A five-year study by the Maternity Department at the University Hospital Burgas proves that vaginal birth after a previous cesarean section (VBAC) is a safe, effective and successful alternative to routine repeat cesarean section. Obstetrician-gynecologists Dr. Antonio Dushepeev, MD and Dr. Zlatko Kirovakov, MD published a comprehensive scientific paper based on the study. They analyze in detail the success rate, success factors and safety of attempts at vaginal birth after one or more previous cesarean sections. The results categorically indicate that with proper patient selection and strict adherence to medical indications, normal birth after cesarean section is completely accessible and possible and brings enormous benefits to both the mother and the newborn. And what else... Dr. Antonio Dushepeev, MD, Head of the Maternity Department at Burgas University Hospital, speaks to FACTI.
- Dr. Dushepeev, your five-year study shows that vaginal birth after a cesarean section is a safe alternative. Why is there still a belief in Bulgaria that a cesarean section is necessarily followed by a new cesarean section?
- I can't peer into the minds of all my colleagues who practice obstetrics, but many factors come into play whether to undertake such a procedure. First, it is in the patient's interest - it saves an operation that has too many unknowns. Both during its performance and in the recovery period after it. Especially if it is a second one. The patient is emotionally protected, she is given the opportunity to experience a truly normal birth and to identify with the role of the mother who gives life. And of course, although I don't want to emphasize this topic, the costs for public healthcare are much lower.
- What are the main medical criteria by which you assess whether a woman is suitable for an attempt at normal birth after a previous cesarean section?
- The first criterion is whether the patient has had a normal birth at some point in time. Secondly, how did the recovery period after the operative birth go, whether there were any complications, fever, prolonged antibiotic treatment. The image of the scar from the previous operation, the indications for the previous cesarean section, the size of the fetus, the shape of the pelvis and of course, not least, even much earlier, are the baseline data - whether labor has begun or not. There are other nuances - I ask patients to sign an informed consent that they refuse operative birth before labor has begun. But they can in no way refuse surgical delivery during labor, when there are specific situations, symptoms and syndromes that threaten the well-being of the mother and fetus. So an initiative, a protocol that requires knowledge and experience.
- Is there an optimal period between cesarean delivery and normal, how many years should have passed?
- This is another myth that is spread in hospitals and cafes, that the uterus heals in two years. No wound, be it surgical or otherwise, heals in two years. In the available literature, there are cases described when the patient had surgery in January and gave birth normally in December, without any additional complications. The difference here is that when the fetus is born normally, the commitments continue. The doctor is obliged to check the integrity of the scar from the previous birth, even if there were no pathological symptoms and syndromes until then. If a defect in the margin from the previous operation is detected, surgical intervention is undertaken. But nowhere is it considered a medical error. Of all the over 200 births that we have described in the monograph, we have had only 2 cases in which it was necessary to restore the integrity of the uterus after a normal birth.
- Are you dispelling the myth about the high risk in such births. What are the most common concerns of expectant mothers and what do the real data show?
- I just dispelled it. Our experience shows that the adverse events are less than 1%. By “adverse events“ I mean what an ignorant and uninformed person would conclude. Otherwise, from a medical point of view, when some additional intervention is necessary after birth, this is not a medical error.
The concerns of expectant mothers are standard – that it will hurt a lot, will they be able to cope... The emotional level rises in a negative direction, especially when the term passes. Then the woman begins to lose confidence and adding additional fears to the already existing ones is not good. But it is imperative to say that both behavioral and emotional support of the woman in labor is necessary.
- Do you think that even women with two previous cesarean sections can successfully give birth naturally? What are the results in this group of patients and how is the risk managed?
- We have several undescribed cases in which we have a normal birth after two previous cesarean sections. But there, each case could already be interpreted and explained separately. A common denominator cannot be put. One must know, be careful and have the necessary senses to catch the beginning of the pathology.
- What factors turn out to be the most important for a successful VBAC - previous normal birth, the interval between pregnancies, the weight of the fetus or something else?
- All of this, plus if labor has already begun. Also the presentation of the fetus. No one disputes breech birth anymore. Although we have such cases, we are not afraid of conducting a normal birth of a fetus with breech presentation. But these are very specific cases in which the responsibility is much greater. The main thing is that the woman has had a normal birth, which guarantees a very high success rate. In those who have not experienced a normal birth, the success rate is below 50%. If labor has already begun, this is also a factor for success.
- What are the benefits for the mother and baby in a successful vaginal birth compared to a repeated operative birth?
- Faster recovery period, earlier emotional contact between the mother and the newborn, shorter hospital stay, less medication.
- At UMBAL Burgas, you report some of the lowest rates of operative births among the large hospitals in the country. How do you manage to maintain this balance between safety and promoting natural childbirth?
- With knowledge and skills.
- Do you think that the results of your study can lead to changes in national clinical protocols and to a wider implementation of VBAC in Bulgaria?
- We can hope for this, but the initiative is in the hands of state and regulatory authorities.
- What would you say to expectant mothers who have already given birth by cesarean section and believe that they have no chance of a normal birth in their next pregnancy?
- I would encourage them to try under the supervision and guidance of an experienced and knowledgeable obstetrician-gynecologist.