Dr. Banka Soujanya Discusses Possibility of Normal Delivery under Various Conditions (Part-7)

Dr. Banka Soujanya: As we have discussed, there is a scale for postpartum depression, and similarly, we use a chart called a partogram to monitor this. Once the woman is in labor, specifically during active labor, when she reaches 4 cm of dilatation. With the help of the partogram, we conduct regular assessments to monitor her vital signs, including blood pressure, pulse, and contractions.

Additionally, we document any medications administered to her, such as those that may induce contractions, as noted on the partogram. Partogram has been designed to track the duration of labor. If the water has broken, we can assess the color of the amniotic fluid to determine whether it is clear or contains meconium. Depending on various factors, the simple partogram helps us decide whether to wait a few more hours or to make a decision regarding the delivery process. There are guidelines indicating that certain timelines are applicable once a woman reaches 4 cm of dilation.

It's a common misconception that labor pain signals an immediate arrival of the baby, as often portrayed in movies. In reality, for first-time pregnancies, labor can take up to 24 hours to progress to 4 cm dilation, a stage known as the latent phase of labor. After reaching 4 cm, the labor enters the active phase, which may last 10 to 12 hours for first-time mothers. In contrast, for those who have delivered previously, this phase typically lasts 8 to 10 hours.

The partogram will guide our decision-making process. However, if labor extends beyond 24 to 44 hours, it raises concerns. In these cases, we must monitor the baby's heartbeat and remain vigilant for signs of obstructed labor, where the baby cannot pass through the birth canal. Conditions such as cephalopelvic disproportion occur when the baby's head is too large for the mother's pelvis, which may either be too small or inadequate to accommodate the baby's head, or when contractions are insufficient.

There are numerous factors to consider when progress is not occurring as expected. When I initiate labor induction, I typically anticipate that a patient, especially one with a history of normal delivery, will progress and deliver by that night. If by morning the delivery has not occurred, I must reflect on what might be wrong. This could involve reviewing the patient’s condition or whether the medications are functioning as intended. If everything appears normal, yet progress is stalled, it may indicate an obstruction preventing the baby from descending through the passage, leading me to consider an emergency cesarean section as the next step.

Dr. Banka Soujanya: People should understand that no delivery is the same. It’s not just about comparing your experience with that of your relatives, neighbors, sisters, or even your previous deliveries. This is a challenge we face every day. Many people assume that obstetricians deliver babies continuously and find it easy. However, every case is unique and presents its challenges for us.

Dr. Banka Soujanya: Not at all. Once a patient has undergone a C-section during their first delivery, the indication that led to a C-section should be addressed first when they come to the clinic with a positive pregnancy test. They often ask, "Madam, I have gone through the C-section before. Will I need to go for another C-section for this Pregnancy?"

If the indication is that 1st pregnancy was due to different circumstances, such as the baby's heart rate dropping, or meconium-stained fetal distress, or the progress was not satisfactory, where the mother attempted a normal delivery, but was not successful, and has gone through emergency c-section. In such a scenario we can consider a trial for vaginal delivery in the second pregnancy. This is known as Vaginal birth after c-section (Vback) or (Tolac) Trial of Labor after cesarean section.

To determine if a patient is a suitable candidate for VBAC, we review the patient's complete clinical history, including data from previous pregnancies as well as the current pregnancy. We assess her vitals, overall physical status, the baby's condition, and any complications that have occurred during the current pregnancy, as every factor is crucial.

For example, If the patient's previous pregnancy is a c- section but the patient is completely healthy now, with natural pregnancy and the baby in a head-down position (cephalic), with issues like hypertension or diabetes, and the patient herself goes into labor on her own though she has come to the hospital in an emergency, where we can perform vaginal delivery in the hospital.

If the patient is nearing their due date and wishes to attempt a vaginal birth, we can induce labor. Our facility must be available 24/7. Access to the anesthetist, pediatrician, blood bank, and OT facilities, so that in case of emergency, where the labor isn't progressing or if the baby shows signs of distress, we can respond, as the most anticipated risk in VBACs is the uterine rupture.

The uterine rupture occurs when a previous surgery site ruptures. If this happens, we must deliver the baby immediately, within minutes, to ensure the baby's safety. With the right facilities, teamwork, and multidisciplinary approach in our setup, we can confidently offer a trial for VBAC. But it's also important to note that the belief that "once a C-section, always a C-section" is a myth.