newcastle, KwaZulu-Natal. “The benefits of a VBAC include all the benefits of a vaginal birth, such as avoiding risks associated with surgery, and satisfying psychological and emotional needs to experience a natural birth process,” says Dr Zinn. “The recovery time after the delivery is quicker, and you’ll be discharged from hospital earlier, compared with a mother who had an operation,” says Dr Matambo. For the mother, a VBAC means avoiding the possibility of post-operative infection, while for the baby, “new research has suggested that the passage through the birth canal could have a role in bacterial gut colonisation and early immunity,” says Dr Zinn. There are risks, however, the most worrying of which is uterine rupture during labour, which happens in about one in 200 VBACs.
HOME BIRTH AFTER CAESAREAN
“Notwithstanding Dorcas’s successful home birth after caesarean [HBAC], I’d be very reluctant to allow a patient who had a prior caesarean delivery to labour and deliver at home,” notes Dr Nkabinde. “The risk of uterine rupture is always there, and should this happen, there won’t be enough time to get the patient to hospital and into theatre to perform either uterine repair or hysterectomy to save her life. The safety of the patient is of paramount importance and for that reason she should be delivered in an environment that will allow for rapid intervention should things not go as planned.” Midwife Heather Pieterse, whose Pretoria-based practice has been assisting with home births for 17 years, agrees. “I don’t advocate a home birth after a C-section, and would encourage any mom wanting a VBAC to rather do it at a midwife unit with a theatre and emergency care close at hand,” she says. Heather, who always ensures there are two medically trained professionals at each of the births she attends, points out that a home birth even for a healthy woman having a low-risk singleton pregnancy must include a very carefully thought-out emergency backup plan, and adds that she chooses not to do home births for women who live far from a backup facility as “in the event of an emergency I need to know we can get to hospital within a certain amount of time”.
IF THE PREVIOUS C-SECTION WAS FOR A NON-RECURRING REASON, LIKE BREECH PRESENTATION OR A PLACENTAL PROBLEM, THE CHANCE OF A VBAC SUCCEEDING IS BETTER