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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
    Ican Outer Banks:
    What is your opinion on the safety of double vs. single layer suturing and VBAC?
    Archived User
    Henci Goer:
    My opinion is that it is best to err on the side of being conservative. Back when double-layer suturing was the norm, scar rupture rates were commonly 5 per 1000 or less. The best research also suggests there is an increase in scar ruptures with single-layer suturing even after controlling for correlating factors such as induction with an unripe cervix and oxytocin for induction or augmentation of labor. That being said, what about the woman who already has single-layer suturing about her risk? We can tell her that the increase is not huge--97% of women will still have no problem with the scar vs. 99.5% of women with double-layer suturing in the same study--and even more important, we don't know what the scar rupture rate with single-layer suturing would be with spontaneous labor, but undoubtedly it would be reduced by awaiting spontaneous labor onset, avoiding or delaying epidural analgesia because it increases need for augmentation, implementing practices that promote labor progress, and having patience. In cases where induction was needed, awaiting cervical ripeness and using a physiological oxytocin regimen should minimize chance of scar rupture, and the same goes for an oxytocin regimen when augmentation is required. The Lamaze website has some great info on what practices and policies promote good progress at http://www.lamaze.org/ExpectantParents/HealthyBirthPractices/tabid/251/Default.aspx, and an appropriate regimen for oxytocin can be found on the package insert, which can be seen at http://www.accessdata.fda.gov/drugsatfda_docs/label/2007/018261s028lbl.pdf.
    Archived User
    Melissa Pate:
    Have you had any experience with uterine dehiscence? I had a 10 cm dehiscence found upon incision after attempted hba2c. The only thing keeping baby in uterus was the peritoneum. The book silent knife states it is "not dangerous for mother or baby." The ob that did the c-section said we were both lucky to be alive. And if I were to become pregnant again he would start looking for dehiscence with ultrasound at 34 weeks and if found he would deliver baby right away, because I would be like a walking hand grenade. It is all so confusing and I cannot find any solid research on the subject as dehiscence is often lumped in with rupture. I would really like as much information on the subject as I can get. I would really appreciate your input on this. Thank you.
    Archived User
    Henci Goer:
    Most modern studies of VBAC are careful to distinguish scar rupture from dehiscence. Scar rupture is defined as penetrating all layers of the uterus and often of causing symptoms such as bleeding or fetal heart rate abnormalities. The general advice is that women who experience a scar rupture should not plan another VBAC, but, to my knowledge, this is not based on specific research but on what seems to make sense. Dehiscence is not generally considered a contraindication to future VBACs because they are relatively common, much more so than scar rupture, which means that since dehiscence is only discoverable at repeat cesarean, many women are laboring uneventfully and giving birth vaginally with dehiscences. I don't know how that would apply to someone like you who had an unusually large "window" in the scar. I am distrustful, though, of the feedback you got from the ob. It was hardly what I would call objective, balanced, complete information on the benefits vs. harms of planned VBAC vs. planned repeat cesarean, and that, in combination with the fact that you were coming in from a planned hba2c, makes me wonder whether this ob was trying to "scare you straight." It even raises the question of how accurate the description of the dehiscence was. I wish I had a dollar for every woman told by a disapproving ob at a VBAC that ended in a cesarean that her uterine scar was s-o-o-o thin and how lucky she was that she had a cesarean. My advice to you is to seek a second opinion from an obstetrician who encourages VBAC and who has a VBAC rate of 75% or more. That way, if she or he says you are not a good candidate, you can trust the ob's judgment.

    All Times America/New_York

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