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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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    Jul 20
    2009

    VBAC after 2 emergency c-sections

    Archived User

    I was given your name by a doula I had used with my second child's birth. She recommended I contact you.

    I had 2 prior c-sections. Both were emergencies and both when in active labor at 8 cm. My oldest went into distress and they lost his heartbeat. My doctor was very pro VBACS, so we attempted one. However, my second also started to show signs of distress. Adding the fact that I had back labor (which supposedly progresses much slower) and that the umbilical cord was around my son's neck, they performed my second c-section.

    My youngest is now 4 1/2 and I am currently pregnant with child number 3 (19 1/2 weeks). My OB had still recommended I do VBAC, however, due to the huge malpractice insurance expenses, he has dropped OB.

    I just switched doctors partially because the first OB I started with refused to even discuss VBAC and insisted on c-section (and I didn't really like her as a doctor in general). It took me some time, but I found a doctor that the staff said has done VBAC after 2 c-sections in the past. I saw him last week for the first time, and of course there is a catch. He has performed VBAC after 2 c-sections in the past, but now the hospital won't let him. He agreed to talk to the head OB of the hospital and with me signing a waiver and the head OB's OK, he'd agree to do a VBAC. I need to wait until the next visit for the final answer (in a month).

    I contacted the doula again. She's not happy with the answer and thinks I should keep looking.

    I'm not sure where to take it from here.

    Henci Goer

    Let me start by saying that I'm sorry that you have had two such difficult experiences. I suggest that you find out more about your doula's concerns because perhaps she knows something specific about this hospital or doctor, but from where I'm sitting, getting a VBAC at all is a coup these days, and getting one after two prior c/secs is a miracle.

    This is not to say that it should be this difficult. Certainly there are risks associated with planning VBA2C, but there are also serious risks associated with accumulating cesarean surgeries. Moreover, the likelihood of the scar giving way is not any higher with multiple prior cesareans (see below), a point you and your current ob may wish to make in your discussion  with the head OB. You may also wish to point out respectfully and calmly that it is your right to make informed decisions about your care, including refusal of surgery. Take along this booklet on patient's rights, which is put out by the Joint Commission, the organization that certifies hospitals.

    While I am at it, your best option for safe vaginal birth is to start labor on your own and continue laboring without stimulation. This means avoiding an epidural if possible because epidurals increase the likelihood of needing I.V. oxytocin (Pitocin or "Pit"). It is true that scar problems are more likely in VBAC labors after the due date, but the excess rate is in women who were induced. (I can provide more detailed information on this if you or your ob would like.)

    You will definitely want a doula if for no other reason than you and your partner are likely to be laboring in an environment hostile to VBAC, and you may need support and encouragement to counteract this. I would have a frank discussion with her, though. Seeing as she is uncomfortable with your choice, you do not want her to become part of the problem instead of part of the solution.

    While I am also at it, I refer you to Lamaze's Six Healthy Birth Practices.

    I hope that this next birth goes as you would hope. Please let us know how things work out.

    -- Henci 

     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.

      OBJECTIVE: To determine whether the risk for uterine rupture is increased in women attempting vaginal birth after multiple cesarean deliveries. METHODS: We conducted a prospective multicenter observational study of women with prior cesarean delivery undergoing trial of labor and elective repeat operation. Maternal and perinatal outcomes were compared among women attempting vaginal birth after multiple cesarean deliveries and those with a single prior cesarean delivery. We also compared outcomes for women with multiple prior cesarean deliveries undergoing trial of labor with those electing repeat cesarean delivery. RESULTS: Uterine rupture occurred in 9 of 975 (0.9%) women with multiple prior cesarean compared with 115 of 16,915 (0.7%) women with a single prior operation (P = .37). Multivariable analysis confirmed that multiple prior cesarean delivery was not associated with an increased risk for uterine rupture. The rates of hysterectomy (0.6% versus 0.2%, P = .023) and transfusion (3.2% versus 1.6%, P < .001) were increased in women with multiple prior cesarean deliveries compared with women with a single prior cesarean delivery attempting trial of labor. Similarly, a composite of maternal morbidity was increased in women with multiple prior cesarean deliveries undergoing trial of labor compared with those having elective repeat cesarean delivery (odds ratio 1.41, 95% confidence interval 1.02-1.93). CONCLUSION: A history of multiple cesarean deliveries is not associated with an increased rate of uterine rupture in women attempting vaginal birth compared with those with a single prior operation. Maternal morbidity is increased with trial of labor after multiple cesarean deliveries, compared with elective repeat cesarean delivery, but the absolute risk for complications is small. Vaginal birth after multiple cesarean deliveries should remain an option for eligible women. LEVEL OF EVIDENCE: II-2.

    Archived User

    The story now gets more complicated. I just went for my midway sonogram. As of now it looks like the placenta is over the cervix and the scar area of my prior 2 c-sections. I have to go back at week 32 to see if the placenta had moved at all and to make sure it didn't go through the uterine wall.

    Henci Goer

    I am sorry to hear this. Please get back to us when you know whether the placenta has moved away from covering  the cervix (placenta previa) and whether it has grown into the underlying muscle (placenta acreta).

    -- Henci

    Archived User

    Hi Henci,

    I'm not pregnant but have had two cesarean sections, like the previous woman who posted has, although mine were planned (1st due to breech presentation, 2nd planned because I had gone to 41+5 (this second one was completely against my will)).

     

    What are the chances of placenta accreta in subsequent pregnancies and if I was to have a third child and had placenta accreta (placenta over the scar), would this mean I could not have a VBAC?

     

    Thanks for taking the time to read this!

    Henci Goer

    Here is the answer to your question. I can't help adding that your question justifies the work I put into achieving my goal for this chapter, which was to supply specific data for decision making as opposed to the more usual vague generalities of "increased" or even "slightly increased" risk.  If you experienced placenta previa (placenta covering the cervix) or accreta (placenta growing into the uterine muscle, you would definitely need another cesarean.

    -- Henci

    Excerpt from the manuscript of the VBAC chapter for the second edition of Obstetric Myths Versus Research Realities to be published by University of Michigan Press.

     

    Two studies reported an increase in placenta previa with increasing number of prior cesareans. The first, of 31,102 women, reported a rate of 3-4 per 1000 with 0-1 prior cesareans and 7 per 1000 with 2 prior cesareans (Getahun 2006). The second, of 155,670 women, reported 3 per 1000 with 0 prior cesareans, 8 per 1000 with 1 prior cesarean, 20 per 1000 with 2 prior cesareans, and 42 per 1000 with ? 3 prior cesareans (Miller 1997). . . . The risk of placenta accreta also increases with accumulation of cesarean surgeries. A study of 30,100 nonlabor cesareans reported an accreta rate of 2-3 per 1000 with 0 or 1 prior cesarean, 6 per 1000 with 2 prior cesareans, 21 per 1000 with 3 prior cesareans, 23 per 1000 with 4 prior cesareans, and 67 per 1000 with ³ 5 prior cesareans (Silver 2006).

     

    Getahun D, Oyelese Y, Salihu HM, et al. Previous cesarean delivery and risks of placenta previa and placental abruption. Obstet Gynecol 2006;107(4):771-8.

     

    Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol 1997;177(1):210-4.

     

    Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006;107(6):1226-32.

     

    Archived User

    Thanks for that info!  When is your book coming out?

    I'm still confused by placenta accreta, does this mean that a placenta growing over scar tissue means outright no to VBA(2)C?  If yes, why?

    Henci Goer

    Placenta accreta doesn't just mean the placenta is growing over the scar, although this is the reason it is thought to occur much more commonly, although it is still rare, in women who have had prior cesareans or other uterine surgery than in women who haven't. Normally, the embryo nestles into a thick layer of loose cells that line the uterus rather like a layer of leaves on the ground, and this is where the placenta develops. (This is, by the way,  the layer that is shed if conception does not occur.) After birth, that layer allows the placenta to peel easily away from the muscular wall of the uterus rather like peeling a navel orange. With placenta accreta, the placenta grows into the muscular wall and sometimes even through it and into adjacent organs, which means it cannot release from the uterus when it is supposed to. As I think about it though--and keeping in mind that I am not a midwife or doctor--I don't see a reason why a woman couldn't have a VBAC, that is, unless the accreta was in combination with a previa, which it very often is because the uterine scar is close to the cervix. Severe hemorrhage, the risk of accreta, wouldn't arise until after the birth. You wouldn't want to try it, though, except a hospital that could deal with obstetric emergencies 24/7.  

    -- Henci

    Archived User

    Miracle of Miracles. I have been monitored for my placenta previa the entire pregnancy. My doctor wanted to do a c-section at week 37. I was being monitored with sonograms and NSTs (due to high levels of amniotic fluid) for about a month before. The day before the scheduled surgery, the doctor wanted to preform an amnio to verify the baby's lungs were developed. As they were doing a sonogram prior to the amnio, they discovered that the placenta had just moved up and was now low laying, and no longer previa. They commented that it is very uncommon for it move so late in the game, but canceled the amnio, pre-op and surgery.

    I will be 38 weeks tomorrow. For now they are scheduling a c-section at week 39, but if I go into labor before, they may consider letting me do a VBAC (as they got permission from the head OB in the hospital).

    For the past few months, I've come to accept the fact that I needed a c-section (due to the previa). Now so late in the game I have more options, but being that I don't have much time, I'm confused what I should be pushing for.

    Henci Goer

    As I understand from your first e-mail, you were planning a VBAC:

    "I just switched doctors partially because the first OB I started with refused to even discuss VBAC and insisted on c-section (and I didn't really like her as a doctor in general). It took me some time, but I found a doctor that the staff said has done VBAC after 2 c-sections in the past. I saw him last week for the first time, and of course there is a catch. He has performed VBAC after 2 c-sections in the past, but now the hospital won't let him. He agreed to talk to the head OB of the hospital and with me signing a waiver and the head OB's OK, he'd agree to do a VBAC. I need to wait until the next visit for the final answer (in a month)."

    You have now, even as the scalpel was poised, been given a reprieve. Besides the general opposition to VBAC, which you had already rejected, are any new factors leading you to consider not going back to Plan A? If not, go back to Plan A--the recommendations on this page of the International Cesarean Awareness Network website should prove helpful in your situation, although it is specifically about hospital bans. If there are new factors, are they of sufficient strength to override your earlier decision? Only you can answer that question.

    -- Henci

    Archived User

    The doctor told me that I could try a VBAC if I went into labor before I hit 40 weeks (actually a few days before). At that point he said he didn't want me to continue and would schedule a c-section.

    On the day of my scheduled c-section, I started bleeding, with contractions, and wasn't dialated at all. The end result was a c-section with a baby who was breech (though he wasn't breech 5 days before when I had had my last sonogram). So I guess in this case the planned c-section was better than the emergency c-section it would have become.

    Henci Goer

    I am sorry that your second pregnancy ended in complications that required a cesarean and glad that all has turned out well for you and your baby, but I don't see why planning a cesarean in the first place would have been the better option. In fact, you may have been better off planning the VBAC even though you were not destined to have a vaginal birth. The fact that you were having contractions tells you that your baby was ready to be born. With a scheduled cesarean, even though the baby is considered full term, this may not be the case. Also, the risks of certain serious complications for mothers and for the babies of future pregnancies goes up with accumulating cesarean surgeries, so a cesarean isn't something you want to do without a good reason. 

    -- Henci

    Archived User

    Actually this was my third c-section. That was why the doctor was hesitant to do VBAC all together.

    My first c-section was do to fetal distress where my son lost a heartbeat. The second c-section was similar where my son also was starting to have fetal distress and his embilical cord was around his neck

    With this birth, I had been contracting for a few weeks prior, but none of the contractions were intense. The were uncomfortable but far from painful and relatively short. At the point of my scheduled surgery I started bleeding but was not dialating at all.

    Archived User

    i had a c-section with my little girl and i was wondering is there way if it was okay  to have my next baby

    Archived User

    how many c-section can a woman have

    Henci Goer

    Yes, you can certainly have a vaginal birth after cesarean (VBAC, pronounced V-back), but it difficult to obtain one in the U.S. You can find lots of information on VBAC on the International Cesarean Awareness Network website.  

    As to your other question, every cesarean exposes you not only to the risk of that cesarean but to increasing likelihood of dense adhesions (internal scar tissue), which can cause chronic pain and make future surgeries of any kind more difficult and dangerous, and to increased likelihood of abnormal placental attachment in future pregnancies that pose serious risks to you and the baby. In short, while there is no absolute number of cesareans, every cesarean surgery you have loads the dice more and more heavily against you if you roll the dice again. Once women have a vaginal birth, on the other hand, almost all will go on having uneventful vaginal births in future pregnancies. 

    -- Henci


    All Times America/New_York

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