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
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
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.
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.
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.
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
Lisa Barrett Independent midiwfe
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.
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
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
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.
All Times America/New_York
Please note that this Forum is intended to help women make informed decisions about their care. The content is not a substitute for medical advice.