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    Sep 16
    2011

    VBAC after premature classical cesarean

    Archived User

    I have 2 babies and 2 completely different pregnancies to go along with them. My son was born at 40 weeks vaginally after being in the care of the best naturopathic physician in the world. He was a scheduled home birth but i pushed him out in the hospital after laboring over 35 hours naturally. It was bliss.(born 7/28/09)

    my 2nd child is a baby girl born at 26 weeks from an emergency csection. i had bleeding from a subchorionic bleed that was diagnosed as a cause of having facotr v leiden mutation. I was on heparin and an array of other drugs to prevent preterm labor and reguardless of all the interventions my water broke and 6 days later i delivered. (11/25/10)

    this baby is due feb 27 2012 just 15 months after the cesarean. i was told by my doctor no way was he gonna let me attemp a trial of labor and was devastated. i cant fathom why not! its my right to attempt right? is there any info i can read up on besides the generic statistics i have found? this pregnancy so far is complication free and to think that i could never birth again saddens me deeply. i felt robbed after my daughter was born so opposite of the empowerment and pride i felt after my sons birth and honestly the recovery of the surgery was 100 times worse. im so frustrated after days of scouring internet that i cant find anything to really tell me in stone the facts to make a decision with.  please help!

    shannon

    Henci Goer

    Let's start with the fundamentals: yes, it is your right to make an informed refusal to repeat surgery. Theoretically, pregnancy does not deprive you of that right, but as you have discovered, practice is another matter. I had hoped to find you support for your right in the American Congress of Obstetricians & Gynecologists' latest VBAC guidelines, but while the guidelines acknowledge your right to autonomy and state that a hospital cannot turn you away or coerce you into a c/sec if you turn up in labor, it also states that your preference should be ascertained in pregnancy so that if the ob or hospital doesn't want to accommodate it, you can be shown the door. This is put more circumspectly, of course, but this is what it amounts to. There is some language that if the hospital does not have the ability to perform an immediate c/sec 24/7, the ob should help transfer your care to somewhere that does. I don't know how much help that would be to you, though. 

    As to the wisdom of pushing for VBAC, to decide that you need to know a couple of things: Did you truly have a classical incision at your daughter's delivery or was it a low vertical incision? Low vertical incisions are not believed to increase risk beyond that of the conventional transverse incision (Guise 2010), but classical incisions are thought to pose more risk, although it is not as high as believed. I have a study finding that among 145 women with a classical vertical scar, none had a scar rupture (Lin 2004) and another study finding 2 scar ruptures (98% intact) in a mixed population of 105 women with T, J, or classical incisions (Landon 2004). The other question is whether the uterus was closed with single- or double-layer suturing. The largest (1500 double layer, 500 single layer) study reported a 3% scar rupture rate with single-layer suturing vs. a 0.5% rate with double-layer suturing; however, we don't know to what extent other factors such as inducing labor might have boosted the rate in women who were vulnerable to extra stress on the scar because of the weaker suturing technique (Bujold 2002). The fact that you have a prior vaginal birth is in your favor. A study reported a scar rupture rate of 0.5% in women with vaginal birth before the 1st c/sec vs. 1.4% in women with no prior vaginal births (Hendler 2004). That the interdelivery interval will be 15 mos is not in your favor. One study reported a rate of 5% but the study was limited to women with no prior vaginal births and nearly half the women had single-layer closure, so this is a worst case scenario (Bujold 2010). The only other study reported a rate of 2.3%, and we have no details on other factors (Shipp 2001). You must also balance the potential harms of planned VBAC with the potential harms of elective repeat c/sec, both the individual surgery and the harms of accumulating scars. The best place I know to send you for that is here.

    ~ Henci

    Archived User

    henci,

    thank you so much for your knowledgable and prompt response. reading it made me feel more empowered and in charge of my decision making. i assumed once the doctor told me no it was no and he made me feel like it was  a 50/50 chance of losing my baby and that it would be my bad judgement that did it. he continued to sAy i got lucky with my daughter(she is an angel you couldn tell wsa 14 weeks early)  and that i shouldn push my luck again. of course hearing those things makes me feel selfish for wanting a naturaL Birth but its labor i crave not an operation. im ok to accept it if there is no safe try but i wanna knOW  all the info and its hard to pull that out of a doctor with an OR agenda. when i read the link you provided i just cryed. i experienced PPD and had a hard time connecting with my girl the way i did with my son and could never explain why these feelings were present but i feel i have a better understanding now after seeing cesareans do cause a slew of emotions to rain on you. add in the babies risks of respiratory illness and its the recipe of disaster i am desperate to avoid. i dont know if its low or high i am going to ask my doctor for my notes. the night of the surgery was horrific, a little more background i have factor v leiden which they suspected cauesed the placental abruption i had which they thought justified the early cesarean. they told me she was better off outside than  in. its hard to wrap my mind around since my son was completely uneventful. i have been taking heparin 2xs a day to prevent clotting although after reading all sorts of contridictory research i question even the necessity of the injections. i dont wanna be foolish but i want to be apart of my care not told waht to do and be unclear why it makes it way harder to go through with when theres so many questions. 

    i am so grateful for your knowledge i doubt i could get any unbiased facts from my doc and i appreciate so much that you took time to share with me what you know i feel like im not so in the dark now and that i can go to my doctor with facts and the information to actively collaborate instead of playing puppet. thank you and thank you again!

    shannon

    Henci Goer

    It sounds like the circumstances around your daughter's delivery, quite understandably, caused you a great deal of emotional and psychological distress. And it seems, not surprisingly, that those feelings are resurfacing as you experience another pregnancy and anticipate another birth. I think you might find it helpful to have some support from women who also have had difficult birth experiences. I highly recommend Solace for Mothers, an online peer support community.

    ~ Henci

    Archived User

    henci,

    thanks so much again for all the helpful information and links. i wish you were a practicing physcian in my city lol more doctors should have this information for women it only makes sense that the more women who are having cesareans these days might want a vbac and to not have anything except outdated statistics is negligent. thanks again and again

    Archived User

    Shannon,

    I am curious to know where you currently stand in your situation.  I have a similar circumstance and feel the same as you about being told a c-section is my only option.  I would really like to connect to discuss further.  My e-mail is [login to unmask email]

    Warm regards,

    Carissa

    Archived User

    hello again henci!

    I am 35 weeks pregnant now and just yesterday found out i had a low vertical incision rather than a classical! i feel so close to having a birth that im almost tempted to not go into the hospital until i am diated too far haha. My doc still suggest a cesarean since the previous cesarean happend at 26 weeks. After everything I have read I feel that his suggestion has more to do with avoiding a malpractice suit then my actual feelings and wants. would you mind telling me what you know about preterm surgeries and if they have a greater afftect on a successful vbac?

    thanks and appreciaton

    shannon

    Henci Goer

    According to the systematic review of the literature that underpinned last year's National Institutes of Health consensus conference on VBAC, a low vertical uterine scar poses no excess risk of scar rupture during VBAC labor. And while there is some concern about certain characteristics predisposing to a repeat cesarean, prior preterm cesarean is not one of them.

    Is there any chance of changing your care provider for one who is more supportive of VBAC? It is not good to have to rely on someone who would much prefer to perform a cesarean. You are vulnerable to being steered in that direction, and your doctor is likely to be looking for any excuse.  If not, I strongly recommend hiring an experienced doula and, barring an emergency, don't make any decisions without taking time to consider the pros and cons of your options. This acronym can help:

    Benefits
    Risks
    Alternatives
    Intuition/instinct
    No or not now

    ~ Henci 

    Archived User

    thanks again henci! as always you have exactly the info I was looking for!

    shannon

    Henci Goer

    You're welcome! Glad I could help.

    ~ Henci


    All Times America/New_York

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