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    Find out what other moms-to-be are asking. Join in the discussion with Henci Goer, whose expertise is determining what the research tells us best promotes safe, healthy birth. If you would like to contact Henci outside of the Ask Henci forum, send an email to Goersitemail@aol.com.

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    Sep 19
    2006

    VBAC with Classical Incision

    Archived User
    Hi Henci,

    I had a classic cesarean in January 2006 (inverted-T incision) and a prior vaginal birth 4 years ago (2002). I am now 13 weeks pregnant and have found a maternal-fetal medicine specialist at a local teaching hospital that is open to me having a VBAC. I am so excited. He suggested continuous fetal monitoring - external and/or internal. He said no drugs would be used (Pitocin, Cytotec) and recommended against having any pain medication. Can you offer any other suggestions for a woman in my position?

    My goal is a healthy baby and mother. My son who was born in January passed away at 4 days old. Not because of the cesarean, but because he had a large sacrococcygeal teratoma that required surgery to remove it.

    Thank you for any feedback.


    By: ACOPE3374
    Archived User
    Apologies, but I'm trying to finish up a project with a hard deadline. I'll respond as soon as I can.

    -- Henci By: Henci Goer
    Archived User
    OK. Project is done, and I'm back online.

    Let me start by saying that I am neither a midwife nor a doctor, so, I don't give medical advice. That being said, I am aware from the research that all of the medications used to induce labor have been shown to increase the risk of scar rupture in at least some studies, likewise, making contractions stronger with oxytocin. The effect on the scar almost certainly depends on who is considered eligible for labor induction or augmentation and what medications, combinations of medications, and dosages are used. Since he doesn't want to induce you, you may wish to discuss the reasons he might normally recommend induction and your alternatives. In many cases, you will want to weigh the potential benefits and harms of awaiting labor vs. a scheduled cesarean. For more information on making an informed decision, go to Informed Decision Making, Informed Consent or Refusal on the Childbirth Connection website. I would guess that your care provider just wants to take a cautious approach in your case.

    I'm not sure why he wants to avoid pain medication -- although there are some good reasons for avoiding it in general -- but I could speculate that the use of epidural analgesia increases the likelihood of needing oxytocin to make labor stronger, which, as just mentioned, may increase the chance of having scar problems. A fairly common side effect of epidurals is episodes of slowing of the unborn baby's heart rate (bradycardia). Such episodes are also the most reliable symptom of scar problems. He -- and you -- may wish to avoid a "false alarm" leading to an unnecessary c/sec. However, if his concern is that an epidural may mask the pain of the scar opening, you should know that pain is not a reliable symptom.

    I strongly recommend that you hire a doula. This is likely to be a more than usually anxious labor for you and your partner, and continuous support from a trained and experienced woman can be helpful. If you are trying to avoid pain medication, a doula can really help you out there. For more information on doulas, go to Options: Labor Support, also on the Childbirth Connection website.

    Continuous electronic fetal monitoring has been shown to be the most reliable way of picking up scar problems as the most common symptom is, as I said, a substantial, sudden drop in the fetal heart rate. What is less clear in the research is whether picking it up via EFM actually improves outcomes. You may wish to discuss the pros and cons of external vs. internal monitoring. At one birth I attended as a doula where there was concern about the baby, the doctor compromised on using external monitoring as long as they were getting an accurate enough recording.

    You may also wish to know whether your care provider wants to put any other restrictions on you. For example, will he set limits on the estimated size of the baby? Set time limits for making progress in labor? The informed decision making page will help you here as well if you want to make informed choices about other elements of your care.

    You didn't ask me this, but you may be interested in knowing what the odds are of the scar opening and causing problems with a c/sec uterine incision that is not the standard type (low, transverse). A large recent study of 17,900 women planning VBACs reported a rate of scar rupture of 2% (2 out of 105) in women with classical (vertical), inverted T, or J incisions. This is compared with a rate of 0.4% in women with the usual type of uterine incision who labored spontaneously (no induction, no augmentation). Keep in mind, though, that while a scar rupture is serious and will almost certainly require an urgent cesarean, the baby is almost always fine. Here is the citation for the study in case anyone is interested:

    Landon MB, Hauth JC, Leveno KJ et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med 2004;351(25):2581-2589.

    Because you are at somewhat increased risk, you will probably want to labor in a hospital capable of handling an urgent cesarean 24/7. You describe your care provider as a "maternal-fetal medicine specialist," so you probably have that base covered, but it might not hurt to double-check. Hospitals in this category have obstetricians, anesthesiologists, and pediatricians in-house at all times, have at least a level II nursery (capable of handling fairly sick babies and stabilizing very sick babies for transport to a level III nursery -- a neonatal intensive care nursery), and 24-hr blood banking.

    As you ponder your choices, be sure to take into account whether there is any chance at all that you will have another pregnancy. The risks of a number of serious, life-threatening complications escalates for the next baby with each successive c/sec. There is also increasing risk of dense surgical adhesions, which poses increased risk to you of surgical injury, should you ever need abdominal or pelvic surgery in the future, as well as increasing your risk of experiencing chronic pain and the possibility, although still rare, of experiencing a twisted bowel at some time in the future.

    -- Henci

    By: Henci Goer
    Archived User
    Hi Henci,

    Thank you for your response.

    The hospital where I plan to birth is highly capable of handling emergency situations (Shands Jacksonville-Florida) and the maternal-fetal medicine specialist/OB has done much research on VBACs and the use of induction/augmentation agents. I do plan to hire a doula and my former midwife has also asked to attend the birth. So, I feel very comfortable being with them.

    The uterine rupture rate you specified sounds even better than the statistics I've read (upward to 7%). I feel OK with those odds (over having a repeat cesarean).

    The MFM recommended no pain medication for both reasons you stated: it could mask uterine rupture pain (although this is not reliable) and it could affect the baby's heartrate. I do not want any "false alarms" which may contribute to a c-section. I personally would rather have a drug-free birth as well (for many reasons).

    I plan to talk to the MFM about using external fetal monitoring if everything is going smoothly. I do not want internal monitoring (for infection reasons and personal reasons) unless the external monitor is not picking up accurately.

    I do not know if we plan to have another pregnancy after this one but it is a possibility. Just another reason to avoid a repeat c-section.

    BTW...I am just finishing reading your book, Obstetric Myths Vs. Research Realities. I picked up some very good points.

    Thank you again,
    Angie By: ACOPE3374
    Archived User
    It sounds like you are in good hands and well on your way to planning the safest possible birth. You are also wise to take into account that another pregnancy, intended or not, is a possibility if you are not planning to do something permanent about preventing it.

    The rate that I have seen bandied about in the literature for scar rupture of a classical incision is even higher than 7%. After reading the Landon 2004's statistic, I looked up the sources for the higher number. Turns out it came from two older studies from back in the days when a fair number of classical uterine incisions were still being done, but these studies did not distinguish between scar dehiscence (a harmless window) and scar rupture (the scar opens completely and causes symptoms). Landon 2004 did, as do all of the more recent studies and reviews.

    If I may make a suggestion, Ob Myths is really dated. In fact, I'm working on a new edition, although it won't be out for awhile, a couple of years at least. Thinking Woman's Guide to a Better Birth is more recent.

    -- Henci By: Henci Goer
    Archived User
    Henci,

    I read Thinking Woman's Guide to a Better Birth during my previous pregnancy (we read it during our Bradley class).

    I'm going to look up Landon's study. I may have already come across it (I've done so much research on this subject). We're out of town at the moment so I can't look up my stash. Thanks for the reference. By: ACOPE3374
    Archived User

    Hi Henci and all,

    I just wanted to update this posting to report that I had an intervention-free vaginal birth after classic cesarean on 3/29/2007. I labored at home for less than 6 hours and arrived at the hospital 26 minutes before our daughter was born. I was complete upon arrival and she came out with 3 contractions. I will say this birth was the most rewarding event in my life. It was significantly empowering. I am quite thankful that I didn't experience uterine rupture and found a supportive provider who respected my wishes to VBAC (although he didn't make it to the birth because of the brief time I was in labor there).

    Thank you for your feedback during pregnancy!

    Angie

    Henci Goer

    I am absolutely thrilled for you! I know personally that an empowering birth experience can be a life-changing event--and that the reverse is also true.

    I am sure your hands are full with your new baby and your older child, but if you can find the time, it might help others if you would write the hospital telling them how much it meant to you to have a flexible care provider who was willing to work with you and who respected your right to make informed decisions about your care.

    -- Henci

    Archived User
    I am 37 weeks pregnant with our third child. We have 2. 5 year old twins. Our son was born vaginally and our daughter was born by emergency c-section. My cervix closed on the doctors arm and when she pulled her arm out, my cervix tore and her umbilical cord came out. Somehow I ended up with a low transverse incision with a curve up one side (j incision). I've been fighting doctors left and right. We are military and don't have 100% control of the care that I've been getting. I've decided to attempt a medicated free VBAC. It is hard to find anyone out there with a VBAC under their belt that is not from a low transverse incision. I am trying to find others out there to help with the moral support. It is hard when it feels like you don't have much support. My husband and family is 100% behind me, I just wish more doctors and hospials were more supportive. Luckily for me I have found a great midwife who is behind me, but a hospital that is fighting me tooth and nail.
    Archived User

    Hi.

    Please could someone give the contacts of any caregivers in the USA or Canada that is willing to handle VBAC after a Classical Incision? I am pregnant and don't want to go through the traumas of a CS again.

    Regards,

    Eby.

    Henci Goer

    I hope someone out there responds, but I have to say that it's a long shot. I suggest you get in touch with people at the International Cesarean Awareness Network (ICAN). If anyone would know who might be willing to take you on, they would. The ICAN website might have helpful advice too. It should be your absolute right to give informed refusal to surgery, but unlike any other patient, it is a right denied to pregnant women. Here are some agencies that affirm that right:

    Office of Personnel Management HIPAA Consumer Rights and Responsibilities. Appendix A. Consumer bill of rights and responsibilities. Chapter four:  Participation in treatment decisions.

    “In order to ensure consumers' right and ability to participate in treatment decisions, health care professionals should:

     

    Provide patients with easily understood information and opportunity to decide among treatment options consistent with the informed consent process. Specifically,

     

    Discuss all treatment options with a patient in a culturally competent manner, including the option of no treatment at all. . . .

     

    Discuss all risks, benefits, and consequences to treatment or nontreatment.

    Give patients the opportunity to refuse treatment. . .

     

    Abide by the decisions made by their patients . . .  consistent with the informed consent process.”

    Department of Health and Human Services. Chapter IV -- Centers for Medicare & Medicaid services, Department of Health and Human Services: Part 482--Conditions for participation for hospitals. In: National Archives and Records Administration; 2005.

    “A hospital must protect and promote each patient’s rights. . . . The patient’s rights include . . . being able . . . refuse treatment. . . . The patient has the right to be free from all forms of abuse or harassment"

    The Joint Commission. Speak Up: Know Your Rights. Note: "The Joint Commission" is formerly "Joint Commission on Accreditation of Healthcare Organizations"

    ·         “You have the right to be informed about the care you will receive. . . .

    ·         You have the right to make decisions about your care, including refusing care. . . .

    ·         You have the right to be listened to.

    ·         You have the right to be treated with courtesy and respect.”

     

     

     Please let us know how things work out for you.

    -- Henci

    Archived User

    My VBAcC took place at Shands Hospital-Jacksonville (FL). The maternal-fetal medicine (MFM) specialist who worked with me did not consent to a VBAcC on the record but supported me off record.

    Henci Goer

    I am sooo happy for you! Congratulations!

    -- Henci

    Archived User

    hi!  i happened to stumble across this thread and wanted to add some info.  i had a vba3c after an initial inverted T incision this past August.  it was a perfect, completely drug-free delivery.  i also showed up at the hospital complete and my baby was born shortly after.

    my provider was very supportive, and also does vbac's after verticle and J incisions.  his name is Fred Cummings, in Denton, TX.  i have also heard that Dr Tate in Atlanta GA also takes these incisions for vbac. 

    good luck to other mommas out there!

    Archived User

    one more thing... there is a yahoo support group out there for women with special scars, im not able to post the link but it's called Special_Scars-Special_Women

    lots of good info and support there for mommas wanting to educate themselves and receive support from others with similiar experiences.  hope that helps!

     

    Archived User

    Hi,

    I wanted to chiime in and say that I also had a classical cesarean.  Many of the details of my firstborn child's arrival were similar to the lady who wrote in first.  My daughter lived for 3 precious days.  The surgery and recovery period were considered to be normal but I couldn't bear to have another one.  My husband and I chose to have a home VBAC in spite of potentially outdated statiscs regarding uterine rutpure.  We know that is the path God paved for us to have a normal birth.   We intentionally spaced the births 25 months apart to increase the likelhood of success.  It also gave us much needed time for healing, both emotionally and physically.  My son was born via VBAC at home with a  midwife.  During labor my baby and I were carefully monitored and would have transported to our closest hospital (10 minutes away) if the need arose. My son was born at home, weighing in at 10 pounds.  :-)  It was a healing birth in many ways.

     

    Henci Goer

    Thank you for sharing your story. ~ Henci


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