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    Questions? Ask Henci!


    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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    Archived User
    Hi Henci and others,

    I'm Ruby, and while I've read your book "Thinking Woman's Guide" a few years back, I have just found this forum today.  I'm wondering if you can offer an opinion and/or links to any research relevant to my situation.

    I had a LUCS in 2003 with my firstborn 46.5 hours after ruptured membranes and failed active management (synto for 17 hours etc).  I don't think I was physically ready for labour, and after conversations with a midwife, think it is likely I had a fluid leak rather than ruptured membranes.  Still, we had fought hard (which wasn't fun) to delay, delay, delay all interventions.

    In 2006,  I again fought for one-to-one midwifery care and planned a homebirth.  First sign of labour again was broken membranes, but labour started naturally.  Stalled after 17 hours or so, at same dilation (4cm) as with No. 1.  Ended up transferring and having a non-emergency casear.  Found out some 6 or 7 months later that No. 2 had craniosynostosis (premature fusion of skull sutures) and that most babies with cranio are casear born. 

    I now feel conflicted - plan for the best damn c/sec, or plan for another VBAC.  I would like 1-to-1 care, but it is impossible legally in my region - a midwife cannot be privately employed.  A doula is a possibility, but I have had such exceptional midwifery care, it's hard to think about that, too.  So I a, currently going through the Australian public system, under the "care" of an interventionist Ob who is not supportive of VBA2Vs (the only woman she "allowed" to labour after 2 caesars ended up with a dead baby.  Our first appointment was truly a joy...).

    This pregnancy is twins, and Baby 1 is currently breech (at 31 weeks) but not engaged.  If the babe stays butt down, I think I will plan a c/sec at 40 weeks. Both of our children were born at 40 weeks (and a couple of days).  However, I would like to have good peer reviewed info to show the Ob that going into labour bnaturally/in the babies time is the best thing to do.  It is my gut feeling that it is, but I can't find researched proof that waiting for labour before having a c/sec is best.

    I also feel inclined to labour at home for as long as possible before transferring, if (and really only if) Baby 1 is head down and it is earlier than 40 weeks, because I think a VBAC might be more successful in that case.

    I know you can't make a decision for me, but if you've got the time to offer your thoughts, I would really appreciate it.

    Regards,
    Ruby
    Henci Goer

    My heart goes out to you. You are between a rock and a hard place. The problem is not so much the two prior caesars; a well-done large study says that having multiple prior caesars does not substantially increase the risk of scar rupture:

    Landon MB, Spong CY, Thom E, et al. Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery. Obstet Gynecol 2006;108(1):12-20.

    No, the bigger problem is that you are also carrying twins and Twin A is breech.

    No one should tell you what to do, because there are risks that increase with accumulating cesarean scars too, but I think maybe a planned cesarean may be your best choice. As for the timing, that is less clear. There is evidence that non-labor cesareans result in more respiratory problems than when the woman has labored, but the difference is small in pregnancies that have reached 39 weeks. I don't know how carrying twins might affect that. There is also evidence that you are less likely to experience an operative injury or an infection if the caesar is planned than if it is done during labor.  

    If you decide to, as you say, plan for "the best damn c/sec," can you choose a more empathetic ob/gyn to work with? As for what that might constitute, follow the link to "Tips and Tools" for cesareans on the Childbirth Connection website, and scroll down to the section on having a safer and satisfying experience. If you decide on the VBAC, I recommend laboring in a hospital that can handle an urgent cesarean and babies that may need special care at delivery 24/7. That would mean in-house ob, anesthesia, and pediatric staff, and at least a Level 2 nursery, which is a nursery that can handle moderate problems and stabilize sicker babies for transport to a neonatal intensive care unit. Even better would be a hospital with a NICU.

    -- Henci

    FYI: I'm coming to Australia to do a speaking tour in September. I'll be in Perth on the 6th, Melbourne on the 14th, Brisbane on the 17th, and the Gold Coast on the 19th.

    Archived User

    In the Public system in Australia you have very little change of birthing in the public system with a VBAC let alone twins with one breech.  only 17% of women have a sucessful vbac here.  You can always give me a call ( I'm in South Australia) and I will help you find someone in your state to support your choices.

    Henci why aren't you coming to South Australia (Adelaide)? 

    Lisa Barrett  Independent midiwfe

     

     

    Archived User

    Ruby, Independent midwifery is Legal all over Australia although Not encouraged.  Sometimes you have to travel home from home but it's all worth it for the right care provider.

    Sorry for two mails and repeating myself in the first.  I can't find an edit button.

     

    Archived User
    Thank you, Henci & Lisa for taking the time to reply.

    I spent far too long awake and worried last night; the work and worry of pregnancy in managed care!  I am not sure whether to keep hoping Twin 1 will turn and then plan on trying for a VBAC.  I feel desperately afraid that a planned c/sec will end badly anyway; with something going wrong if I fight to make it more "mother friendly".  The ob that I have seen has not helped me feel safe or secure on either front.  My husband and I are wondering if getting a private ob is a better solution - although a lot more costly.  They would not be pro-VBAC, but we may be able to negotiate more positive care.  A VBAC is only an option in my mind if Twin 1 is not breech. 

    Is there any available research on muliple birth/VBACs?

    Lisa, I have some great contacts in Darwin, with really supportive midwives but to the best of my knowledge, there is no one available to employ independently.  I know the midwives in the Home Birth Group here pretty well.  I am still hoping to have a midwife 'allocated' to me through the public system -assuming we remain in the public system - who will be able to give us 1-to-1 care.  I would be interested in hearing more about independent midwifery elsewhere, though.  It isn't likely that I would relocate, but it is possible I could stay with family in Adelaide.

    Henci, I hope you enjoy your trip Down Under.  It's a long way to come, but in my opinion, there's not many places on earth better!  I won't be in any of the cities you are, but will be glad to pass on the dates and info through the birthing community here.  I'll keep an eye on your website for a pdf flyer or similar.

    Regards,
    Ruby
    Henci Goer

    You can find more details on my speaking engagements on my own website at www.HenciGoer.com/talks, except for the Brisbane one. Details haven't been decided yet, so I haven't posted anything on that one. There is research on twin VBAC, most recently a large sample from a national U.S. dataset. The risk of scar rupture was similar to that found in some studies of singleton gestations: 0.9% or 9 per 1000. In other words, there is a 99% chance that the scar will cause no problems.

    Ford AA, Bateman BT, Simpson LL. Vaginal birth after cesarean delivery in twin gestations: a large nationwide sample of deliveries. Am J Obstet Gynecol 2006;195:1138.

    I do not know whether having two prior cesareans will affect that, but it shouldn't increase the risk greatly. We have another large study that found that multiple prior cesareans did not increase scar rupture risk.

    Landon MB, Spong CY, Thom E, et al. Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery. Obstet Gynecol 2006;108(1):12-20.

    If you decide to go for the VBAC, avoid induction and oxytocin augmentation. Most, although not all, studies find they increase the risk of scar rupture and decrease the likelihood of VBAC.

    -- Henci


    All Times America/New_York

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