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Subject: vbac with prior CPD

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nancywinston (guest)
08/28/2008 9:27 AM Quote Reply
Hi Henci
(From Canada)
I am planning a vbac after having a cesarean birth 2.5 years ago for failure to progress, unengaged baby (She was still floating) and no dilation after high dose pit and amniotomy.  My daughter was only 7 lbs and I did go into labour on my own. There were no decelerations at all. I had contractions 1-2 minutes apart 45-60 seconds for 24 hours.  My MW doesn't have much of faith and tells me my chance is very low (less than 5%) if I started labour at 41.5 with an unengaged baby. Feeling my pelvis, she feels it is misshapped. I see a chiropractor weekly for pelvis treatment and he will try to help, but states my pelvis is very out of alignment. Prior to my first pregnancy I was a nationally ranked marathon runner and had a very intense training schedule. I continued to jog throughout my pregnancy, workout, swim, yoga , ect... truely believing my physical fitness would help me during labour. The MW and Chiro believe I had muscles that were too tight and combined with my pelvis issue. I just don't beleive my body isn't capable of a natural birth. The problems are the road blocks In order to have a vbac, I must see an OB at 30 weeks and normally they will not let you go over 40 weeks... I can't find any research that indicates going post 40 weeks (which I really beleive I will) increases the risk of uterine rupture. I plan on acupunture, moxibustion and nipple stimulation to induce labour naturally. I know prostaglandins are contraindic08/28/2008ated, but they will allow oxytocin in Canada. Do you have any research that indicates it to be a higher risk after 40 weeks so long as baby is good?
The other issue is they want you to be admitted as soon as you are in early labour. I was planning on prolonging calling the midwife so I can stay home a little longer...Noramlly uterine rupture would occur in active labour anyway? The other issue is of course CEFM which i think I can deal with... we don't have any water proof ones.. but maybe I can convince the midwife to allow me to labour in the tub and have very frequent monitoring with a doppler.
I also do not want oxytocin for induction or augmentation and will try to avoid.
So, I will continue with chiro, breast stroke, jogging and remaining physical. I will try to naturally iduce labour, i will have a doula and plan to go without an epidural (Had one after 18 hours last time, after augmentation)  and hope to not go into the hospital until active labour. My main question is research on going post dates... what can I present to the OB when they want to induce with pitocin go right for the c-section. Also, is it safe for me to consider staying at home in early labour?
I love your forum and also your book! Thanks for your amazing knowledge.
Nancy
Henci Goer
Posts:0
08/29/2008 9:56 AM Quote Reply

You are in luck insofar as my having current information about pregnancy duration and scar rupture. I have just finished reading and digesting studies for the VBAC chapter in the forthcoming new edition of  Obstetric Myths Versus Research Realities. I found a systematic review (Lieberman 2001) and three studies that address VBAC after longer pregnancy duration vs. shorter duration. The systematic review did not find a statistically significant (meaning unlikely to be due to chance) increase in scar rupture rate with longer duration. One of the studies did not find a significant increase in scar rupture after taking induction and augmentation (giving oxytocin to make contractions stronger) into account, although there was a slight excess in the group (0.5%) at or beyond 41 wks vs. less than 41 wks. (Coassolo 2005). The other two found an excess that was explained by the excess use of induction in the group with longer pregnancy duration (Hammoud 2004; Zelop 2001). In other words, according to the medical research, you are not at excess risk of scar rupture unless you are induced. I should add as well that studies report a consistent association between inducing VBAC labors and lower VBAC rates, which makes inducing labor batting 0 for 2.

I don't have any data on timing of scar rupture, but you should have the right to make informed decisions about your care, including informed refusal of your care provider's recommendations. And there is much to be said for doing whatever helps maximize your chances for vaginal birth, which, as you have realized, includes feeling relaxed, confident, and encouraged. Maximizing your chance for VBAC minimizes your chance of experiencing the harms associated with any individual cesarean surgery as well as the likelihood of serious harms that escalate with accumulation of cesarean surgeries.

One more idea that is totally in the realm of anecdote and speculation. I have heard that athletes and dancers--women who are used to having exact and complete control over their bodies--may have trouble letting go of control and letting the labor take over, which may interfere with progress. You might look into strategies to help you do this if you think this may be an issue for you. 

-- Henci

Coassolo KM, Stamilio DM, Pare E, et al. Safety and efficacy of vaginal birth after cesarean attempts at or beyond 40 weeks of gestation. Obstet Gynecol 2005;106(4):700-6.

Hammoud A, Hendler I, Gauthier RJ, et al. The effect of gestational age on trial of labor after Cesarean section. J Matern Fetal Neonatal Med 2004;15(3):202-6.

Lieberman E. Risk factors for uterine rupture during a trial of labor after cesarean. Clin Obstet Gynecol 2001;44(3):609-21.

Zelop CM, Shipp TD, Cohen A, et al. Trial of labor after 40 weeks' gestation in women with prior cesarean. Obstet Gynecol 2001;97(3):391-3.
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