15 SPANISH FILMS YOU MUST SEE

Spain has always had a reputation of good quality cinema. During its long story, it was the great filmmaker Luis Buñuel who first achieved universal recognition, when together with Salvador Dalí made the surrealistic Un Chien Andalou in 1928. However, due to the nation’s political isolation, Spain did not participate in the European cinema new waves, and remained mostly inconspicuous.

The “new cinema” of the ‘60s produced some great films, but only after Franco’s death in 1975, Spanish cinema gained renewed international recognition, led particularly by its “terrible child” Pedro Almodóvar. Since then, a whole generation of filmmakers has grown-up and kept producing interesting work, and many other talented, cine-literate artists have emerged.

For this list I picked 15 great Spanish films of the 21st century, which put in evidence the talent of Spain’s contemporary filmmakers; for the sake of variety I chose only one film per director. Enjoy them, and let me know which one is your favourite!

1. TODOS LOS SABEN (EVERYBODY KNOWS), 2018

The plot: A Spanish woman living in Buenos Aires returns to her hometown to assist to her sister’s wedding. Unexpected events, though, will upset the wedding and bring deeply buried family secrets to the surface.

Go see it, because… This is another great film by the Iranian director Asghar Farhadi, who reunites this time an outstanding cast: Penélope Cruz, Javier Bardem and Ricardo Darín, among others. Everybody Knows provides an emotional and thought-provoking journey into a small Spanish community, evokes several contemporary dilemmas, and leaves the morality of the story open to the viewer’s judgement.

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2. CONTRATIEMPO (THE INVISIBLE GUEST), 2016

The plot: A young businessman wakes up in a hotel room next to the body of his dead lover. He hires a prestigious lawyer to defend him, and over the course of one night, they work together to find out what happened.

Go see it, because… It is an awesome thriller with great acting and pacing, masterfully directed and exquisitely written by Catalán Oriol Paulo. Tense and suspenseful, it is certain the plot twist at the end will leave completely shocked!

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 3. TRUMAN, 2015

The plot: Julián, a theater actor, has had cancer for a year, and his only companion is his dog Truman. When he receives an unexpected visit from his friend Tomás who lives in Canada, the two men, together with Truman, will share emotional and surprising moments trying to cope with Julián’s complicated situation.

Go see it, because… Directed and written by Cesc Gay, with the adequate dose of honesty and realism, Truman is a moving, sweet and sour, well-acted comedy/drama about grief, friendship, love and family. Cámara and Darín are superb in their roles, providing effortless, emotional depth to their characters.

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4. 8 APELLIDOS VASCOS (SPANISH AFFAIR), 2014

The plot: Rafa is a Sevilian who has never left his native Andalucía, until he meets a Basque girl named Amaia and decides to follow her to the Basque Country. A series of misunderstandings forces Rafa to impersonate a full-blooded Basque with eight Basque surnames, getting more and more entangled in that character in order to please Amaia.

Go see it, because… Emilio Martínez Lázaro’s romantic comedy was a box-office phenomenon in Spain, becoming the highest-grossing Spanish film of all time! Besides its solid script and amusing characters, the film’s huge success is arguably due to the way it deals with the different stereotypes and preconceptions among the different Spanish regions, a subject always relevant to the country. People who are not familiar with Spanish local traditions, accent and politics may miss some of the gags, but everybody will enjoy most of the hilarious situations, and the beautiful scenery of País Vasco (Basque Country) and Andalucía (Andalusia).

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 5. LA ISLA MÍNIMA (MARSHLAND), 2014

The plot: In 1980, two Madrid homicide detectives are sent to the Guadalquivir Marshes in Spain’s ‘Deep South’ to investigate the disappearance of two teenage sisters during the town’s festivities. Both detectives must settle their ideological differences and bring the murderer to justice before more young women lose their lives.

Go see it, because… It is a hypnotic, multi-layered thriller, masterfully directed by the talented Alberto Rodríguez, with breathtaking photography and superb acting. A careful character-study, which also introduces some political undertones during a turbulent period of the Spanish history. The film received 10 Goya awards (Spain’s main national annual film awards), among many other prizes and nominations.

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6. TAMBIÉN LA LLUVIA (EVEN THE RAIN), 2010

The plot: As a director and his crew shoot a controversial film about Christopher Columbus in Bolivia, local natives rise up against the privatisation of their water supply. The production is beset by more and more problems and the riots escalate, raising the tension between the crew members and leading them to a moral crisis.

Go see it, because… Written by Paul Laverty (Ken Loach’s regular collaborator) and skilfully directed by Icíar Bollaín (who is also a well-known Spanish actress), the film examines a social and political event that took place in Cochabamba, Bolivia in the year 2000, known as the Water War. Featuring an excellent cast, which includes the Mexican actor Gabriel García Bernal, the film parallels indigenous resistance 500 years ago and nowadays, managing not only to teach us without dogmatism and bias, but also to be moving and entertaining.

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7. CELDA 211 (CELL 211), 2009

The plot: Juan Oliver reports to his new work as a prison officer one day earlier to make a good impression, leaving at home his pregnant wife Elena. During his tour of the prison though, a riot in the High Security zone begins, leaving him trapped inside Cell 211. Juan must then pretend to be another inmate in order to guarantee his own safety, while trying to draw a plan to get him out of the prison. The situation escalates though, and unexpected shifts occur, both within and outside the prison.

Go see it, because… It is a raw, enthralling thriller, with great plot and character development, and edge-of-the-seat suspense. Excellent direction by Daniel Monzón and top-notch acting add up to make Celda 211 a memorable film. It was an artistic and commercial success; it received 43 awards (including 8 Goya Awards) and 24 other nominations. 

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8. [REC], 2007

The plot: Late-night TV reporter Angela and her cameraman are following the night shift of Barcelona’s fire station. When they receive a call from an old lady trapped in her apartment, journalists and firemen remain confined inside the perilous building. A terrible nightmare ensues, which is thoroughly recorded by the TV crew.

Go see it because… It is a superb horror film, among the scariest I have seen lately, but also a dark satire of the mass media. It may remind us The Blair Witch project; nevertheless, it is quite fresh and original in its plot development and ending. Co-directed by Jaume Balagueró and Paco Plaza, the film was so successful that inspired an American remake, Quarantine and three sequels, [REC]2, [REC]3 and [REC]4.

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9. EL ORFANATO (THE ORPHANAGE), 2007

The plot: A woman brings her family back to her childhood home, which used to be an orphanage. Before long, her son disappears, and is later presumed dead. Grief-stricken Laura believes she hears spirits, who may be trying to help her find the boy.

Go see it, because… It is a scary, creepy, thrilling and suspenseful film, but also a moving and intelligent one, wonderfully acted by Belén Rueda and carefully directed by Juan Antonio Bayona. It was critically acclaimed and received multiple national and international awards, including 7 Premios Goya.

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10. EL LABERINTO DEL FAUNO (PAN’S LABYRINTH), 2006

The plot: In the falangist Spain of 1944, a young girl fascinated by fairy-tales is sent to live with her stepfather, a captain of the Spanish army. As the girl witnesses her stepfather’s sadistic brutality, she is drawn into Pan’s Labyrinth, a magical world of mythical beings.

Go see it, because… This is one of the most critically acclaimed films of Spain’s contemporary cinema, directed by Mexican-born Guillermo del Toro. It won 99 awards, including 3 Oscars; it is on IMDB’s best films of all time list (#129), with a Metascore of 98! Of course, all of them deserved: El laberinto del fauno is indeed a beautiful, magical, dark fairy tale, a brilliant and timeless masterpiece.

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11. MAR ADENTRO (THE SEA INSIDE), 2004

The plot: The true story of former sailor and writer Ramón Sampedro, who was quadriplegic for almost thirty years and fought in court in favor of euthanasia and his own right to die. Despite his wish to die, he taught everyone he encountered the meaning, value and preciousness of life.

Go see it, because…Young director Alejandro Amenábar had already displayed his talent before in the films Tesis, Abre los ojos (Open your eyes) and The Others. With this movie, though, not only he established himself as one of the best Spanish directors of his generation – he also wrote, edited and scored the film – but also managed to tackle an extremely delicate subject with utmost dexterity and sensibility. Not to mention the exceptional cast –Javier Bardem, Belén Rueda, Lola Dueñas-  which adds up to make this film a beautiful and unforgettable piece of art. Mar adentro won the Oscar for Best Foreign Language film, as well as many other national and international awards.

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12. HABLE CON ELLA (TALK TO HER), 2002

The plot: After a chance encounter at a theater, Benigno and Marco meet at the private clinic where Benigno works. Marco’s girlfriend is a bullfighter who has been gored and is in a coma. Benigno is looking after Alicia, a young ballet student who is also in a coma. The lives of the four characters will intertwine, dragging them towards an unsuspected destiny.

Go see, it because… Pedro Almodóvar is arguably Spain’s most iconic filmmaker; his particular style, although irreverent, sarcastic and witty, always manages to dig deeply into the human soul. Hable con Ella is regarded as Almodovar’s greatest film: it is a very profound and multi-layered film about love, friendship and existence. Brilliant, disturbing and thought-provoking… Hable con ella was internationally acclaimed, obtaining many international awards such as Oscar, Golden Globe, BAFTA, Cesar, among others.

IMDB link

13. LOS LUNES AL SOL (MONDAYS IN THE SUN), 2002

The plot: A group of men left jobless by the closure of the shipyards in Vigo, Galicia bide their time together in the local pub, opened and run by one of their former coworkers. The group is held together by the affable Santa, who is the de facto leader and sometimes father-confessor. 

Go see, it because… Director Fernando León de Aranoa deserves credits for capturing the feeling of the unemployed with no family, possession or future in such a poignant and realistic manner, without becoming dull or boring. Besides its impeccable direction, the film delivers a really intelligent – and relevant – script, and outstanding acting by two among Spain’s best: Javier Bardem and Luis Tosar.

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14. LA COMUNIDAD (COMMON WEALTH), 2000

The plot: A real state agent accidentally discovers a treasure hidden in the apartment of a deceased man. She is determined to escape with the loot, but the rest of the building’s tenants think otherwise…

Go see, it because… Alex De La Iglesia is well known for his dark comedies – his 1995 El día de la Bestia (The day of the Beast) catapulted him into fame – and this film is no exception: it is a terrific dark tale that brings out the darkest side of human nature. No need to show devils, zombies, or evil spirits: nothing is scariest than the guy next door! The film is creepy, suspenseful and crazily funny; the characters – led by the great Carmen Maura- are all memorable.

IMDB link

15. EL BOLA, 2000

The plot: El Bola (“the Pellet”) is a 12-year-old boy emotionally and physically damaged by the constant abuse of his father. The arrival of a new boy at school exposes him to the true meaning of friendship and family.

Go see, it because… The film deals with a very relevant issue, that of child beating, which is displayed with great realism – although keeping violence to a strict minimum, pertinent to the story-telling – and deep characters, who avoid exaggerating the crude and difficult situations enacted. Remarkable cast, excellent direction by Achero Mañas, who won 4 Goya awards with this film, including best film and best new director.

IMDB link

 

Do you agree with this list? Let me know of other, great Spanish Films!

TRYING TO GET PREGNANT: 14 FERTILITY MYTHS DEBUNKED

We live in the era of informatics. Knowledge is easily accessible to us: we can learn virtually anything by just googling it. But paradoxically too much information many times leads to misinformation.

When it comes to fertility issues, there is a lot of disinformation going around. Therefore, it is no surprising what a recent survey showed: knowledge regarding ovulation, fertility, and conception issues is limited among women, and many tend to believe certain myths and misconceptions.

These are 14 fertility myths most people believe, but that science has debunked:

MYTH #1.  Maternity wise, 40s is the new 30s

Our life expectancy is longer, and we tend to postpone maternity due to career or study purposes. From that aspect, the 40s can be easily regarded as the new 30s. Unfortunately, this is not true for our ovaries: by the age of 30, a healthy woman has about a 20% chance of conceiving each month, by the time she reaches 40 her odds drop to about 5%.

This is one of the most commonly believed misconceptions: unaware of the age-related fertility decline, many women start seeking  help to conceive in their 40s, when they may have already missed the opportunity to become parents. 

You should be aware that there is a biological clock, and it’s ticking! If for personal reasons you cannot have a child right now, you may freeze your eggs to use them in the future.

MYTH #2. Certain sex positions increase the chances of getting pregnant

You will find plenty of (mis)information on this topic! In general, it is said that the best positions for getting pregnant are the missionary position (the woman lying on her back, her partner on top) and the “doggy position” (rear vaginal penetration, with the woman on her hands and knees) because they provide the deepest penetration, allowing the man to ejaculate closer to the opening of the cervix. 

In fact, there’s no scientific evidence to prove that. This belief is largely based on a single study that looked at the position of the penis in relation to these two sex positions, but it didn’t address pregnancy chances at all.

Therefore, no position seems to be better when it comes to maximizing your chances of making a baby. Sperm can be found in the cervical canal just a few seconds after ejaculation, and within 5 minutes in the tube, regardless of the coital position.

MYTH #3. Lifting your legs in the air for 20 minutes after having sex will help you get pregnant

You have probably heard this one: “lie in bed with your feet in the air after having sex to increase your chances of getting pregnant”. In fact, this is not (totally) true. You may lay in bed for 10-15 minutes after intercourse, as by this time the sperm have largely reached the cervix, and many may even be inside the tube.

In fact, a new study challenged both beliefs: women having artificial insemination were split into two groups – one that rested on their back with their knees raised for 15 minutes after the procedure and one that got up immediately. It turned out that, after several courses of treatment, 32% of the immobile group fell pregnant, compared with 40% per cent in the active group.

Therefore, there is no need to put pillows under your bottom during intercourse to get an advantageous tilt, or to perform cycling motions with your feet in the air.

MYTH #4. If we have sex every day the sperm becomes too weak, reducing our chances of getting pregnant 

How often should we make love to boost our chances of pregnancy? You will find all sorts of advice on the web: every other day, 3 times a week, every single day! Which one is correct?

One thing is clear: abstinence intervals greater than 5 days impair the sperm number and quality. Nevertheless, there is not much difference whether men ejaculate every day or every other day. Most fertility specialists used to recommend intercourse every other day, as this would increase sperm quality, particularly in men with lower sperm counts (oligozoospermia). However, recent studies show exactly the opposite: oligozoospermic men had better semen quality with daily ejaculation!

Recent scientific evidence suggests that making love every day confers a slight advantage: the highest chances of pregnancy (37% per cycle) were associated with daily intercourse, although sex on alternate days had comparable pregnancy rates (33%). On the other hand, we should keep in mind that the “obligation” to have sex every day may induce unnecessary stress to the couple, resulting in lack of sexual desire, low self esteem, and ultimately reduced frequency of intercourse.

Therefore, reproductive efficiency is highest when you have sex every day or every other day. The optimal frequency, though, is best defined by each couple’s own preference.

MYTH # 5. We only have sex when I ovulate, on day 14 of my cycle

Ovulation (when the egg drops from the ovary into the tubes) occurs once a month, usually between day 11 and day 21 of the cycle (measured from the first day of your period).

Each woman ovulates on her own schedule. While it is usually said that a woman with a 28-day cycle ovulates on cycle day 14, that’s not necessarily true: a study found that fewer than 10 percent of women with regular, 28-day cycles were ovulating on day 14.

We know that sperm cells are able to survive in the reproductive tract of a woman for about 5 days, and that once the egg is released, it will die in about 12-24 hours. Therefore, the fertile period -or “fertile window”- is a 6-day interval ending on the day of ovulation.

To boost your odds to become pregnant, have sex before and during ovulation, every day or every other day. If your cycles are irregular and you cannot figure out your fertile days, you may use an ovulation predictor kit, or otherwise visit a specialist, who can help you find your fertile window.

MYTH # 6. Smoking doesn’t affect our chances of getting pregnant. I will quit smoking as soon as I get pregnant

You are most likely aware that smoking during pregnancy is dangerous, as it can lead to miscarriage, premature birth, low-birthweight babies and -according to recent studies– congenital malformations.

But you should also know that smoking is harmful for your fertility: smoking as few as five cigarettes per day is associated with reduced fertility, both in women and men, and this seems to be true even for secondhand smoking. It has been estimated that smokers may have a 10-40% lower monthly fecundity (fertility) rate, and that up to 13% of infertility is due to smoking.

Smoking can affect ovulation, as well as the ability of the fertilized egg to implant in the uterus. The effect of tobacco is so harmful for the ovaries that menopause occurs, on average, one to four years earlier in smoking women than in nonsmoking ones.

Men are also affected by tobacco: decreases in sperm density, motility, and abnormalities in sperm morphology have been observed in men who smoke, which impact a man’s ability to fertilize an egg. 

Therefore, before trying for a baby, do yourself a favor … and put out the cigarette for good!

MYTH # 7. You don’t need to worry about your age. There’s always IVF

Another common misconception! Many women believe that, if age-related infertility strikes, they can overcome their problem by getting treated with in vitro fertilization (IVF). In fact, just as natural fertility declines with age, success rates with IVF also decline as a woman gets older.

According to the USA Center for Disease Control and Prevention (CDC), women younger than 35 years old have 33% chances of having a baby after IVF; for women ages 38 to 40 the success rate drops to 17%, while those 43 to 44 years old have only 3% chances of giving birth after IVF (using their own eggs).

IVF is not a guarantee to have a baby, and does not extend a woman’s reproductive life. Despite the number of celebrities having babies in their mid-40s and beyond, they may have not necessarily used their own eggs. While every woman has the right to keep her privacy, there is a wrong perception left that fertility treatments can extend a woman’s fertility span. There is a very low probability of improving success of conceiving after age 43 by using assisted reproduction using your own eggs. Nevertheless, you may opt to use oocyte donation (eggs of a younger woman) if age-related infertility stands in the way of parenthood.

MYTH # 8. A woman can’t get pregnant if she doesn’t have an orgasm

For men, things are clear: no orgasm, no pregnancy, as ejaculation occurs during orgasm. Well, that’s not entirely true: semen can be released during intercourse prior to orgasm in the so-called pre-ejaculation fluid, or pre-come (read more here).

For women though, getting pregnant has nothing to do with an orgasm. But could female orgasm improve the chances for conception? The answer is not clear.

Researchers have wondered for years about the purpose of female orgasm, and many theories have been proposed: 

  • Just the pleasure it provokes, so that women want to reproduce and preserve the species!
  • The “poleaxe” hypothesis: orgasms make women feel relaxed and sleepy so that they will lie down after sex and the sperm reach their destination more easily.
  • The “upsuck” theory: the contractions of the uterus “suck up” the sperm released in the vagina and help them travel through the uterus to the tubes.
  • Pair bonding: the hormones produced during orgasm (such as oxytocin and prolactin) contribute to warm feelings towards her partner.

Orgasms are not necessary to get pregnant, but there are plenty of good reasons to have one! Nevertheless, it is not uncommon that women trying to conceive link the desire for an orgasm with their desire to have a baby; this leads to psychological pressure and difficulty achieving orgasm, adding frustration to a process that is supposed to be pleasurable…

Try not to consider the orgasm just as goal to get pregnant. Enjoy the intimate time with your partner, without any pressure. If you have an orgasm, great. If not, that’s fine, too!

MYTH #9. We’ve already had one child, so conceiving again will be easy

Perhaps, but it’s no guarantee. Many individuals experience secondary infertility, or difficulty conceiving a second or subsequent child. 

Secondary infertility may be caused by age-related factors, both for you and your partner. Sometimes, a new underlying medical condition develops. Eventually, a fertility issue that always existed gets worse; while it didn’t prevent pregnancy before, now it has become a problem. A previous pregnancy may actually be the reason you don’t get pregnant again: surgical complications or infection after childbirth may have provoked scarring, which may in turn led to infertility.

Things change with time. Even if you got easily pregnant on your own before, if you’re struggling to have another child talk to your doctor, who can advice you on the next steps to follow.

MYTH #10. Infertility is a woman’s issue

Typically, the causes of infertility break down like this: 

  • Approximately one third of the couples struggle with male infertility;
  • In another third, the problem is female infertility;
  • The remaining third will either face both male and female fertility issues, or a cause will never be found (unexplained infertility).

Common causes of female infertily are: age, PCOS (polycystic ovary syndrome), tubal or pelvic issues, endometriosis, and family history. 

Common causes of male infertility tend to be from prior surgery, infection, or a problem present at birth.

As part of the preliminary work-up to determine the cause and treatment of infertility, both women and men will need to undergo clinical and specialized complementary exams.

MYTH #11. Men’s age doesn’t matter

While some men can father children into their 50’s or 60’s, men’s fertility isn’t age-proof: it starts declining in their 40s, although less drastically as compared to women’s fertility.

As a man ages, the concentration of mobile, healthy sperm and semen volume overall will decrease. It is clear now that men over the age of 40 have higher chances of having children with chromosomal abnormalities, causing miscarriages in their female partners. Moreover, researchers have found a direct link between paternal age and an increased risk of autism and schizophrenia. 

A man’s age does matter. While men may not have a complete drop off in fertility like women do, “advanced paternal age” is something couples should be aware of. Men’s biological clock is also ticking!

MYTH #12. If I take good care of my general health, my fertility will be in check too

Whereas a healthy body and mind may boost fertility in certain cases, most infertility situations cannot be resolved by a lifestyle or diet change, particularly those related to age.

It is a common belief that certain diet types can help you get pregnant. There is no evidence that vegetarian diets, low-fat diets, antioxidant- or vitamin-enriched diets will increase your chances of having a child.

A woman’s weight plays a role in fertility: those who are either very thin or obese may find it hard to conceive. If you are trying to get pregnant, learn more about some lifestyle tips to boost your chances of getting pregnant here.

MYTH #13. If a man can ejaculate, his fertility is fine

Many myths surround male fertility and their sexual performance. It is a common (and unfortunate) myth that if a man’s fertility is compromised, this means his sexual performance is the problem. This is not true. Problems with sperm count, shape, and movement are the primary causes of male infertility. 

Another common myth is that you can tell there is a problem with the sperm just by looking at the semen. In fact, even men that have no sperm cells at all (azoospermia) usually have normal-looking semen. 

For the vast majority of men with infertility, there are no visible or obvious signs that anything is wrong. Healthy erectile function and normal ejaculation are not guarantee that the sperm is in good shape.

That said, erectile dysfunction can be a possible symptom of infertility; it may due to low testosterone levels or a physical injury. Difficulty with ejaculation can also be a signal certain medical problems. But these are uncommon signs of male infertility.

If you are struggling to get pregnant, have your partner check in with his doctor. A semen analysis will help clarify whether his sperm are fit for conception.

MYTH #14. The birth control pill will affect your future fertility

All scientific evidence agrees that hormonal contraceptives do not make women sterile. Moreover, they may confer increased likelihood of pregnancy with long-term use, and in certain cases they can also preserve fertility. Read more on the contraceptive pill here.

 

To summarize:

Myths and misconceptions regarding fertility and conception are, unfortunately, widely disseminated. This is a serious problem, as misinformation may lead not only to unnecessary stress, but also to take wrong decisions…

Get yourself well informed! Consult your gynecologist, who can help you with any concerns you have. Your doctor can also give you some tips on lifestyle changes to optimize your fertility, prescribe some exams, and tell you when to come back if you don’t achieve pregnancy on your own.

Last, a good piece of advice: if you want to get pregnant, have lots of sex – as much as you want, whenever you want – and enjoy it! After you have had sex, do whatever you want – just don’t smoke 😉

 

Photo credits

Intro: pixabay.com; 1: rma-fl.com; 2: motherandbaby.co.uk; 3: romper.com; 4: pixabay.com; 5: wsaw.com; 6: babycenter.com; 7: nexter.org; 8: irishtimes.com; 9: health.clevelandclinic.org; 10: thefertilechickonline.com; 11: businessinsider.com; 12: hayatouki.com; 13: livescience.com; 14: pinterest.com

HPV TEST: ΜΙΑ ΚΑΙΝΟΤΟΜΟΣ ΜΕΘΟΔΟΣ ΓΙΑ ΤΗΝ ΠΡΟΛΗΨΗ ΤΟΥ ΚΑΡΚΙΝΟΥ ΤΟΥ ΤΡΑΧΗΛΟΥ ΤΗΣ ΜΗΤΡΑΣ

Πιθανώς να έχετε ακούσει για το τεστ Παπ, και γνωρίζετε ότι πρέπει να το κάνετε τακτικά. Τα τεστ Παπανικολάου είναι μια πολύ σημαντική εξέταση που έχει σώσει εκατομμύρια γυναίκες εδώ και πάνω από 70 χρόνια, επειδή επιτρέπει την ανίχνευση ανωμαλιών στον τράχηλο της μήτρας πριν μετατραπούν σε καρκίνο. 

Παρότι πολύτιμη εξέταση, τα τελευταία χρόνια πιο σύγχρονη τεχνολογία έχει γίνει διαθέσιμη, η οποία βελτίωσε ακόμα περισσότερο την ικανότητά μας να βρούμε προκαρκινικές αλλοιώσεις του τράχηλου της μήτρας. Αυτή η νέα εξέταση ονομάζεται τεστ HPV.

Σε αυτό το άρθρο θα βρείτε όλες τις πληροφορίες που πρέπει να ξέρετε σχετικά με αυτή την καινοτόμο τεχνική, η οποία έχει γίνει πια εξέταση ρουτίνας σε πολλές χώρες του πλανήτη.

Εισαγωγή

  • Ο καρκίνος του τραχήλου της μήτρας είναι ο δεύτερος πιο συχνός καρκίνος που πλήττει τις γυναίκες παγκοσμίως. Είναι ένας τύπος καρκίνου που μπορεί εύκολα να αποφευχθεί, καθώς η αιτία του είναι γνωστή: ο ιός του ανθρωπίνου θηλώματος (HPV, διαβάστε περισσότερα εδώ).
  • Ο HPV είναι μια πολύ μεγάλη οικογένεια, που περιλαμβάνει περισσότερους από 120 υποτύπους. Από αυτούς, μόνο 15 τύποι σχετίζονται με καρκίνο. Aυτοί είναι γνωστοί ως τύποι “υψηλού κινδύνου”.
  • Ενώ οι περισσότερες λοιμώξεις από τον HPV υποχωρούν χωρίς θεραπεία, οι μολύνσεις με HPV υψηλού κινδύνου που επιμένουν με την πάροδο του χρόνου μπορεί να προκαλέσουν προκαρκινικές αλλαγές στον τράχηλο της μήτρας.
  • Οι προκαρκινικές αλλοιώσεις, αν δεν αντιμετωπιστούν, μπορεί να γίνουν καρκίνος του τραχήλου της μήτρας. Συνήθως χρειάζονται 10 ή περισσότερα χρόνια για να μετατραπούν οι προκαρκινικές αλλοιώσεις σε καρκίνο. Όμως, δεν πρέπει να επαναπαυόμαστε διότι αυτό σε μερικές περιπτώσεις μπορεί να συμβεί σε μικρότερο χρονικό διάστημα.
  • Οι προκαρκινικές αλλοιώσεις του τραχήλου είναι σιωπηλές. Τα συμπτώματα εμφανίζονται μόνο στον προχωρημένο καρκίνο. Για αυτό το λόγο όλες οι γυναίκες πρέπει να υποβληθούν σε προληπτικές (προσυμπτωματικές) εξετάσεις.
  • Η ανίχνευση προκαρκινικών αλλοιώσεων του τραχήλου της μήτρας γινόταν μέχρι πρότινος μόνο με το τεστ Παπανικολάου. Κατά τη διάρκεια αυτής της διαδικασίας, κύτταρα από τον τράχηλο αποξέονται απαλά με ένα βουρτσάκι, και στη συνέχεια εξετάζονται για ανώμαλη ανάπτυξη, συνήθως αποκαλούμενη τραχηλική δυσπλασία, CIN (ενδοεπιθηλιακή νεοπλασία του τραχήλου) ή SIL (πλακώδης ενδοεπιθηλιακή αλλοίωση).
  • Πρόσφατα, καινοτόμος τεχνολογία έχουν γίνει διαθέσιμη για να ανιχνεύσουμε τους τύπους του HPV που προκαλούν καρκίνο, και να καθοριστεί αν μια γυναίκα διατρέχει κίνδυνο  ανάπτυξης καρκίνου. Αυτή η δοκιμασία ονομάζεται τεστ HPV.

Τι είναι το Τεστ HPV;

  • Το τεστ HPV ανιχνεύει την παρουσία των τύπων του ιού που μπορεί να οδηγήσουν στην ανάπτυξη καρκίνου του τραχήλου της μήτρας.
  • Η προσυμπτωματική αυτή δοκιμασία είναι διαθέσιμη μόνο για τις  γυναίκες. Αν και οι άνδρες δυνητικά μπορούν να μολυνθούν με τον ιό HPV και να τον μεταδώσουν στους σεξουαλικούς τους συντρόφους, δεν υπάρχει ακόμη εξέταση για την ανίχνευση του ιού HPV πριν εκδηλωθεί κάποια αλλοίωση.

Αξίζει να σημειωθεί ότι τo τεστ HPV διαφέρει από την “ταυτοποίηση” ή “τυποποίηση”, δηλαδή την εξέταση που γίνεται με μια διαφορετική τεχνική (αλυσιδωτή αντίδραση πολυμεράσης, ή PCR). Το τεστ HPV είναι πολύ πιο αξιόπιστο από την ταυτοποίηση με PCR για τον εντοπισμό προκαρκινικών αλλοιώσεων, επειδή εντοπίζει ειδικά τις περιπτώσεις στις οποίες υπάρχει σημαντικό ιικό φορτίο από ογκογόνους HPV. Αυτό σημαίνει πως το τεστ HPV ανιχνεύει την ενεργή λοίμωξη, η οποία αποτελεί ουσιαστικό κίνδυνο για εξέλιξη σε καρκίνου. Αντιθέτως, η τεχνική PCR ανιχνεύει ακόμη και ελάχιστες ποσότητες του DNA του ιού, που δεν έχουν κλινική σημασία. Για το λόγο αυτό, οι αμερικανικές, βρετανικές και άλλες επιστημονικές εταιρείες δεν συνιστούν την ταυτοποίηση με PCR για τον μαζικό έλεγχο του υγιούς πληθυσμού.

Γιατί να κάνω το Τεστ HPV;

  • Το τεστ Παπανικολάου είναι μια απλή εξέταση που έχει σώσει τις ζωές αμέτρητων γυναικών. Ωστόσο, δεν είναι 100% ακριβές: πολλές φορές ανιχνεύει ανωμαλίες του τραχήλου της μήτρας που δεν θα προχωρήσουν ποτέ σε καρκίνο, και από την άλλη πλευρά ενδέχεται να μην βρει ανώμαλα κύτταρα που είναι πιθανόν να εξελιχθούν σε καρκίνο χωρίς θεραπεία.
  • Συνεπώς, γνωρίζοντας αν υπάρχει ένας τύπος HPV υψηλού κινδύνου για καρκίνο, θα έχουμε πολύτιμες πληροφορίες που θα μας βοηθήσουν να αποφασίσουμε ποια θα είναι τα επόμενα βήματα: είτε απλή παρακολούθηση, είτε περαιτέρω εξετάσεις, είτε θεραπεία της προκαρκινικής αλλοίωσης.
  • Πρόσφατες μελέτες έχουν δείξει ότι το τεστ HPV είναι πιο αποτελεσματικό από το τεστ Παπανικολάου για την την ανίχνευση προκαρκινικών αλλοιώσεων.
  • Ο συνδυασμός του τεστ Παπανικολάου και του τεστ HPV (που ονομάζεται “co-testing”) είναι ο αποτελεσματικότερος τρόπος για να εντοπιστεί ο προκαρκίνος ή ο πρώιμος καρκίνος του τραχήλου της μήτρας σε γυναίκες ηλικίας 30 ετών και άνω.

Ποιος πρέπει να κάνει το τεστ HPV;

Η εξέταση HPV συνιστάται στις ακόλουθες περιπτώσεις:

  • Είστε ηλικίας 30 ετών και άνω. Το τεστ HPV μπορεί να γίνει μόνο του ή σε συνδυασμό με ένα τεστ Παπανικολάου.
  • Το τεστ Παπ έδειξε άτυπα πλακώδη κύτταρα μη καθορισμένης σημασίας  (“ASCUS”). Το ASCUS είναι ένα κοινό εύρημα στο τεστ Παπανικολάου. Μπορεί να είναι ένδειξη λοίμωξης από τον ιό HPV, αν και πολλές φορές σχετίζεται με πολύποδες του τραχήλου της μήτρας, βακτηριακή λοίμωξη ή χαμηλά επίπεδα ορμονών (εμμηνόπαυση).
  • Προηγήθηκε χειρουργική αφαίρεση προκαρκινικών βλαβών, συνήθως 6 μήνες μετά τη θεραπεία. Αυτό ονομάζεται “έλεγχος Θεραπείας” (Test of Cure, TOC).

Παρότι οι συστάσεις ποικίλλουν σε διάφορες χώρες, σε γενικές γραμμές όλες οι γυναίκες ηλικίας 30 έως 65 ετών θα πρέπει να κάνουν το τεστ HPV κάθε 3 έως 5 χρόνια.

Η συστηματική ανίχνευση του ιού HPV σε γυναίκες κάτω των 30 ετών δεν συνίσταται, ούτε είναι χρήσιμη. Ο ιός HPV μεταδίδεται μέσω σεξουαλικής επαφής και είναι πολύ κοινός σε νέες γυναίκες. Τις περισσότερες φορές, οι λοιμώξεις από τον HPV υποχωρούν από μόνες τους μέσα σε ένα ή δύο χρόνια. Δεδομένου ότι για να εξελιχθούν σε καρκίνο οι αλλαγές του τραχήλου θέλουν αρκετά χρόνια – συνήθως 10 χρόνια ή περισσότερο, οι νεαρές γυναίκες γενικά παρακολουθούνται προσεκτικά, αντί να υποβληθούν σε θεραπεία για τις αλλοιώσεις του τραχήλου που οφείλονται σε μόλυνση από τον HPV.

Ποιοι είναι οι κίνδυνοι του τεστ HPV;

Αν και το τεστ HPV είναι πολύ αξιόπιστο, υπάρχει ο κίνδυνος ψευδώς θετικών ή ψευδώς αρνητικών αποτελεσμάτων, όπως άλλωστε μπορεί να συμβεί σε οποιαδήποτε εργαστηριακή δοκιμασία.

  • Ψευδώς θετικό. Αυτό σημαίνει ότι το τεστ έδειξε HPV υψηλού κινδύνου ενώ στην πραγματικότητα δεν τον έχετε. Ένα ψευδώς θετικό αποτέλεσμα θα μπορούσε να οδηγήσει σε περιττές εξετάσεις παρακολούθησης, όπως κολποσκόπηση ή βιοψία, και αδικαιολόγητο άγχος λόγω του αποτελέσματος της εξέτασης.
  • Ψευδώς αρνητικό. Σημαίνει ότι ενώ έχετε μια μόλυνση από τον ιό HPV υψηλού κινδύνου, η δοκιμασία εσφαλμένα υποδεικνύει ότι δεν υπάρχει ιός. Αυτό θα μπορούσε να προκαλέσει καθυστέρηση στις κατάλληλες διαδικασίες παρακολούθησης ή θεραπείας.

Πώς πρέπει να προετοιμαστώ για το τεστ HPV;

Το τεστ HPV συνήθως γίνεται ταυτόχρονα με το τεστ Pap. Για να είναι όσο το δυνατόν ακριβέστερες οι δύο αυτές εξετάσεις συνιστάται να λάβετε τα ακόλουθα μέτρα :

  • Αποφύγετε τη σεξουαλική επαφή, τις κολπικές πλύσεις ή τη χρήση οποιωνδήποτε κολπικών φαρμάκων, κρεμών ή τζελ τις δύο ημέρες που προηγούνται της εξέτασης.
  • Προσπαθήστε να μην προγραμματίσετε το τεστ κατά τη διάρκεια της εμμήνου ρύσεως. Η εξέταση μπορεί να γίνει, αλλά καλύτερο δείγμα κυττάρων συλλέγεται σε άλλη φάση του κύκλου.

Πώς γίνεται το τεστ HPV;

  • Η δοκιμασία HPV, μόνη της ή σε συνδυασμό με το τεστ Pap, εκτελείται στο ιατρείο και διαρκεί μόνο λίγα λεπτά.
  • Ενώ είστε ξαπλωμένη με τα γόνατά σας λυγισμένα, ο γιατρός θα εισάγει απαλά στον κόλπο ένα εργαλείο που ονομάζεται κολποδιαστολέας.
  • Ο κολποδιαστολέας επιτρέπει την εξέταση του τραχήλου. Τα δείγματα των τραχηλικών κυττάρων λαμβάνονται χρησιμοποιώντας μια μαλακή βούρτσα.
  • Συνήθως αυτό δεν πονάει, ενίοτε μπορεί να προκαλέσει μια ήπια δυσφορία.
  • Μετά τη διαδικασία, μπορείτε να κάνετε τις καθημερινές σας συνήθεις δραστηριότητες χωρίς περιορισμούς.
  • Ρωτήστε το γιατρό σας πότε θα λάβετε τα αποτελέσματα των εξετάσεων σας.

Τι σημαίνουν τα αποτελέσματα;

Τα αποτελέσματα του τεστ HPV θα είναι είτε θετικά είτε αρνητικά.

  • Θετικό τεστ HPV. Αυτό σημαίνει ότι έχετε έναν τύπο του HPV υψηλού κινδύνου που συνδέεται με τον καρκίνο του τραχήλου της μήτρας. Ενώ οι περισσότερες γυναίκες που έχουν μολυνθεί από τον HPV δεν προκειται να αναπτύξουν καρκίνο στον τράχηλο της μήτρας, το θετικό εύρημα είναι ένα προειδοποιητικό σημάδι και χρίζει περαιτέρω παρακολούθησης.
  • Αρνητικό τεστ HPV. Ένα αρνητικό αποτέλεσμα σημαίνει ότι δεν έχετε κανένα από τους τύπους του HPV που προκαλούν καρκίνο του τραχήλου και συνεπώς θα συνεχίσετε μόνο την παρακολούθηση ρουτίνας.

Ανάλογα λοιπόν με το αποτέλεσμα της εξέτασης, ο γιατρός σας μπορεί να συστήσει ένα από τα παρακάτω ως επόμενο βήμα:

  • Συνήθης παρακολούθηση. Αν είστε άνω των 30 ετών, η εξέταση HPV είναι αρνητική και το τεστ Pap φυσιολογικό, ακολουθείτε το γενικά συνιστώμενο πρόγραμμα ελέγχου.
  • Κολποσκόπηση. Διαδικασία παρακολούθησης που χρησιμοποιεί ένα είδος μικροσκοπίου για να εξεταστεί με περισσότερη λεπτομέρεια ο τράχηλος της μήτρας, και γενικά το κατώτερο γεννητικό σύστημα.
  • Βιοψία. Σε συνδυασμό με την κολποσκόπηση, ο γιατρός παίρνει ένα δείγμα ιστού του τραχήλου με ένα ειδικό εργαλείο, το οποίο θα εξεταστεί μικροσκοπικά μετά από ειδική επεξεργασία και χρώση.
  • Εξαίρεση ανώμαλων κυττάρων. Σε περίπτωση εμφανούς αλλοίωσης κυττάρων του τραχήλου της μήτρας, για να αποφευχθεί η εξέλιξη των μη φυσιολογικών κυττάρων σε καρκίνο, ο γιατρός σας θα προτείνει την αφαίρεση των περιοχών αυτών που περιέχουν τα ανώμαλα κύτταρα.

Συμπέρασμα…

Ίσως η επίσκεψη στον γυναικολόγο σας τρομάζει. Ίσως και να είστε πολύ απασχολημένη με περιορισμένο ελεύθερο χρόνο. Ενδεχομένως να πιστεύετε ότι δεν κινδυνεύετε από λοίμωξη HPV, ούτε από καρκίνο. Πρέπει όμως να ξέρετε ότι κάθε σεξουαλικά ενεργός γυναίκα ανεξαρτήτως, διατρέχει κίνδυνο για καρκίνο του τραχήλου της μήτρας. Το τεστ HPV είναι μια απλή, ανώδυνη δοκιμασία που απαιτεί μόνο 5 λεπτά για να γίνει, αποτρέποντας και προλαμβάνοντας τυχόν σοβαρά προβλήματα στο μέλλον…

Κάντε το τεστ HPV! Πέντε λεπτά από το χρόνο σας μπορεί να σας σώσουν τη ζωή!

Βιβλιογραφία

  1. The HPV DNA test – American Cancer Society
  2. Gynecological Cancers – Centers for Disease Control and Prevention
  3. Cervical Cancer Screening: Pap and HPV tests – National Cervical Cancer Coalition
  4. Cervical Screening – National Health System UK

Photo credits

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HPV TEST: A NOVEL TECHNIQUE TO PREVENT CERVICAL CANCER

You have probably heard the term Pap test and know that you should be getting it regularly. Pap tests are important because they allow us to detect abnormalities in the uterine cervix before they turn into cancer. Thus, Pap tests have saved millions of women’s lives for more than 70 years now.

Nevertheless, as valuable as this test has been for so many years, new technology has come to improve even further our ability to find pre-cancer or early cancer of the cervix. This novel exam is called the HPV test.

In this article you will find all the information you need to know regarding this new technique, which is becoming a routine exam in most countries.

Background

  • Cervical cancer is the second-most-common cancer affecting women worldwide. It is a type of cancer that can easily be prevented, as its cause is known: the human papillomavirus (HPV, read more here).
  • Not all types of HPV are responsible for the development of cancer of the uterine cervix. Approximately 15 types of HPV are related to cancer, these are known as high-risk types or oncogenic viruses.
  • While most HPV infections resolve without treatment, infections with high-risk HPV strains that persist over time can cause precancerous changes in the cervix.
  • Precancerous conditions are not cancer, but if these abnormal changes are not treated, they may become cervical cancer. It may take 10 years or more for precancerous conditions to turn into cancer, but eventually this happens within a shorter time period.
  • Pre-cancer lesions of the cervix do not cause any symptoms. Symptoms only appear in advanced cancer. That is why all healthy women should undergo preventive exams.
  • The mainstay of cervical cancer screening for the last 70 years has been the Pap test (also called Pap smear or Test Papanicolaou). During the procedure, cells from the cervix are gently scraped away with a brush and then examined for abnormal growth, usually called cervical dysplasia,  CIN (cervical intraepithelial neoplasia), or SIL (squamous intraepithelial lesions).
  • More recently, newer technologies have become available to test for the cancer-causing types of HPV and determine if you may be at risk. This test is called the HPV test.

What is the HPV test?

  • The human papillomavirus (HPV) test detects the presence of the types of HPV virus that can lead to the development of cervical cancer.
  • The HPV test is available only to women. Although men can be infected with HPV and pass the virus along to their sex partners, no HPV test yet exists to detect the virus in men.

Why test for HPV?

  • The Pap test is a simple test that has saved uncountable women lives. However, it is not 100% accurate. The Pap test detects certain cervical abnormalities that will never progress to cancer; on the other hand, it may miss abnormal cells even when they are there.
  • Thus, knowing whether you have a type of HPV that puts you at high risk of cervical cancer will provide valuable information on the next steps in your health care, such as follow-up monitoring, further testing, or treatment of precancerous cells.
  • Recent studies have shown that HPV testing is more effective than Pap smears at detecting precancerous lesions.
  • A Pap test plus an HPV test (called co-testing) is the most effective way to find pre-cancer or early cervical cancer in women 30 and older.

Who should do the HPV test?

The HPV test is recommended if:

  • You are age 30 or older. The HPV test may be done alone or in combination with a Pap smear.
  • Your Pap test showed atypical squamous cells of undetermined significance (ASCUS). ASCUS is a common finding in a Pap test; it may be a sign of HPV infection, although many times it is just related to benign cervical polyps, a bacterial infection, or low hormone levels (menopause).
  • You had a surgical removal of a precancerous lesions, usually 6 months after the treatment. This is called “test of cure”.

Although recommendations vary in different countries, all women aged 30 to 65 years old should have the HPV test every 3 to 5 years.

Routine use of the HPV test in women under age 30 is not recommended, nor is it very helpful. HPV spreads through sexual contact and is very common in young women. Most of the times, HPV infections clear on their own within a year or two. Since cervical changes that lead to cancer take several years — often 10 years or more, younger women are usually advised to follow a watchful waiting instead of undergoing treatment for cervical changes resulting from an HPV infection.

What are the risks of HPV testing?

Although the HPV test is very accurate, it carries (like any other test) the risk of false-positive or false-negative results.

• False-positive. This means that the test showed a high-risk HPV when you really don’t have it. A false-positive result could lead to an unnecessary follow-up procedure, such as colposcopy or biopsy, and undue anxiety over the test results.

• False-negative. A false-negative test result means you really do have an HPV infection, but the test indicates that you don’t. This might cause a delay in appropriate follow-up tests or procedures.

How should I prepare for an HPV test?

The HPV test is usually done at the same time as the Pap test. You can take these measures to make both tests as accurate as possible:

  • Avoid intercourse, douching, or using any vaginal medicines or spermicidal foams, creams or jellies for two days before the test.
  • Try not to schedule the test during your menstrual period. The test can be done, but a better sample of cells can be collected at another time in your cycle.

How is the HPV test done?

  • The HPV test, alone or in combination with the Pap test, is performed at the doctor’s office and takes only a few minutes.
  • While you lie on your back with your knees bent, your doctor will gently insert an instrument called a speculum into the vagina.
  • The speculum allows the visualisation of the cervix. Samples of the cervical cells are taken using a soft brush.
  • Usually this doesn’t hurt, sometimes it may cause a mild discomfort.
  • After the procedure, you can do your normal daily activities without any restrictions.
  • Ask your doctor about when you can expect to receive your test results.

What do the results mean?

Results from your HPV test will come back as either positive or negative.

  • Positive HPV test. This means that you have a type of high-risk HPV that is linked to cervical cancer. While most women who are infected with HPV will never develop cervical cancer, it’s a warning sign that cervical cancer could develop in the future.
  • Negative HPV test. A negative test result means that you don’t have any of the types of HPV that cause cervical cancer, and you will continue with normal monitoring.

Depending on your test results, your doctor may recommend one of the following as a next step:

  • Normal monitoring. If you’re over age 30, your HPV test is negative and your Pap test is normal, you will follow the generally recommended schedule (differences apply for each country).
  • Colposcopy. In this follow-up procedure, your doctor uses a special magnifying lens (colposcope) to more closely examine your cervix.
  • Biopsy. Done in conjunction with colposcopy, a sample of cervical cells (biopsy) is taken to be examined more closely under a microscope.
  • Removal of abnormal cervical cells. To prevent abnormal cells from developing into cancerous cells, your doctor may suggest a procedure to remove the areas of tissue that contain the abnormal cells.

The bottom line…

It is true that a visit to the gynaecologist may sound frightening. You may be too busy, and feel that you don’t have the time. You may believe that you are not at risk for cancer. While all this may be true, you should know that every sexually active woman is at risk for cervical cancer, the HPV test is a simple, painless test that takes 5 minutes to be done, and will prevent some serious issues in the long run. Have your HPV test! Five minutes of your time can save your life!

References

  1. The HPV DNA test – American Cancer Society
  2. Gynecological Cancers – Centers for Disease Control and Prevention
  3. Cervical Cancer Screening: Pap and HPV tests – National Cervical Cancer Coalition
  4. Cervical Screening – National Health System UK

Photo credits

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ΞΑΝΑ ΚΑΙΣΑΡΙΚΗ Η ΦΥΣΙΟΛΟΓΙΚΟΣ ΤΟΚΕΤΟΣ ΜΕΤΑ ΑΠΟ ΚΑΙΣΑΡΙΚΗ ΤΟΜΗ; ΟΛΑ ΟΣΑ ΠΡΕΠΕΙ ΝΑ ΞΕΡΕΤΕ ΠΡΙΝ ΑΠΟΦΑΣΙΣΕΤΕ

“Μια φορά καισαρική, για πάντα καισαρική”… υπήρξε σαν αξίωμα για πολλά χρόνια, εδώ στην Ελλάδα και σε πολλές άλλες χώρες. Όμως, τα συνεχώς αυξανόμενα ποσοστά καισαρικής τομής παγκοσμίως έχουν οδηγήσει στην επανεξέταση των κινδύνων της καισαρικής τομής σε σχέση με την κολπικό τοκετό μετά από προηγηθείσα καισαρική. Έντονη συζήτηση γίνεται γύρω από αυτό το θέμα, με τις απόψεις να είναι διχασμένες. Συνεπώς, όταν έρχεται η ώρα να αποφασίσουν πολλές γυναίκες αναρωτιούνται: εγώ τελικά τι πρέπει να κάνω, ξανά καισαρική ή να επιχειρήσω μια φυσιολογική γέννα;

Η αλήθεια είναι πως η απάντηση δεν είναι τόσο εύκολη. Και οι δύο επιλογές έχουν πιθανούς κινδύνους, ο οποίοι διαφέρουν σε κάθε γυναίκα και σε κάθε εγκυμοσύνη ξεχωριστά.

Σε αυτό το άρθρο θα βρείτε όλες τις απαραίτητες πληροφορίες σχετικά με τον φυσιολογικό τοκετό μετά από καισαρική τομή, ώστε να μπορείτε να το συζητήσετε με το γιατρό ή τη μαία σας, και να πάρετε μια συνειδητοποιημένη και υπεύθυνη απόφαση.

1) Τι είναι ο κολπικός τοκετός μετά από καισαρική τομή (VBAC);

Αν είστε έγκυος και γεννήσατε το προηγούμενό σας μωρό με καισαρική τομή, αυτή τη φορά έχετε δύο επιλογές για το πώς θα γεννήσετε:

  1. μια εκλεκτική επαναλαμβανόμενη καισαρική τομή (ERCS: elective repeat caesarean section), ή
  2. ένας φυσιολογικός τοκετός μετά από καισαρική τομή (VBAC: vaginal birth after cesarean section). Το VBAC αναφέρεται στη γέννηση μέσω του κόλπου σε μια γυναίκα που είχε ήδη κάνει μια καισαρική τομή σε προηγούμενη κύηση. Ο κολπικός τοκετός περιλαμβάνει και τις περιπτώσεις στις οποίες ο τοκετός υποστηρίζεται με εμβρυουλκία (“κουτάλες”) ή ανναρώφηση (βεντούζα).

Τόσο ο κολπικός τοκετός, όσο και η επαναλαμβανόμενη καισαρική έχουν οφέλη και κινδύνους (βλ. παρακάτω).

Η δοκιμασία τοκετού μετά από καισαρική τομή (αγγλικά TOLAC: trial of labor after cesarean delivery) είναι η προσπάθεια να διεξάγεται ένα VBAC. Εάν είναι επιτυχής, θα έχει ως αποτέλεσμα τη φυσιολογική γέννηση. Αν δεν είναι επιτυχής, θα χρειαστείτε ξανά καισαρική τομή.

2) Πόσες πιθανότητες έχω να γεννήσω κολπικά μετά από μια καισαρική;

Εφόσον έχετε τις κατάλληλες προυποθέσεις για VBAC, υπάρχουν πολλές πιθανότητες να το πετύχετε: περίπου το 60 έως 80% των γυναικών που επιχειρούν ένα VBAC θα γεννήσουν κολπικά.

Υπάρχουν ορισμένοι παράγοντες που επηρεάζουν τις πιθανότητες επιτυχίας, τόσο από την μητέρα όσο και από το μωρό (βλ. παρακάτω). Παρόλα αυτά, είναι αδύνατο να προβλέψουμε με βεβαιότητα ποια γυναίκα θα καταφέρει να γεννήσει φυσιολογικά και ποια θα καταλήξει σε μια επαναλαμβανόμενη καισαρική.

Ένας προηγούμενος φυσιολογικός τοκετός, ιδιαίτερα ένα προηγούμενο VBAC, είναι ο καλύτερος προγνωστικός δείκτης επιτυχούς VBAC, και συνδέεται με ποσοστό επιτυχίας 85-90%.

3) Είμαι καλή υποψήφια για VBAC;

Το VBAC είναι κατάλληλο για την πλειοψηφία των γυναικών που:

  • είναι έγκυος με ένα έμβρυο (και όχι με δίδυμα ή παραπάνω),
  • το μωρό είναι τοποθετημένο με το κεφάλι κάτω (κεφαλική προβολή),
  • έχουν μια τελειόμηνη κύηση (37 εβδομάδες ή παραπάνω),
  • έχουν μία προηγηθείσα εγκάρσια καισαρική τομή.

4) Πότε αντενδείκνυται το VBAC;

Το VBAC δεν συνιστάται στις ακόλουθες περιπτώσεις:

  • Τρεις ή περισσότερες προηγούμενες καισαρικές τομές. Δείτε παρακάτω σχετικά με δύο προηγηθείσες καισαρικές.
  • Έχει γίνει ρήξη μήτρας κατά τη διάρκεια προηγούμενης προσπάθειας τοκετού, καθώς αυξάνεται σημαντικά ο κίνδυνος (7 φορές υψηλότερος) μιας υποτροπιάζουσας ρήξης της μήτρας στην επόμενη εγκυμοσύνη.
  • Η προηγούμενη καισαρική τομή ήταν “κλασική”. Στη συντριπτική πλειοψηφία των γυναικών, κατά την διάρκεια της καισαρικής η μήτρα κόβεται οριζόντια, στο χαμηλότερο τμήμα της. Αυτό ονομάζεται κατώτερη εγκάρσια καισαρική τομή. Σπάνια απαιτείται μια κάθετη τομή της μήτρας, η οποία είναι γνωστή ως κλασική καισαρική τομή. Περιστασιακά, πραγματοποιείται τομή σε σχήμα J ή T. Και στις δύο περιπτώσεις της κάθετης και της J / T-τομής υπάρχει υψηλότερος κίνδυνος ρήξης της μήτρας. Επομένως, είναι πολύ σημαντικό να γνωρίζετε ποια τομή πραγματοποιήθηκε στην προηγούμενή σας καισαρική. Να έχετε υπόψη σας πως ο τύπος της ουλής στο δέρμα δεν αντιστοιχεί κατ ‘ανάγκη εκείνο της μήτρας.
  • Μια προηγούμενη χειρουργική επέμβαση της μήτρας, όπως η αφαίρεση ινομυωμάτων (ινομυωματεκτομή), καθώς αυξάνει τον κίνδυνο ρήξης της μήτρας.
  • Υπάρχουν και άλλες επιπλοκές της εγκυμοσύνης που αποτελούν απόλυτη αντένδειξη για φυσιολογικό τοκετό, ανεξάρτητα από την παρουσία ή όχι προηγηθείσας καισαρικής (π.χ. προδρομικός πλακούντας)
  • Ισχιακή προβολή του εμβρύου (το μωρό έρχεται πρώτα με τους γλουτούς ή τα πόδια) ή άλλες μη φυσιολογικές θέσεις.
  • Πολύδυμη κύηση (με δίδυμα ή περισσότερα έμβρυα).

5) Ποιοι παράγοντες μειώνουν τις πιθανότητες επιτυχίας ενός VBAC;

Γενικά, οι πιθανότητες επιτυχίας είναι χαμηλότερες όταν:

  • Ο λόγος για την προηγούμενη καισαρική είναι πιθανό να είναι πρόβλημα και αυτή τη φορά. Ας πούμε ότι μια γυναίκα που είχε ήδη μια κολπική γέννα και στη συνέχεια έκανε μια καισαρική επειδή το μωρό της ήταν σε ισχιακή προβολή (γλουτοί ή πόδια πρώτα) είναι πολύ πιο πιθανό να καταφέρει να γεννήσει με VBAC από κάποια άλλη που είχε κάνει καισαρική μετά την επίτευξη πλήρους διαστολή και εξώθηση για τρεις ώρες, το ότι μπορεί να υποδηλώνει πως αυτή η γυναίκα έχει στενή λεκάνη (η λεγόμενη κεφαλο-πυελική δυσαναλογία).
  • Γίνεται πρόκληση τοκετού (ο τοκετός δεν ξεκίνησε αυτόματα).
  • Είστε ηλικίας άνω των 40 ετών.
  • Είστε υπέρβαρη.
  • Το μωρό είναι μεγάλο (πάνω από 4 κιλά εκτιμώμενο βάρος).
  • Η κύηση είναι παρατεταμένη (περισσότερο από 40 εβδομάδες).
  • Υπάρχει μικρό χρονικό διάστημα ανάμεσα στις κυήσεις (λιγότερο από 19 μήνες).
  • Έχετε προεκλαμψία (υψηλή αρτηριακή πίεση) τη στιγμή του τοκετού.

Θα πρέπει να συζητήσετε με τον γιατρό σας σχετικά με τις πιθανότητες επιτυχίας συγκεκριμένα  για την δικιά σας περίπτωση και να σταθμίσετε προσεκτικά τα οφέλη και τους κινδύνους.

6) Ποια είναι τα πλεονεκτήματα ενός VBAC;

Η καισαρική τομή είναι μια χειρουργική επέμβαση, και ως εκ τούτου συνδέεται με ορισμένους αυξημένους κινδύνους σε σχέση με την φυσιολοκιγή γέννα. Επομένως, ένα επιτυχημένο VBAC συνεπάγεται:

  • Βραχύτερη περίοδος ανάρρωσης.
  • Λιγότερος πόνος μετά τον τοκετό.
  • Χαμηλότερος κίνδυνος μόλυνσης.
  • Μειωμένη απώλεια αίματος, μειωμένη ανάγκη μετάγγισης αίματος.
  • Λιγότερες πιθανότητες να χρειαστεί μια επείγουσα υστερεκτομή (αφαίρεση μήτρας).
  • Χαμηλότερη πιθανότητα βλάβης άλλων οργάνων (ουροδόχου κύστης και εντέρου).
  • Χαμηλότερος κίνδυνος εμφάνισης θρόμβου αίματος (θρόμβωση) στα πόδια (εν τω βάθη φλεβική θρόμβωση) ή πνεύμονες (πνευμονική εμβολή).
  • Μειωμένος κίνδυνος πυελικών συμφήσεων (ουλώδης ιστός που σχηματίζεται μεταξύ των οργάνων, ο οποίος μπορεί να είναι υπεύθυνος για χρόνιο πόνο, υπογονιμότητα ή εντερική απόφραξη).
  • Μειωμένες πιθανότητες αναπνευστικά προβλήματα στο μωρό. Περίπου το 4-5% των νεογνών που γεννιούνται με προγραμματισμένη καισαρική έχουν αναπνευστικά προβλήματα, σε σύγκριση με 2-3% μετά το VBAC. Ο κίνδυνος είναι ελαφρώς υψηλότερος αν η καισαρική τομή έγινε πριν τις 39 εβδομάδες. Είναι γεγονός πως τα προβλήματα αναπνοής είναι αρκετά συνηθισμένα μετά από καισαρική τομή, αλλά συνήθως δεν διαρκούν πολύ.
  • Πολλές γυναίκες θέλουν να βιώσουν την εμπειρία μιας φυσιολογικής γέννας, και όταν το VBAC είναι επιτυχές, τις προφέρει αυτή την δυνατότητα.

Αν σχεδιάζετε να έχετε περισσότερα παιδιά, το VBAC μπορεί να σας βοηθήσει να αποφύγετε ορισμένα προβλήματα υγείας που συνδέονται με πολλαπλές καισαρικές τομές. Μάλιστα, κάποιες επιπλοκές της καισαρικής, όπως η αιμορραγία, η επείγουσα υστερεκτομή, οι τραυματισμοί του εντέρου ή της ουροδόχου κύστης, οι σχηματισμοί συμφήσεων είναι όλες πιο συχνές όσο αυξάνεται ο αριθμός καισαρικών τομών. Επιπλέον, κάθε καισαρική αυξάνει τον κίνδυνο σε μελλοντικές εγκυμοσύνες επιπλοκών του πλακούντα, όπως ο επιπωματικός πλακούντας (ο πλακούντας είναι χαμηλά στη μήτρα και καλύπτει τον τράχηλο) και ο στιφρός πλακούντας (η πρόσφηση του πλακούντα είναι πολύ βαθιά στα τοιχώματα της μήτρας και δεν αποκολλάται σωστά κατά τον τοκετό). Και οι δύο καταστάσεις μπορούν να οδηγήσουν σε μαζική αιμορραγία (απειλητική για τη ζωή) και σε υστερεκτομή. Εάν γνωρίζετε ότι θέλετε περισσότερα παιδιά, πρέπει και αυτό να το λάβετε υπόψη στην απόφασή σας.

7) Ποιοι είναι οι κίνδυνοι ενός VBAC;

  • Μια από τις πιο επίφοβες επιπλοκές ενός VBAC είναι η ρήξης της μήτρας, δηλαδή όταν η ουλή της μήτρας σχίζεται ή διαχωρίζεται. Ακόμα κι αν έχετε τις καλύτερες προϋποθέσεις για ένα VBAC, υπάρχει ένας κίνδυνος 0,7% (δηλαδή 7 στις 1000 γυναίκες που υποβάλλονται σε VBAC) η μήτρα να σπάσει στο σημείο της προηγούμενης καισαρικής τομής. Εάν αυτό συμβεί, μπορεί να προκαλέσει μαζική, απειλητική για τη ζωή αιμορραγία στη μητέρα, και ενδεχομένως στέρηση οξυγόνου στο μωρό, με επακόλουθη εγκεφαλική βλάβη (σε 8 από τις 10.000 περιπτώσεις) ή ακόμη και θάνατος (2-3 στις 10.000 περιπτώσεις). Ενώ ο κίνδυνος αυτός είναι πολύ μικρός συνολικά, είναι υψηλότερος σε σύγκριση με μια προγραμματισμένη καισαρική τομή.
  • Ανεξάρτητα από τη ρήξη της μήτρας, το VBAC φέρει αυξημένο κίνδυνο μακροπρόθεσμης νευρολογικής βλάβης ή ακόμη και θάνατο του εμβρύου. Και πάλι, ο κίνδυνος είναι πολύ μικρός, αλλά είναι υψηλότερος στις γυναίκες που η προσπάθεια για VBAC απέτυχε σε σχέση με εκείνες που κατάφεραν να γεννήσουν κολπικά ή που γέννησαν με προγραμματισμένη καισαρική τομή.
  •  Ενδέχεται να υποβάλλεστε σε πολλές ώρες προσπάθειας τοκετού και στο τέλος να κάνετε καισαρική. Η ανεπιτυχής δοκιμασία για VBAC συχνά προκαλεί μεγάλη απογοήτευση στις γυναίκες, καθώς οι προσδοκίες τους για φυσιολογικό τοκετό δεν πληρούνται.
  • Σε περίπτωση VBAC ενδέχεται ο τοκετός να χρίζει υποβοήθηση με αναρρόφηση ή εμβρυουλκία, τα οποία αυξάνουν τον κίνδυνο κάκωσης των μυών που ελέγχουν τον πρωκτό ή το ορθό (ρήξη του περινέου τρίτου ή τέταρτου βαθμού).
  • Μπορεί να χρειαστεί να γίνει μια έκτακτη καισαρική κατά τη διάρκεια της δοκιμασίας τοκετού. Αυτό συμβαίνει στο 25% των γυναικών. Μια επείγουσα καισαρική τομή φέρει περισσότερους κινδύνους από μια προγραμματισμένη καισαρική. Οι πιο συνηθισμένοι λόγοι για μια έκτακτη καισαρική είναι αν ο τοκετός επιβραδύνεται ή υπάρχει ανησυχία για την ευημερία του μωρού.

Πρέπει να επισημάνουμε πως ενώ ένα επιτυχημένο VBAC είναι λιγότερο επικίνδυνο από μια προγραμματισμένη καισαρική τομή, ένα ανεπιτυχές VBAC που απαιτεί καισαρική φέρει μεγαλύτερο κίνδυνο από μια προγραμματισμένη καισαρική. Και ο κίνδυνος επιπλοκών είναι ακόμη υψηλότερος αν χρίζει επείγουσα καισαρική τομή.

8) Μπορώ να προχωρήσω σε VBAC εάν έχω ήδη κάνει δύο καισαρικές;

Σύμφωνα με τις αμερικάνικες (ACOG) και της βρετανικές (RCOG) κατευθυντήριες οδηγίες, το VBAC μπορεί να προσφέρεται σε γυναίκες που έχουν δύο προηγηθείσες εγκάρσιες καισαρικές τομές, μετά από λεπτομερή συμβουλευτική. Παρόλα αυτά, πρέπει να γνωρίζουν ότι ο κίνδυνος ρήξης της μήτρας αυξάνεται έως και 5 φορές (0,9 έως 3,7%).

Το VBAC μετά από δύο προηγούμενες καισαρικές είναι εξαιρετικά αμφιλεγόμενο, και ενδέχεται να μην είναι αποδεκτό από ορισμένους γιατρούς ή ιδρύματα.

9) Τι να περιμένω κατά τη διάρκεια ενός VBAC;

  • Το VBAC πρέπει να λαμβάνει χώρα σε νοσοκομείο ή μαειυτήριο που μπορεί να διαχειριστεί επείγουσες καταστάσεις που θα μπορούσαν να απειλούν τη ζωή της γυναίκας ή του εμβρύου, και ΔΕΝ πρέπει να επιχειρείται στο σπίτι.
  • Θα πρέπει να πληρούνται όλα τα κριτήρια και να μην υπάρχει καμία από τις αντενδείξεις για VBAC που έχουν αναφερθεί προηγουμένως.
  • Οι παράγοντες που μπορεί να μειώσουν ή να αυξήσουν την πιθανότητα επιτυχίας θα συζητηθούν διεξοδικά, επειδή είναι ξεχωριστοί για κάθε γυναίκα και για κάθε εγκυμοσύνη.
  • Οι καλύτερες υποψήφιες για VBAC είναι οι γυναίκες στις οποίες ο τοκετός ξεκινά αυτόματα, καθώς η πρόκληση τοκετού (με φάρμακα ή άλλες μεθόδους) μειώνει τις πιθανότητες επιτυχούς κολπικού τοκετού και φέρει 3 φορές μεγαλύτερο κίνδυνο επιπλοκών.
  • Γενικά συνιστάται να προσέρχεστε στο νοσοκομείο με τα πρώτα σημάδια τοκετού, για προσεκτική και έγκυρη αξιολόγηση.
  • Ο καρδιακός παλμός του μωρού θα παρακολουθείται συνεχώς κατά τη διάρκεια του τοκετού για να εξασφαλίζεται η ευημερία του μωρού, αφού οι αλλαγές στην καρδιακή λειτουργία είναι ένα από τα πρώιμα σημάδια προβλημάτων με την προηγούμενη καισαρική τομή.
  • Ένας ενδοφλέβιος καθετήρας είναι απαραίτητος για την άμεση αντιμετώπιση οποιασδήποτε ενδεχόμενης επιπλοκής.
  • Να αποφεύγετε να τρώτε οτιδήποτε κατά τη διάρκεια του τοκετού, σε περίπτωση που χρειαστεί να γίνει μια έκτακτη καισαρική αργότερα.
  • Επιτρέπονται τα φάρμακα για την ανακούφιση του πόνου, συμπεριλαμβανομένης και η επισκληρίδιος αναλγησίας.
  • Τα ακόλουθα σημάδια μπορεί να είναι ένδειξη ρήξης της μήτρας και χρίζουν μια επείγουσα καισαρική:
    1. Συνεχιζόμενη βραδυκαρδία στο έμβρυο (η καρδιακή συχνότητα του μωρού πέφτει, είναι το συνηθέστερο σημάδι ρήξης της μήτρας).
    2. Κολπική αιμορραγία.
    3. Ευαισθησία στην ουλή της καισαρικής.
    4. Πόνος ανάμεσα στις συσπάσεις.
    5. Παύση συσπάσεων.
    6. Πόνος που επιμένει ακόμα και με την επισκληρίδιο αναλγησία, ή υπερβολικές ανάγκη για επισκληρίδια φάρμακα.
    7. Ψηλαφήση εμβρυϊκών μερών έξω από τη μήτρα.
    8. Αιματουρία (αίμα στα ούρα).

Είναι σημαντικό να καταλάβετε πως η ρήξη της μήτρας μπορεί να είναι σιωπηρή, και ότι ακόμα και μια επείγουσα καισαρική μπορεί να μην αποτρέψει σοβαρές επιπλοκές, τόσο για εσάς όσο και για το μωρό σας.

Εν κατακλείδι:

  • Ένα επιτυχές VBAC έχει τις λιγότερες επιπλοκές.
  • Ο μεγαλύτερος κίνδυνος ανεπιθύμητων αποτελεσμάτων που σχετίζονται με το VBAC συμβαίνει όταν το VBAC καταλήξει σε επείγουσα καισαρική τομή.
  • Είναι συχνά αδύνατο να προβλέψουμε ποιες γυναίκες θα έχουν ένα επιτυχημένο VBAC και ποιες θα χρειαστούν μια επαναλαμβανόμενη καισαρική.
  • Ένα VBAC που ξεκινάει αυτόματα (χωρίς πρόκληση) έχει κίνδυνο 1: 150 ρήξης της μήτρας.
  • Η ρήξη της μήτρας είναι μια σπάνια, αλλά δυνητικά απειλητική για τη ζωή κατάσταση, τόσο για τη μητέρα όσο και για το μωρό της.
  • Ακόμα και όταν η καισαρική γίνεται αμέσως, ενδέχεται να μην μπορέσει να αποτρέψει σοβαρές επιπλοκές, τόσο για τη μητέρα όσο και για το μωρό της.
  • Ο απόλυτος κίνδυνος σοβαρών προβλημάτων και θανάτου του εμβρύου που σχετίζονται με το VBAC είναι πολύ χαμηλός, αλλά υψηλότερος από την προγραμματισμένη καισαρική.
  • Τα νεογνά που γεννιούνται μέσω προγραμματισμένης καισαρικής τομής έχουν αυξημένο κίνδυνο αναπνευστικών προβλημάτων, τα οποία όμως είναι συνήθως βραχύβια.
  • Η προγραμματισμένη καισαρική σχετίζεται με αυξημένο κίνδυνο επιπλοκών της πρόσφυσης του πλακούντα (επιπωματικός / στιφρός πλακούντας) σε μελλοντικές εγκυμοσύνες. Και άλλες επιπλοκές όπως οι πυελικές συμφύσεις είναι πιο συχνές όσο αυξάνεται ο αριθμός των καισαρικών.

Τα VBAC είναι πολύ αμφιλεγόμενο και μπορεί να είναι δύσκολο να αποφασίσετε αν είναι το καλύτερο για εσάς. Συζητήστε το διεξοδικά με τον/την γιατρό σας. Δώστε στον εαυτό σας αρκετό χρόνο για να ενημερωθείτε και να εξετάσετε προσεκτικά τα πλεονεκτήματα και τα μειονεκτήματα της κάθε επιλογής.

Βιβλιογραφία

  1. The American College of Obstetricians and Gynecologists (ACOG) – Vaginal Birth After Cesarean Delivery FAQ 070, December 2017 (For patients)
  2. ACOG Practice Bulletin Number 184 – Vaginal Birth After Cesarean Delivery, November 2017
  3. Royal College of Obstetricians & Gynaecologists (RCOG) –  Birth options after previous caesarean section – July 2016 (For patients)
  4. Royal College of Obstetricians & Gynaecologists (RCOG) –  Birth After Previous Caesarean Birth – Green-top Guideline No. 45, October 2015
  5. National Health System (NHS) UK – Clinical Guideline for: The Management of Vaginal Birth After Caesarean (VBAC). July 2016

Photo credits

1.Parents.com; 2.EvolutionaryParenting.com; 3.goldengateobgyn.org; 4.Healthymummy.com; 5.YouTube.com; 6.Scarymummy.com; 7.geoscripts.meredith.services

VAGINAL BIRTH AFTER CESAREAN SECTION (VBAC): ALL YOU NEED TO KNOW BEFORE MAKING YOUR EDUCATED CHOICE

“Once a Cesarean, always a Cesarean” has been the standard recommendation for many years. But the increasingly high cesarean section (C-section) rates around the world have led doctors to reassess the risks of a cesarean section versus delivering vaginally after having a previous C-section.

Repeat C-section or VBAC? The answer is not straightforward. Both options do come with some risks, and those risks vary depending on the woman and the specific pregnancy.

Here’s what you need to know about a vaginal birth after cesarean section and what you should discuss with your doctor if you want to try delivering your next baby vaginally.

1) What is a vaginal birth after cesarean delivery (VBAC)?

If you’re pregnant again and your last baby was born via cesarean section, this time you have two choices about how to give birth:

  1. an elective repeat caesarean section (ERCS), or
  2. a VBAC. “VBAC” stands for “vaginal birth after cesarean” and refers to giving birth through the vagina after a woman has already had a C-section. Vaginal birth also includes deliveries assisted by forceps or ventouse.

Planning for a vaginal birth after caesarean (VBAC) or choosing an ERCS have different benefits and risks (see below).

A TOLAC (trial of labor after cesarean delivery) is the attempt to have a VBAC. If it is successful, TOLAC results in a vaginal birth. If it is not successful, you will need another cesarean delivery.

2) What are my chances of giving birth vaginally after having a C-section?

As long as you are an appropriate candidate for a VBAC, there are good chances to succeed: about 60 to 80% of women who attempt a VBAC will deliver vaginally.

There are certain factors which affect the chances of success, both related to the mother and the baby (see below). Nevertheless, it’s impossible to predict with certainty who will be able to have a vaginal delivery and who will end up with a repeat c-section.

A previous vaginal delivery, particularly previous VBAC, is the single best predictor of successful VBAC and is associated with a VBAC success rate of 85–90%.

3) Am I a good candidate for a VBAC?

Planned VBAC is appropriate for the majority of women who:

  • are pregnant with one fetus (as opposed to twins/multiples),
  • their baby is positioned head down (cephalic presentation),
  • have a pregnancy at term (37+0 weeks or beyond),
  • have had one previous lower segment caesarean delivery.

4) When is VBAC contraindicated?

Planned VBAC is strongly discouraged in the following cases:

  • Three or more previous caesarean deliveries. See below in case you have two previous C-sections.
  • The uterus has ruptured during a previous labor, as this increases considerably your risk (7 times higher) of a recurrent uterine rupture with the next pregnancy.
  • The previous caesarean section was “classical”.  In the vast majority of women, the uterus is cut horizontally, in its lower segment. This is called a low-transverse uterine incision. Rarely, a vertical incision in the upper uterus is required, this is known as a “classical” incision. Occasionally, a J- or T-shaped cut is performed. In both cases of vertical and J/T-shaped incision there is higher risk for uterine rupture. Therefore, it is very important to know which incision was performed in your previous C-section. You should note that the type of scar on your skin does not necessarily match the one on your uterus.
  • A previous uterine surgery, such as fibroid removal (myomectomy), as this increases the risk of uterine rupture.
  • There is other pregnancy complications that requires a C-section.There are certain absolute contraindications to vaginal birth that apply irrespective of the presence or absence of a scar (e.g. placenta previa)
  • Breech presentation (the baby comes with buttocks and/or feet first) or other abnormal presentations.
  • Multiple pregnancies (twins or more).


5) What factors reduce my changes of having a successful VBAC?

In general, the chances of success are lower in the following situations:

  • The reason for the previous c-section is likely to be problem this time around. Let’s say that a woman who already had a vaginal delivery and then had a c-section because her baby was breech (buttocks or feet first) is much more likely to have a successful VBAC than one who had a previous c-section after achieving full dilation and pushing for three hours, which may signal a narrow basin.
  • Labor is induced (did not start spontaneously).
  • You are older than 40 years old.
  • You are overweight.
  • The baby is big (over 4,000 grams estimated weight, or 8.8 pounds).
  • Advanced gestational age at delivery (more than 40 weeks).
  • Having a short time between pregnancies (less than 19 months).
  • You have preeclampsia (high blood pressure) at the time of delivery.

You should discuss with your practitioner about your individual chance of success and carefully weigh the benefits and the risks.

6) What are the benefits of a VBAC?

C-section is a major abdominal surgery, and as such is associated with certain increased risks as opposed to a vaginal birth. Therefore, a successful VBAC entails:

  • Shorter recovery period
  • Less post-partum pain.
  • Lower risk of infection.
  • Less blood loss, reduced need for a blood transfusion.
  • Less chances of needing an emergency hysterectomy (uterine removal).
  • Lower likelihood of damaging other organs (bladder and bowel).
  • Lower risk of developing a blood clot (thrombosis) in the legs (deep vein thrombosis) or lungs (pulmonary embolism).
  • Reduced risk of pelvic adhesions (internal scar tissue that forms between the organs, which may be responsible for chronic pain, infertility or intestinal obstruction).
  • Decreased chances of breathing problems for your baby. About 4-5% of babies born by planned C-section have breathing problems, compared with 2-3% following VBAC; the risk is  slightly higher if you have a planned caesarean section earlier than 39 weeks. In fact, breathing problems are quite common after caesarean delivery, but usually do not last long.
  • Many women would like to have the experience of vaginal birth, and when successful, VBAC allows this to happen.

If you plan to have more children, VBAC may help you avoid certain health problems linked to multiple cesarean deliveries. In fact, C-section complications, such as haemorrhage, emergency hysterectomy, bowel or bladder injury, adhesion formations are all higher with the increased number of cesarean deliveries. Moreover, every C-section you have raises your risk in future pregnancies of placenta complications, such as placenta previa (the placenta lyes low and covers the cervix) and placenta accreta (the placenta implants too deeply and doesn’t separate properly at delivery). Both conditions can result in life-threatening bleeding and a hysterectomy. If you know that you want more children, this may figure into your decision.

7) What are the risks of a VBAC?

  • One of the most feared complications of a VBAC is the possibility of uterine rupture, that is, the scar of the uterus tears or separates. Even if you’re a good candidate for a VBAC, there is a 0.7% risk (that is, 7 out of 1000 woman undergoing a VBAC) that your uterus will rupture at the site of your C-section incision. If this happens, it may result in severe blood loss for you, eventually life-threatening, and possibly oxygen deprivation for your baby, which may result in brain damage (in 8 out of 10,000 cases) or even death (in 2-3 out of 10,000 cases). While this risk is very small overall, it is higher as compared to a scheduled C-section.
  • Regardless of uterine rupture, VBAC carries in increased risk of long-term neurological damage or even death. Again, the risk is very small, but is higher in women who undergo an unsuccessful VBAC than in women who have a successful vaginal delivery or a scheduled C-section.
  • If you end up being unable to deliver vaginally, you could endure hours of labor only to have an unplanned C-section. This may be very frustrating for certain women, as their expectations for a vaginal birth are not fulfilled.
  • You may need an assisted vaginal birth using ventouse or forceps, which may lead to increased risk of having a tear involving the muscle that controls the anus or rectum (third or fourth degree tear).
  • You may need to have an emergency C-section during labour. This happens in 25% of women. An emergency cesarean carries more risks than a planned C-section. The most common reasons for an emergency caesarean section are if your labour slows or if there is a concern for the wellbeing of your baby.

You should note that while a successful VBAC is less risky than a scheduled repeat C-section, an unsuccessful VBAC requiring a C-section after the onset of labor carries more risk than a scheduled C-section. And the risk of complications is even higher if you end up needing an emergency cesarean.

8) Can I have a VBAC if I have two prior C-sections?

According to the American (ACOG) and British (RCOG) guidelines, women who have had two prior lower segment caesarean deliveries may be offered VBAC after careful counselling. Nonetheless, they should be aware that the risk of uterine rupture is increased up to 5 times (0,9 to 3,7%).

VBAC after 2 previous C-sections is highly controversial, and may not be acceptable for certain physicians or institutions.

9) What to expect during a VBAC 

  • VBAC should take place in a hospital or maternity that can manage situations that threaten the life of the woman or her fetus, and should NOT be attempted at home.
  • You should meet all the criteria, and have none of the contraindications for VBAC above-mentioned.
  • Factors that may reduce or increase the likelihood of success will be thoroughly discussed, and are different for each woman and each pregnancy.
  • Best candidates for VBAC are those women whose labor starts spontaneously, as induced labor (started with drugs or other methods) reduces the chances of a successful vaginal delivery and carries 3 times higher risk of complications.
  • You will be advised to present yourself at the hospital at the earliest sign of labour for careful assessment.
  • Your baby’s heartbeat will be monitored continuously during labour; this is to ensure your baby’s wellbeing, since changes in the heartbeat pattern can be an early sign of problems with your previous caesarean scar.
  • An intravenous (IV) line is indispensable in order to promptly manage any eventual complication.
  • You’ll have to refrain from eating anything during labor in case you require an emergency c-section later.
  • You can choose various options for pain relief, including an epidural.
  • The following signs may be indicators of uterine rupture, and warrant an emergency C-section:
    • Persistent fetal bradycardia (the baby’s heart rate drops; this is the commonest sign of uterine rupture).
    • Vaginal bleeding.
    • Uterine scar tenderness.
    • Pain between contractions.
    • Cessation of contractions.
    • Pain “breaking through” the epidural analgesia, or excessive epidural requirements.
    • Palpation of fetal parts outside the uterus.
    • Haematuria (blood in the urine).

It is important that you understand that uterine scar rupture may be silent, and that even an emergency C-section may not prevent serious complications, both for you and your baby.

In conclusion:

  • Successful VBAC has the fewest complications.
  • The greatest risk of adverse outcomes associated with VBAC occurs when a VBAC results in an emergency caesarean section.
  • It is often impossible to predict who will be able to have a successful VBAC and who require a repeat C-section.
  • Spontaneous (not induced) VBAC has a 1:150 risk of uterine rupture.
  • Uterine rupture is a rare but potentially life-threatening condition, both for the mother and her baby.
  • Even an immediate emergency C-section may not prevent serious complications, both for the mother and her baby.
  • The absolute risk of severe fetal problems and death associated with VBAC are very low, but higher than for planned C-section.
  • Babies born via planned C-section have increased risk of neonatal respiratory problems, which are usually short-lived.
  • Planned C-section is associated with an increased risk of placenta praevia/accreta complicating any future pregnancies; other complications such as pelvic adhesions are higher as the number of C-sections increases.

VBACs are controversial, and it may be challenging to decide whether is the best choice for you. Find a practitioner willing to support VBAC, discuss with him/her your options. Give yourself plenty of time to inform yourself and consider carefully the pros and cons of each option.

References

  1. The American College of Obstetricians and Gynecologists (ACOG) – Vaginal Birth After Cesarean Delivery FAQ 070, December 2017 (For patients)
  2. ACOG Practice Bulletin Number 184 – Vaginal Birth After Cesarean Delivery, November 2017
  3. Royal College of Obstetricians & Gynaecologists (RCOG) –  Birth options after previous caesarean section – July 2016 (For patients)
  4. Royal College of Obstetricians & Gynaecologists (RCOG) –  Birth After Previous Caesarean Birth – Green-top Guideline No. 45, October 2015
  5. National Health System (NHS) UK – Clinical Guideline for: The Management of Vaginal Birth After Caesarean (VBAC). July 2016

Photo credits

1.Parents.com; 2.EvolutionaryParenting.com; 3.goldengateobgyn.org; 4.Healthymummy.com; 5.YouTube.com; 6.Scarymummy.com; 7.geoscripts.meredith.services

100 ESSENTIAL BRAZILIAN SONGS YOU MUST HEAR Part 7: The 2000-2010s

Contemporary music –in Brazil, France and elsewhere- has been greatly influenced by social media, video sharing and music streaming, all trademarks of the 2000s and beyond. Specifically for Brazilian music, this globalizing phenomena has had positive, as well as deleterious consequences: increased foreign songs topping the charts on one side, but also Brazilian mainstream music massively available to the rest of the world. The proof: songs like Mc Fioti’s “Bum Bum TamTam” with more than 1 billion! views on YouTube, and Michel Teló’s “Ai Se Eu Te Pego” with over 800 million views…

Despite globalization, Brazil internal music market has seen a meteoric increase in popularity of regional rhythms during this period, mainly sertanejo. Actually, sertanejo is Brazilian audiences‘ preferred music genre .

No one can deny that Brazil is a country with a powerful musical history. Going through all its music repertoire while preparing this series of articles, I can’t help but admire even more its distinct and perennial beauty. Are things changing though? Is Brazilian music going through a phase of decadence? This is an ongoing debate in the country nowadays… Many music critics are definite: today’s consumer society –they believe- leads to “consumable music”; moreover, they blame the universal predominance of sertanejo as responsible for the lack of musical diversification nowadays. “We always had good music and bad music in Brazil -says one critic- but there was a balance. At this time, at least 90% of what record companies release is totally disposable”. Some go even further and state that pagoda, sertanejo and electronic forró are “a tsunami of musical trash unprecedented in the history of Brazilian music”. Other critics are more optimistic. Véronique Mortaigne, writing an article in The Guardian, states that: “Brazil is surfing a musical new wave that is now reaching Europe”, making emphasis on the quality of certain musicians’ work “not afraid to mix the old and the new, irritating a few purists along the way”.

The debate could go on forever. What is certain is that there are still many bright examples of fine Brazilian music. Check out my list with some of the most remarkable songs of the 2000-2010s, go ahead and Brazilify” your playlist!

87) Bebel Gilberto – “Samba da Bênção” (2000) 

Bebel Gilberto is an extremely talented bossa nova singer, and it couldn’t be otherwise: she is the daughter of Joao Gilberto and Miucha, and the niece of Chico Buarque

She became worldwide known after the release of her amazing album Tanto Tempo.  This particular song was written by Vinicius de Moraes and Baden Powell; it was featured in the movie Eat, Pray, Love. Read more here.

 

88) Pato Fu – “Ando meio desligado” (2001) 

This psychedelic anthem was composed by the iconic band Os Mutantes in 1970; it was listed by Rolling Stone Brazil as the 50th greatest Brazilian song.

Of the many re-recordings the song has had, I like this one, by the Belo Horizonte band Pato Fu.

 

89) Gabriel o Pensador – “Até Quando?(2001) 

Known for his intellectual and controversial lyrics, rapper Gabriel o Pensador (“Gabriel the Thinker”) stepped into the limelight with his provocative composition “Tô Feliz (Matei o Presidente)” [I’m Happy (I killed the President)]. He has had a highly successful career since then, topping often the charts with his gold or platinum-certified albums.

Até Quando? (“Until when?”) was released in the album Seja Você Mesmo (mas não Seja sempre o Mesmo) (“Be Yourself (but not always the same”). Its compelling lyrics address the issue of conformism. It was highly praised by most critics and received an award at Brazil’s MTV Video Music Awards.

 

90) Cássia Eller & Nando Reis – “Relicário” (2001)

Cássia Eller is one of the most successful pop singers/composers in Brazil. Owner of a distinctive contralto voice, she was rated as the 18th greatest vocalist by Rolling Stone Brasil.

This beautiful song was composed by Nando Reis and was included in the live album Acústico MTV, where she sings it together with Reis; it is Cássia’s final album before her death on December 29, 2001 at 39 years old.

 

91) Tribalistas – “Velha Infancia ” (2002)

Tribalistas is a Brazilian musical supergroup consisting of Arnaldo Antunes (ex-Titãs), Marisa Monte and Carlinhos Brown (Timbalada). Their debut collaboration resulted in the popular album Tribalistas, which attained considerable popularity in Brazil and Europe. The curious thing with this popular group is that, despite their great success, they have rarely performed together, deciding to go on a world tour just now in 2018.

Among their most popular songs are “Já Sei Namorar” (included on the video game FIFA Football 2004), “Passe em Casa“, “É Você” and “Velha Infância“, played on the Brazilian soap opera Mulheres Apaixonadas.

 

92) Paulinho da Viola & Marisa Monte – “Carinhoso” (2003)

Alfredo da Rocha Vianna Jr. was not yet Pixinguinha when he began to be called a prodigy, enchanting with his unusual musicality and facility for instruments and improvisations. Considered till nowadays a musical genius,  Pixinguinha is regarded as  one of the greatest Brazilian composers of popular music, particularly within the genre choro. “Carinhoso“,  was recorded in 1928 and has remained as one of the most famous melodies of Brazilian popular music. Incredibly enough, he received heavy negative criticism at that time, with complaints that it was “too Americanized.”

From Marisa Monte to Elizeth Cardoso, from Paulinho da Viola to Francisco Alves, from Elis Regina to Marcelo Camelo, dozens of artists made their impassioned interpretations of “Carinhoso”; one of my favorites is this one, by Marisa Monte and Paulinho da Viola.

93) Zeca Pagodinho – “Deixa A Vida Me Levar” (2004)

Zeca Pagodinho is a singer and songwriter considered a great name of the genre samba and pagode. He has recorded more than 20 albums and has become immensely popular, not only due to his irreverence and jocosity, bur mostly due to his rare talent, praised by critics and consecrated artists.

This song gives name to his 2004 album Deixa A Vida Me Levar (“Let life take me”), it was extremely successful, becoming double-platinum certified.

 

94) Sergio Mendes feat. Stevie Wonder & Gracinha Leporace – “Berimbau / Consolação ” (2006)

The berimbau is a single-string percussion instrument. Originally from Africa, it was eventually incorporated into the practice of the Afro-Brazilian martial art capoeira. The instrument became worldwide known for being the subject matter of this song, which belongs to Baden Powell and Vinicius de Moraes.

Maybe one of the most famous versions of “Berimbau / Consolação ” is the one performed by Toquinho and Maria Creuza in 1970; nevertheless I love this version, featured in Sergio Mendes’ 2006 Album Timeless, with the participation of his wife, Gracinha Leporace and iconic American artist Stevie Wonder.

 

95) Vanessa Da Mata & Ben Harper – “Boa Sorte/Good Luck ” (2007)

Award-winning, chart-topping singer, composer, and novelist, Vanessa da Mata got her start writing songs for artists such as Maria Bethania and Daniela Mercury. Despite the strength of her voice, it took her several years until she finally decided to record her own material, releasing her self-titled debut in 2002. It was her next album, Essa Boneca Tem Manuel, however, that really pushed her into the limelight, aided by the strength of the single “Ai Ai Ai“. Three years later her third album, Sim, was released. Sim spawned the hit single “Boa Sorte/Good Luck“, a duet with Ben Harper, which peaked at number one in both Brazil and Portugal and was the most played song in Brazilian radio stations in 2008.

96) Criolo – “Subirusdoistiozin” (2011)

Criolo is a rapper and soul singer. With a career starting in 1989, he originally got a reputation as one of São Paulo most important rappers. After the release of his second album, “Nó na Orelha” (Knot in the ear), he saw his popularity grow beyond São Paulo to all Brazil and abroad, leading to a successful worldwide tour. He has been characterized as “ the most interesting and unruly representative of the Brazilian new wave”.

Nó na Orelha” mixes rap, afrobeat, hip hop, reggae, samba and brega. It received positive reviews and was considered the best national album of 2011 by the magazine Rolling Stone. From this album, “Subirusdoistiozin” (Two-Old-Guys-Died) is the most popular track; it describes the general waywardness of favela street culture.

 

97) Marisa Monte – “Ainda Bem” (2011)

Multi-awarded singer, composer, instrumentalist, and producer, Marisa Monte is considered one of Brazil’s greatest singers; in fact, Rolling Stone Brasil listed Monte as the second greatest singer of all time after Elis Regina. She also has two records (MM and Verde, Anil, Amarelo, Cor-de-Rosa e Carvão) among the 100 best albums of Brazilian music.

Ainda Bem (“Just as well”) belongs to her highly praised eighth record O Que Você Quer Saber de Verdade (“What do you really want to know”), was considered by Billboard Brasil the best album of 2011. Originally, “Ainda Bem” was composed by Marisa for Italian singer Mina, who included it in her 2011 album Piccolino.

 

98) Dominguinhos & Arthur Maia – “Lamento Sertanejo ” (2014)

An emblematic representative of the forro music genre, Dominguinhos has had success as a musician, both solo and as a sideman for consecrated artists like Luís Gonzaga, Caetano VelosoGilberto Gil, Gal Costa, and Maria Bethânia. But also as a composer, he has produced hits recorded for some of the most important Brazilian artists; he has also written cinema soundtracks and has won four Prêmio Sharp Awards.

This is one of his biggest hits, composed in 1941. Initially instrumental, it was later re-recorded by Gilberto Gil, who wrote its lyrics. The song has received countless recordings and has been included in the soundtrack of several films and soap operas. The original version is beautiful; this version though, by Dominguinhos himself together with the great Brazilian bassist Arthur Maia, it’s just beguiling.

 

99) Adriana Calcanhotto – “Felicidade” (2015)

Adriana Calcanhotto is an MPB (Brazil popular music) singer and composer revealed in 1990, who has had great success in Brazil and helped bring MPB back to the hit parade after the 1980s’ Brazilian rock period.

Felicidade (“Happiness”) was written in 1947 by the great samba-canção composer Lupicínio Rodrigues; it was re-presented to Brazil by Caetano Veloso in 1974 who made it widely popular. Calcanhotto included it in her fourth live album Loucura (“Madness”), which is a tribute to Lupicínio Rodrigues.

 

100) Tiago Iorc & Milton Nascimento – “Mais Bonito Não Há” (2017)

Tiago Iorc is one of Brazil’s new talents. Singer-songwriter and record producer, with his debut album Let Yourself In, he gained notoriety after several of Tiago’s songs were featured on major Brazilian primetime soap operas, TV ads and films. Let Yourself In was also released in Japan with great success and in South Korea, where the public granted Tiago a Best Foreign Artist Award.

In 2017, he partnered with the incomparable Milton Nascimento (who declared being Tiago’s fan) and recorded some songs for the purpose of a national tour. This exquisite song (“Nothing more beautiful”) is the result of this partnership.

 

See also: