VBAC or Scheduled C/S (What to do)??Thread
Jul 24, 2006 06:42 PM
I emailed a few months ago about my worry that c/s were on the rise due to "the fear of having large babies". Anyway, now I've got another issue that I'd like your opinion about. I'm haivng a really hard time making a decision on this one.
I’m just about 6 months along with my 3rd baby. I had 2 previous c/s's. I'm at a point where I feel like I need to make a decision about this birth. No one is really pressuring me (besides myself) but I just feel like I need to make some progress. I’ve even made an appointment with a therapist to have some cranio-sacral work done. I’ve heard great things about it and I’ve spoken with the therapist over the phone and she agrees that I have issues to work out with regards to my previous births – so much so that those issues may be hindering me from making a decision about this birth.
Anyway, I wish my decision was cut and dry, black and white – you know! My OB is a high risk OB (not that I'm high risk though) and after having an initial 2-hour consultation with him, he recommends another c/s but will support me through a vaginal birth if that’s my choice. I was thrilled once I heard that but then there are some other circumstances that are making me worry. I took references to so many studies on VBACs (with more than one prior c/s) with me when I spoke with him. I was not going to be told that my only risk factor for not being allowed a VBAC was that I had 2 previous surgeries. The good thing is that he assured me that that was not even a consideration for him. He said that if that were my only risk factor that he would definitely recommend a VBAC. However, after reading my post-op notes from both my previous surgeries he is more worried about the amount of scar tissue I have. Apparently I have an abnormal amount of it and the adhesions are covering most of my abdominal cavity including my bladder and bowel. So, of course if something happened during labor and they had to get baby out fast, there are 2 things to worry about 1) getting baby out fast enough and 2) he would have to cut through me and risk hitting my other organs. He didn’t say it in so many words but that’s what he meant. To be 100% honest with myself at this point, I’m more scared of surgical complications (i.e. nicking my bladder, etc) than the actual wish of a vaginal birth. Does that make sense? Sure, I want a vaginal birth so badly but I’m more scared of having a terrible recovery like last time. I expressed this him and he mentioned that I apparently had a pretty nasty infection after my last surgery (which is more common with women who labor and then have surgery) and that was probably why I felt so horrible and had such a bad recovery. My first c/s was for a breech baby and the second was due to baby's heart rate issues and me having a fever.
So, these are my 3 options….1) I can try for a VBAC 2) I can schedule another surgery (which scares the heck out of me) or 3) I could have another surgery but let myself go into labor naturally and then have the surgery.
After discussing my worries, my OB again encouraged me to go with the scheduled surgery so that he would be able to take more time with the surgery and hopefully there will be less risk to me.
I’m really frightened to admit that I’m leaning towards #3 ( a c/s but going into labor on my own) – mainly because with more “scheduled” conditions, I’m less likely to get an infection and have surgical complications. I think???
I feel like I’m just rambling on here. Like I said, I just wish things were more cut and dry. I feel like my background in childbirth education and all the knowledge that I have is really making this decision hard. I worry that I can’t get a straight answer from anyone. I know that some c/s are "true" necessities but when is that the case?? I've been such an advocate for normal birth and for unneccesary c/s's that I don't know what is best for me at this point.
I'm so research oriented - I just wish there were more research out there that pertained to c/s vs. VBAC risk and adhesions.
Jul 29, 2006 02:22 AM
You are right that there are no easy answers. Your ob has a sensible reason for recommending a c/sec, but there is another side: Every c/sec that you have will cause yet more dense adhesions. This increases your risk of ending up with chronic pain, or worse yet, a bowel torsion. Bowel torsion is a rare complication of adhesions, but it is a risk not just in the postpartum period but at any time in the future. Every c/sec also increases your risk of other serious complications as well as this recent study documents:
Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006;107(6):1226-32.
OBJECTIVE: Although repeat cesarean deliveries often are associated with serious morbidity, they account for only a portion of abdominal deliveries and are overlooked when evaluating morbidity. Our objective was to estimate the magnitude of increased maternal morbidity associated with increasing number of cesarean deliveries. METHODS: Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999-2002). RESULTS: There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively. CONCLUSION: Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery.
And, while the greater risk for surgical injury during an unplanned c/sec is a consideration, keep in mind that you have a 3 out of 4 chance of having a vaginal birth. In fact, your odds are probably higher because the study's percentage includes women who had c/secs for reasons that could repeat such as lack of progress whereas you did not:
Macones GA, Cahill A, Pare E, et al. Obstetric outcomes in women with two prior cesarean deliveries: is vaginal birth after cesarean delivery a viable option? Am J Obstet Gynecol 2005;192(4):1223-8; discussion 8-9.
OBJECTIVE: This study was undertaken to compare clinical outcomes in women with 1 versus 2 prior cesarean deliveries who attempt vaginal birth after cesarean delivery (VBAC) and also to compare clinical outcomes of women with 2 prior cesarean deliveries who attempt VBAC or opt for a repeat cesarean delivery. STUDY DESIGN: We performed a secondary analysis of a retrospective cohort study, in which the medical records of more than 25,000 women with a prior cesarean delivery from 16 community and tertiary care hospitals were reviewed by trained nurse abstractors. Information on demographics, obstetric history, medical and social history, and the outcomes of the index pregnancy was obtained. Comparisons of obstetric outcomes were made between women with 1 versus 2 prior cesarean deliveries, and also between women with 2 prior cesarean deliveries who opt for VBAC attempt versus elective repeat cesarean delivery. Both bivariate and multivariate techniques were used for these comparisons. RESULTS: The records of 20,175 women with one previous cesarean section and 3,970 with 2 prior cesarean sections were reviewed. The rate of VBAC success was similar in women with a single prior cesarean delivery (75.5%) compared with those with 2 prior cesarean deliveries (74.6%), though the odds of major morbidity were higher in those with 2 prior cesarean deliveries (adjusted odd ratio[OR] = 1.61 95% CI 1.11-2.33). Among women with 2 prior cesarean deliveries, those who opt for a VBAC attempt had higher odds of major complications compared with those who opt for elective repeat cesarean delivery (adjusted OR = 2.26, 95% CI 1.17-4.37). CONCLUSION: The likelihood of major complications is higher with a VBAC attempt in women with 2 prior cesarean deliveries compared with those with a single prior cesarean delivery. In women with 2 prior cesarean deliveries, while major complications are increased in those who attempt VBAC relative to elective repeat cesarean delivery, the absolute risk of major complications remains low.
I wish you were not facing this difficult decision. It is VERY good news, though, that your ob respects your right to make it.
-- Henci By: Henci Goer
All Times America/New_York
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