VBAC after uterine dehiscence

Hi, I am desprate to find some information. I will try to be brief. I had my first child in '98 I was induced for preeclampsia and I was also past 42 weeks by a few days. I ended up with a c/s. Five years later during my preg. I tested positive for group B strep. I went to the hospital leaking fluid and they decided to keep me. I was a week or so past due. I was given time to see how things went and after a few hours the doctors wanted to do a "soft induction" with a prostaglandin gel. I continued to labor for about 15-20 hours. I was having a lot of pain in my hips and felt like I wanted to maybe push, well I was still only 4cm. Now here, I think, was my mistake, I asked for an epidural. I'd been in labor almost 30hours and I just was so let down that I'd not really made any progress. After having the epidural I fell asleep for a few hours and woke up with pain in my abdomen. Only with contractions. I was feeling it along my old scar and a popping feeling. Baby was doing well still and no heavy bleeding. At this point they took me in for another c/s. What I was told was I had ruptured, and not to become preg. again. Also they thought the reason I was not dilating and the hip pain was because my son was "star gazing" like with his head tipped back I think. This was in a German hospital so I'm not sure of the correct term. When I asked for more info they said my scar was open all the way across and I'd torn into my cervix. They also said my son was still in my uterus. I've since seen a high risk OB here and he said that was dehiscence and I wold need another c/s around 38wks but could become preg. again and be followed by a regular OB.
Now my question is, is it totally out of the question to have a VBAC? I live in FL which is one of the worst states for VBAC right now but I am willing to fight for it, I just need more information. I can't find any studies that relate to my case. I also need to "prove" it to my husband, who is very worried for me. He was told I could have died after my son was born. Please Help me find something. It is hard for a lay person to search when I don't know where to even look.
Thank you,
Heather By: Heather

I leave for Australia today and won't be back until July 10, but I know I'll have internet access during at least part of the trip. I will download your post so I can work on it off line.

-- Henci By: Henci Goer

Thank you so much for taking the time.
Warmly,
Heather By: Heather

It sounds from your story like the scar gave way entirely even though it didn’t do any harm to you or the baby. In such cases, it is recommended that the woman plan a repeat cesarean. I am not aware of any research on this point. I doubt that there would be enough cases where women with scar rupture in a previous labor after c/sec would be allowed to labor again to produce any. Even so, it does seem just common sense that if the scar gave way in one labor, it is likely to do so again. It should be your right to refuse surgery under any circumstances, although that right is being flouted in this country when it comes to women and repeat cesarean surgery, but would it be wise for you to do so?

If you want to learn more about VBAC vs repeat c/sec, you cannot do better than VBAC or repeat cesarean?. Among other things, you will find information on planning for a safer cesarean and a positive cesarean birth experience.

Speaking of safer cesareans, scheduling a c/sec at 38 weeks increases the chance of the baby having respiratory problems severe enough to require admission to intensive care. At the very least, you should wait until 39 wks, although even then, there is still an increase in the rate of respiratory complications. But were I you, I would want some evidence of increased risk of scar problems in the final weeks of pregnancy before scheduling surgery at all before your due date. Not every baby is “done” according to the calendar. The onset of labor is still the best way of determining this. It is possible, of course, to have the scar open during pregnancy, but it is extremely rare and I don’t know if there is any association with week of pregnancy. If the concern is labor starting in the middle of the night, I suggest you plan to have your baby in a hospital where there is no problem setting up for a c/sec any time of the day or night. In fact, if your ob calls ahead, they can be set up for you when you get there.

As a side note, you are correct in your understanding of “stargazing.” It means the baby’s head is tipped back so that the baby is looking up. The problem can occur in breech babies—babies who are head up instead of head down—in which case they would be looking at the sky.

Henci
By: Henci Goer

Thank you for the input. I did look at the site you recommended. One section said if there was seperation of the scar that may not be a reason to have a repeat c/section. Is my case somewhat different since mine opened all the way along? I was also thinking the use of a prostagiandin gel and pitocin really effected the outcome of my labor. I have heard of a midwife in my area who does homebirth VBAC. Would that be too risky?
Heather By: Heather

The recommendation differs for symptomatic scar separation, usually called scar or uterine "rupture" and "dehiscence," meaning a window opens in the scar. Since different caregivers described what happened to you using both terms, and, in fact, you didn't experience any alarming symptoms, it isn't clear which category you fit into. You are also correct that prostaglandin gel and Pitocin could have affected your uterine scar.

At this point, I think your best bet is to discuss your individual case with a practitioner who encourages VBAC, although unfortunately such a person is hard to find these days. Then if a repeat cesarean is recommended, you will have a basis for trusting the practitioner's judgment because you will know it isn't just because he or she prefers repeat c/secs. If you connect with this midwife, she should frankly discuss the potential harms as well as benefits of planning a home VBAC if she is willing to attend you. You need both sides in order to make an informed decision.

Please keep us posted on what you decide and how everything goes for you.

-- Henci By: Henci Goer

Henci,
We are still TTC at this point, but, I have a question. You mentioned in your post that the recomendation differs for rupture and dehiscence. Can you point me to where I can read what they say? I have been doing a lot of reading and joined an ican group online, these things have helped me clear my mind so much. I have will try to HBAC if I can find a provider. I felt so much stress just thinking about going in to another hospital. However, if it is recomened by a provider I trust(someone who supports VBAC and normal birth) that I should plan another c/s I will give it serious thought. I am also wondering if mulitple induction drugs are given do the risks that go along with them go up accordingly. What I mean is say a prostaglandin gel increases rupture risk by 4%- don't have numbers in front of me- and pit also by 4%, would that give an 8% increased chance of rupture? Hope I'm making sense.
Thank you,
Heather

I can't think of a specific reference on the dehiscence vs. scar rupture recommendation. I just know that it is pretty much universally recommended that if the scar has come completely unzipped in a prior VBAC labor, a planned repeat c/sec is recommended. I also know that I have read that a dehiscence, a small, harmless "window" in the scar, is not believed to pose excess risk in subsequent labors.

As for the use of cervical ripening/induction agents, several studies have found increases in scar rupture with various agents and combinations of agents, but it isn't as straightforward as adding the increased risk of individual agents together. The degree of increased risk--and some studies do not find any--depends on the characteristics of the women in the study, what agents were used, in what combinations, and at what dosages. No two studies are alike on that score.

I still think your best bet is to review your medical records with an obstetrician who encourages VBAC. Now that you are in contact with ICAN, hopefully you can find someone through their network. Considering how important this decision is, it may be worthwhile to travel if such a person is not available in your community.

-- Henci

You say that a dehiscence is not an excess risk in subsequent labor…

But isn’t such a small window just the beginning of a rupture and would widen with each contraction?

I am trying to see the difference here, because I would really really really like to try a VBAC (my scar ruptured for about 2 inches)

Do you have any research to show me (which I can then show my doctor)?

Thanks!

Dear Henci,

I know this subject is old, but as it came up on a different board, could you tell me which studies you are referring to in  your last post?

Thank you very much!

I have a 1992 study of dehiscence, which the authors defined as "silent separation of a scar incidentaly diagnosed at laparotomy or vaginal examination with no fetal or maternal compromise" (p. 540). One woman of 475 (2 per 1000) having a VBAC had a dehiscence detected whereas 19 of 924 (21 per 1000) had one found incidentally at cesarean surgery. I also have a 1989 study distinguishing between dehiscence, which authors defined as "separation of the uterine scar with unruptured membranes" (p. 570), and scar rupture. Six of 1008 women (6 per 1000) had a scar rupture, but 44 of 1105 (40 per 1000) had a dehiscence discovered at either repeat elective cesarean or VBAC ending in cesarean.

~ Henci

Dear Henci,

Thank you very much! That helps a lot!

You're welcome! ~ Henci

Dear Henci,

I have a related question.  I was "diagnosed" with a thin LUS during a term (39w) repeat cesarean due to double footling breech presentations in both twins.  Twin B flipped breech at 33 weeks; twin A at 37 weeks.  Argh!

My Baby A initiated labor by violently kicking and breaking her amniotic sac.  Labor contrax began 15 minutes later; the cesarean took place about 3 hours after that.

I'm planning for a VBA2C (22 mo. intrapartum interval; age 38; healthy; BMI under 30) and been urged to find an OB.  Local docs are 'behind the times' when it comes to revising their VBAC practices and finding a VBAmC supporter is next to impossible.  VBA2C is still in the SOP for homebirth midwives in my state.

I interviewed an OB last week who agreed to take me if I sign an AMA waiver.  The first words out of his mouth before I even gave him my background were "DON'T DO IT!"  Awesome.

Anyway, he's certain that if I had a thin LUS at term with the twins, that my scar is weaker and more likely to rupture.  I was under the impression that 'back in the day' when docs were palpating VBAC scars, they would leave dehiscences alone because the uterus would heal itself.  What is your impression of "thin LUS" (parchment paper) and implications for my upcoming plans.  Other docs I've talked too about this in the past said there's really no way to "know" what it means.

Many thanks,

Kimberly James

Whoever told you there is no way to know what implications a thin scar has for a planned VBAC  was on the money. Here are the problems with sonographic measurements:

• Studies used scar "defect" as their outcome. "Defect" includes harmless dehiscences, which we know (see previous posts in this thread) occur more frequently than scar ruptures. In fact, in all but one study, the scar evaluation was made at repeat cesarean, which means we don't know how many VBAC women had an uneventful vaginal birth despite having a "defect."
• While thicker lower uterine segments are less likely to develop defects in labor, i.e. good negative predictability, the positive predictability of thinner ones for defects isn't that great. Furthermore, a pooled analysis of multiple studies could not establish a useful cutoff point because of variability among studies.
• The likelihood of scar rupture is influenced by other modifiable factors such as labor induction, oxytocin augmentation of contractions, single- vs. double-layer uterine closure. Investigators do not account for these in their studies of LUS thickness, which means we have no idea of the isolated effect of thickness in an otherwise optimally treated population. 
• Accuracy of measurement depends on the skill and experience of the ultrasonographer. 

Guise JM, Eden K, Emeis C, et al. Vaginal birth after cesarean: new insights. Evid Rep Technol Assess (Full Rep) 2010(191):1-397.

Jastrow N, Chaillet N, Roberge S, et al. Sonographic lower uterine segment thickness and risk of uterine scar defect: a systematic review. J Obstet Gynaecol Can 2010;32(4):321-7.

Meanwhile, any discussion of planned VBAC vs. planned elective repeat cesarean surgery should take into account the escalating risks of serious maternal and perinatal complications with scar accumulation.

I hope this helps.

~ Henci 

Thank you, Henci.  That helps reaffirm what I had already discovered about dehiscence and the limitations of sonographic assessment of the uterine thickness. ~ Kimberly

I just wanted to give a little update.  I did give birth vaginally earlier this week.  My uterus did its job in spite of having multiple scars and a previous diagnosis of 'thin lower uterine segment.'  Hopefully women with this diagnosis will find some comfort in reading this.

I am delighted to hear this! ~ Henci

Good morning,

I am looking for a second opinion.  I am 35yo, FTM, approximately 33weeks.  I have been seeing a group of midwives since the beginning of this pregnancy and planned for a natural, unmedicated L&D.  In 2008, I underwent a myomectomy to remove multiple uterine fibroids.  I provided this information at my first prenatal appointment but the post operative report was not reviewed until this week during a routine 2-week check up.  The midwife had some concerns and had me schedule an appointment the following day with one of the physicians.  I was told that I have a classical uterine incision and because of the risk of dehiscence, I have to schedule a ceasarean at 39 weeks.  My preliminary findings give me no assurance that I have any other option.  This is devastating news for me as I may not conceive again.  I understand the type of incision I have bears a 4% chance of uterine rupture or dehiscence, but what about the other 96%?  Thank you in advance for your response.

Sincerely,

Carissa

I wrote a post in this thread that provides the best information I could find on the risks of scar rupture with a vertical, AKA, "classical" uterine incision. As you can see, it is lower than commonly believed, although it is probably still higher than it would be with a prior transverse uterine incision. I would assume that the same odds would apply to an incision made for fibroid surgery. In that same post, I also wrote about every patient's right to refuse surgery, a right that is not suspended by pregnancy, and I provided a link to a fact sheet on the risks of cesarean surgery, which further strengthens the argument that the choice should be yours. As you have discovered, though--"I have to schedule a cesarean at 39 weeks"--all too often, that right is not honored by obstetricians. I wish I could do more to assist you, but the best I can offer is to affirm that your preference for planning vaginal birth is reasonable, but if you cannot convince your doctors to respect your right to do so, see if you can find another doctor who will.

~ Henci

There are women very regret for have tried VBAC after c/s because their losses. , I will suggest not have VBAC at all because you don't want take risk with you and your baby life.  Bless your heart!

It sounds like you have experienced a personal  loss or someone you know has experienced a loss as a result of planned VBAC. If this is the case, you have my deepest sympathy. However, I am bound to point out that elective repeat cesarean surgery is not risk free. In fact, the odds of a woman dying as a result of elective repeat surgery are roughly the same as the odds of a baby dying as a result of a scar rupture in a VBAC labor. Accumulating cesarean surgeries also poses escaling risks to future babies whereas a VBAC will almost always be followed by future uneventful VBACs. No one can predict the future, but the odds for most women favor planning VBAC. 

~ Henci