VBAC After Prior Surgeries
Q1: Possibility of VBAC after 2 previous laparoscopies
Q3: Fibroid Myomectomy & VBAC
Q4: Cesarean for large babies
Q5: 2nd C section or VBAC?
Q6: Average Length of Pregnancy
Q7: Use of continuous monitoring during labour due to VBAC and diabetes
Q8: Suturing Technique
Q9: Vaginal birth after 3 cesareans (vba3c); single layer closure with last 2 c-cesareans
Q10: VBAC and Gestational Diabetes
Q11: VBAC attempt, premature rupture of membranes (PROM) with no contractions = cesarean?
Q12: Android Pelvis
Q13: How dangerous is a dehiscence in future labors?
Q14: Can I have a VBAC after 2 cesareans and a dehiscence?
Q15: A second VBAC?
Q16: 3 cesareans then VBAC?
Q17: Is a 2nd VBAC Safe?
Q18: Can I have a vaginal birth after a classical incision for myomectomy
Q19: VBAC after inverted – T incision
Q20: VBAC after cesarean with a J incisions
Q21: Needed: Contacts for providers who will assist with VBAC after a classical incision
Q22: Myomecomy, Csection...VBAC?
Q23: Infant death with VBAC
Q24: A successful VBAC in spite of the worry
Q25: VBAC with history of incision infection and extension of uterine incision during surgery
Q26: VBAC after Cesarean for breech position
Q27: VBAC after 2 cesareans
Q28: Home VBAC after cesarean with classical incision
Q29: VBAC with twins at home
Q30: VBAC after 2 cesareans: one for infection and the second for breech twins
Q31: Are Vba2c Labors Longer, more difficult?
Q: I've been doing some research on VBAC and feel really depressed about being pregnant again because I feel so isolated in terms of the birthing options available to me. I had a cesarean with my first child because the nurse said the labor was too long and I wasn't dilating as I should (I was at 6cm in 15hours). I was young and tired and agreed to have the cesarean which I really regret now. 4 years later I am 6weeks pregnant with my 2nd child and I want to give natural birth but it seems as if no one wants to consider it. I have had 2 previous laparoscopies to treat endometriosis. Will this in combination with the cesarean render me an unfit candidate for a VBAC? I want a big family and can't imagine having more cesarean deliveries. I have read about the trial of labour after cesarean section (TOLAC). Could I be viable for this? Please help, I need more information.
A: I would consult an ob/gyn about this, but while there is some concern about the effect of uterine surgery (for fibroid tumors, for example) on the safety of planned VBAC, I don't see how having had laparoscopic surgery for endometriosis would make a difference--unless it involved the uterine scar. Choose an ob/gyn who ordinarily is in favor of VBAC so you can trust the doctor's judgment if you are told VBAC isn't a good idea. In so far as general information goes, you can get good, evidence-based information here and here.
Q: I am a mother of five and expecting another child. Baby one was a 39 week scheduled cesarean due to breech position. Baby two was a 42 week cesarean after 16 hours of mild labor (got to 4) and to being induced too fast causing fetal distress (pitocin). Third was a 40 week breech scheduled cesarean (he flipped at 39 1/2 weeks). He was going to be a vbac but when he flipped they refused to even let me try. Baby four was a 40 week vba3c. It was the best experience ever. I had the same midwife for 3 and 4 but the month after having baby four the facility quit allowing vbacs. For baby five (40 weeks). I attempted another vbac at a bigger hospital but my baby's head was stuck on my pubic bone so didn't descend. Thinking back I bet he would have dropped had I labored longer. My labors start out very slow and it takes me hours to get to four centimeters so during my vbac I wasn't even allowed the option of pain meds until after I reached six cms. Once I reached 6 cms. I went right to 10 and only pushed for 30 minutes.
My cuts are all in the right location for a vbac and I'm going to same facility as the last attempted vbac so I know vbacs are allowed there but just not recommended after so many cesareans. The facility is listed online under hospitals that fully support vbacs. I'm trying to get my ob to approve a vbac with me. I know my body can do it. With each child I’ve researched vbacs and am fully aware of risks for both repeat cesareans and vbacs. My recovery time was incomparable between vbac and cesarean. I was able to get up and do things right after birth with vbac but with the last cesarean it took me more than a week to really be able to do much. I know it'll be worse this time. My depression after each cesarean was horrible too.
I didn’t even get depressed with the vbac. It was the best experience ever.
I want to labor regardless of whether I can do a vbac or not. With the one child not wanting to come till 42 weeks I want to be sure that this one will be born when ready and not when an ob says he has time. It’s a large city hospital so there would be staff on for any complications.
How do I go about getting the care I want and getting the medical staff to see that I understand the risks but still know its better for me and baby to at least try a vbac?
A: The key point in your post is this: "I want to labor regardless of whether I can do a vbac or not. With the one child not wanting to come till 42 weeks I want to be sure that this one will be born when ready not when an ob says he has time.” The other key point is that the hospital is prepared to handle urgent complications 24/7 because as you no doubt know, after four cesareans, you are at increased risk of potentially needing an urgent cesarean.
I'm not knowledgeable about hospital systems, but I expect a big hospital will have people who act as patient advocates. A patient advocate will know who you need to talk to and (hopefully) will represent your interests and act as a liaison between you and the hospital. The bottom line is that every competent adult has the right to refuse surgery and pregnancy does not deprive women of that right. Informed consent is meaningless unless there is also the possibility of informed refusal. This pamphlet on the rights of childbearing women can prove helpful in explaining your rights. The position I suggest taking is that you are exercising your right to refuse surgery and wanting to plan with obstetric staff on how to maximize your chances for a safe, healthy VBAC labor. You may also wish to discuss under what conditions you would agree, or consider agreeing, to a cesarean either before or during labor. Finally, I hope this will not be the case, but during discussions stay alert for scare tactics. Reject arguments based in attempts to manipulate your feelings, as opposed to making decisions based on objectively presented information.
Q: My reproductive endocrinologist discovered a fibroid during an early ultrasound with Baby #1. It was pedunculated, and off the back side of the uterus attached near the (lower uterine segment) LUS.
Baby #1 Utterly boring and normal pregnancy. 1 1/2 weeks overdue. Very high. Low Bishop's score. PROM. I was 3-3-1 when we left for the hospital after ten or so hours after the rupture. When I got to the hospital labor stopped. I was using a midwifery practice, and was given up to 24 hours after my rupture of membranes for labor to resume, at which point I would be augmented. I ended up being augmented for about 24 hours. 4 cm. I consented to an epidural. Pitocin dialed up a few times. I gained another centimeter after 2 1/2 total days of labor. Failure to progress (FTP) @ 5 cm. Cesarean. Baby was 9 lbs 11 oz. Lots of blood loss, fibroid was about the size of a russet potato. I asked if they would remove it during the section, and they declined.
Baby #2 at a delivery interval of 23 months. HBAC planned with CNM. Boring and normal pregnancy once again. Uterine scar measurement at 37 weeks was 3.5 mm. Went into labor about a week after the due date. Progressed easily to 10 cm within seven hours. CNM said I was complete but that the baby was incredibly high. Bouncing off her fingers she said. She said I had lots of room for him to come down. Pelvis was adequate and open. I was dilating off my bag of waters - not from his head. Did some crazy stuff at home to try bring him down. With history of scar on my uterus and no descent after four more hours, she recommended transferring. Transferred to hospital and gave it another four or so hours. No descent. Pitocin. Epidural. Broke my water. Lots and lots and lots of fluid. No head. My midwife and hospital midwife both agreed after 24 hours of no change that a cesarean was indicated. I requested my fibroid be removed. Denied again. Baby was 9 lbs 3 oz, posterior with a deflexed neck. My midwife said in 25 years she had only ever seen something like that in one other client. She encouraged me to investigate a fibroid removal if it could be done laparoscopically and if I wanted to have another child and a chance at a vaginal birth.
We are now considering baby #3. Baby #2 is one year old. We would hope to space at least two years to get a good delivery interval. I consulted with a surgeon who said I'm a perfect candidate for a laparoscopic removal of my fibroid. It is on the small side of large when I'm not pregnant and very large during pregnancy. (I had an U/S during pregnancy #1 and it was very good sized.) He was an ob/gyn before focusing on surgery. He said the fibroid could have contributed to my posterior babies and challenging births. I asked him if removing the fibroid would preclude me from another VBAC. He said he would have no issue with writing a letter post surgery supporting another VBAC since the uterus itself wouldn't be cut - just the stalk clipped to remove the fibroid from its surface. I do have other symptoms from this fibroid, which are minor, but annoying, occasional pain during intercourse, and frequent urinary urges especially at night. It would be nice to get rid of those complaints. However, to be honest, I would be having this fibroid removed mainly to have a chance at a VBAC with a third child. I've read research that indicates unplanned cesareans are performed at a rate of 50% in those with fibroids versus 30%.
Since I've used midwives with both of my births, I'm not aware of the culture surrounding fibroid removals and vaginal birth. Is it common that an ob/gyn would discourage or refuse a vaginal birth after 2 cesareans (VBA2C) after a fibroid removal? What are your thoughts based on what I'm considering to avoid a third cesarean? I feel the risk of a third cesarean is greater than a laparoscopic removal of a fibroid. Of course there are no guarantees that the fibroid is the reason for my difficult births. Also, what are the rupture statistics after two cesareans? I may consider another home birth, especially given how quickly and easily I progressed in my second birth.
A: Realistically, I have to say your chances of finding an ob willing to attend a VBAC after 2 cesareans and a uterine surgery are not good regardless of whether the surgery involved cutting into the uterus. Few obs agree to VBACs even in optimal cases these days, let alone women with obstetric histories such as yours. Not that it isn't worth it to try and find one. A recent systematic review of the literature of women planning VBAC after two cesareans reported a pooled scar rupture rate of 1.4% among 16 studies (5666 women). That rate will be affected, though, by whether labor is induced or augmented and whether you had single-layer uterine closure at your last cesarean. The same review reported a pooled VBAC rate of 72%, although the range was 45% to 89%, which gives you an idea of the degree to which care provider practices and beliefs affect vaginal birth rates. I can't help but think, though, that removing a physical impediment to the baby's getting into the anterior position and descending into the pelvis has to make a major difference in your odds of vaginal birth.
Reply from sender: With my first section, I was repaired with a single layer. Of course, I didn't even know to ask for a double layer repair. I was more savvy with the second section and requested a double layer repair - despite the surgeon's insistence it was irrelevant. So, I did get that double layer with round #2.
How do rupture rates change for a second VBAC with a double layer repair? I know scar measurements weren't conclusive with my birth last year based on the research. Any new stats available related to scar measurements at 37 weeks?
Henci’s response: I am not aware of any studies looking at a single-layer repair followed by a double-layer repair at the next cesarean. I would think, though, since they would be cutting through the old scar, that the last closure is the one that counts. I assume by scar measurements you mean measuring scar thickness. Here is what I have on that from the VBAC chapter manuscript for the forthcoming new edition of Obstetric Myths Versus Research Realities:
Thin uterine scar: Both a systematic review of scar thickness and rupture prediction (12 studies, 1834 women) and the AHRQ (2010) systematic review (3 studies) reject using scar thickness as a predictor because studies do not establish a cut-off with good positive predictive value.44, 55 A major problem noted by the scar thickness reviewers was that most investigators measured uterine dehiscence, but the predictive value of defect (overall rate 6.6%; range 1-46%), for rupture is unknown. Both reviewers note that other factors such as uterine closure or previous vaginal birth will influence scar rupture rates.44, 55
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.
The problem is that while a thicker scar is a good predictor that the scar will not give way in labor, a thinner scar isn't a good predictor that it will.
VBAC After 2 Cesareans
Q: I opted to go for a homebirth with my second pregnancy because with my first pregnancy I ended up going until almost 43 weeks and the CNM practice would have induced me as a vbac at 42 weeks. I was afraid of rupturing. With my second pregnancy I did go into labor at exactly 42 weeks but without my doula and midwife supporting me (my contractions were not regular enough for them to come, (they were 2-4 minutes apart lasting only 30-40 seconds) my husband and I went to a nearby teaching/women’s hospital where we were allowed to continue laboring and try for our vbac. I was 8 cm but stalled out and got an epidural where they then broke my waters and I was complete within 20 minutes. After 1.5 hours of pushing my son’s heart rate was 220 and it was determined we had an infection (probably from exams). He was also still at 0 station so cesarean was recommended again.
My question is the ob who did my delivery said my sons head was floating above my pubic bone. I am confused by this since the ob who I pushed with said he was 0- plus 1 station. Also my son was 10 lbs. The ob who performed my surgery said he must have been too large for my pelvis size. However with my first son who was 9 lbs. 5 oz the midwife said I had a very nice roomy pelvis. Is it unreasonable for me to attempt a vba2c with this type of history? I was on my back pushing so I do not know if other positions would help. I have read in the NIH analysis that women with a taller stature are more likely to vbac. I am only 5'3 and very short waisted. Could this be a reason it is hard for me to birth such large babies? I did not have gestational diabetes, I might add, so I do not know why the babies are so large.
A: As you yourself point out in your story, there are reasons why you may have ended up with a cesarean that could go differently with another labor. I wouldn't worry overmuch about the OB who said the head was above the pubic bone. That may have been the case during the surgery but not the case while you were pushing. I'd be more inclined to trust the midwife who said you had a roomy pelvis. Certainly pushing for only 1 1/2 hrs on your back with an epidural on board and a big baby says nothing about your ability to birth a big baby under more favorable circumstances with more time. The research supports the safety of planning a VBA2C as well. A systematic review (a study of studies) pooling data from 16 studies of VBA2C comprising 5666 women in all found similar maternal and neonatal morbidity rates between women planning VBA2C compared with women planning their third cesarean.
Tahseen S, Griffiths M. Vaginal birth after two caesarean sections (VBAC-2)-a systematic review with meta-analysis of success rate and adverse outcomes of VBAC-2 versus VBAC-1 and repeat (third) caesarean sections. BJOG 2010;117(1):5-19.
Reply from sender: I am glad you pointed that out about pushing. Perhaps the baby’s head did move back up during the surgery. Is there anything I can do to prevent such a large baby or is that mostly out of my control since I didn't have gestational diabetes? I see in one of the other posts that one study showed only a 48 percent chance of success with a baby that large. I am not overweight either. My BMI was only 22.8 and I gained 38 lbs during the pregnancy.
Henci’s reply: If you had a high BMI, I would advise losing weight sensibly before the next pregnancy because maternal pre-pregnant weight has the strongest correlation with with baby's birth weight, but your BMI is great. You didn't have gestational diabetes, which would be better termed "carbohydrate intolerance of pregnancy" as it rarely involves sugar levels that would be diagnostic of diabetes in a woman who isn't pregnant. Still, it wouldn't hurt to keep to a diet in pregnancy that is high in fruits and vegetables and whole grains and moderate in fat and to minimize junk food as well as to get moderate, regular exercise. That diet and regular exercise help metabolize blood sugar and can only do you good even if you aren't prone to higher than average blood sugar levels. It seems likely, though, that you just grow big babies, in which case, the best that can be done is to maximize your chances of birthing a big baby vaginally. Along those lines, I recommend these strategies:
- Choose a care provider who puts no preset time limits on length of labor or pushing. It often takes longer to birth a big baby.
- Hire a doula. This is for two reasons: first, she will have ideas that can help promote labor progress and descent in pushing, and second, she can offer support and reassurance should you or your partner become discouraged or frustrated, something you can't count on receiving from hospital staff.
- Begin labor spontaneously. Inducing labor isn't a great idea with a uterine scar under any circumstances because it can increase the risk of scar rupture, but it also decreases likelihood of vaginal birth.
- Refuse membrane rupture. It doesn't increase likelihood of vaginal birth. In fact, the opposite is probably true. One potential problem is that early release of the forewaters can drop the head prematurely into the pelvis in the occiput posterior position (facing your belly instead of your spine). OP babies don't fit well in this position, and persistent OP leads to high risk of cesarean for this reason. (You can find out more about OP babies here.)
- Have patience with a longer labor. You and your partner should remind yourselves that it is normal for labor or pushing to take longer than average.
- Push in positions other than on your back or semi-reclining. An epidural shouldn't rule out alternative positions. Today's "light" epidurals offer adequate pain relief while still giving you enough muscle control for hands and knees or squatting during contractions, although you may need assistance or "spotters."
- Preplan to give birth on hands and knees or to be able to turn quickly to hands and knees if the head is born, but the shoulders hang up (shoulder dystocia). This is occasionally a problem with big babies, and the best way of releasing them is all fours.
As for the 48% VBAC rate with a big baby and no prior vaginal birth, keep in mind that we don't know how the labors were managed, which can make a huge difference in VBAC rates, and if you schedule a cesarean, the chance of surgical delivery is 100%.
Q: I am 11 weeks pregnant and this is my 2nd baby. 1st baby was delivered through emergency cesarean, major fetal stress - cord was wrapped three ways, blood pressure dropped for both of us, long induced labor at 41 weeks because of back labor pain, horrible. Anyway, my delivering OB at the time said that I had the narrowest pelvic inlet she'd ever seen in 20 years of delivering babies, and what I guess my question is, does that make me unable to deliver vaginally or no? I was freaking out so badly on the medicine and never did receive a particularly clear answer even at the follow up appointments. What kinds of questions / tests do I need to do with my current OB, my next appointment is in two weeks, to see if we can not do a cesarean this time, I never want to do that again if possible. Any info would be so appreciated.
A: If I had a nickel for every woman who was told she would never be able to birth a baby vaginally who went on to VBAC--many women to babies bigger than the first one--I wouldn't have to worry about retirement. Aside from some sort of pelvic deformity, the ability of any particular woman to birth any particular baby is not predictable ahead of time because 1) the ligaments connecting the joints of the pelvis soften under the hormones of pregnancy so that they can flex open, 2) the joints of the baby's skull and the openings allow the skull to mold to the shape of the pelvis and pass through, and 3) labor management practices have a powerful effect on the odds of vaginal birth. For example, pushing while lying on the back prevents the pelvis from flexing open and inducing labor in a first-time mother doubles the odds of cesarean. Lamaze has some great general information on VBAC here. I'm sure you will find it helpful.
You have another problem, though. Few obstetricians will agree to a VBAC under any circumstances, and a fair number who agree early in the pregnancy don't really mean it. As the pregnancy advances, they become more and more negative on the idea and set up more and more hoops for the woman to jump through to be "allowed" to labor. I call these "Cinderella VBACs," i.e. "You can go to the ball if you don't gain too much weight and if you go into labor by your due date and if . . ." If you don't want a repeat surgery, your task will be to find a care provider who encourages VBAC and believes that the woman will birth vaginally until proven otherwise. This is not likely to be your current ob, seeing as she has already told you she doesn't think you can birth a baby vaginally. Your best bet in finding someone is to see if there is a local International Cesarean Awareness Network (ICAN) chapter and ask them. Failing that, you might see if there is a birth resources center in your community or talk to some of the local doulas.
Reply from sender:
Thank you so much for your advice as it eased a lot of tension in my mind, I will be thoroughly talking with my new doc at my appointment tomorrow regarding this situation and what she found with my previous birthing records. I am so thankful that there are new procedures and new advances every day in medicine to help make this natural part of life a little easier each time. I will also definitely check out the resources you gave.
Policies & Procedures
Q: I have just finished (and quite enjoyed) the Thinking Woman's Guide to a Better Birth. I read in the chapter on Induction of Labor that the "average" length of pregnancy for a first-time mom is 40 weeks + 8 days, while for a mom with prior births it is 40 weeks + 3 days.
I am due with #2, however, #1 was delivered via scheduled C-section due to frank breech presentation. My question is whether the "average" length for multiparous women depends on whether the first birth was vaginal. I could not find the reference to the 1990 study that is mentioned in the section on "overdue" pregnancy. I have heard that VBACs when the C-section was performed in the absence of labor are very much like first-time deliveries (e.g. longer pushing stage, for example) but I have not read any studies on the topic.
I am also interested in learning what the error bars are on the average length estimates.
A: As far as I know, the timing of the onset of labor is not affected by whether the first delivery was vaginal or via cesarean. What I can tell you is that research finds that the length of labor tends to be more like a first labor than like labor in a multiparous woman, as this study and this study attest. This would make sense. Many women have a first cesarean because their labor progressed more slowly than their care provider was willing to allow and so the VBAC population would skew toward women who labor more slowly. It is also possible that women having VBAC labors may be more anxious--especially if those around them are unsupportive and doubtful of their ability to birth vaginally--and this too could inhibit labor progress. The lesson to be learned is that women and their care providers should be patient in VBAC labors. Unfortunately, though, at least one study has found that women were given less time in labor, not more, if their prior cesarean was for delayed progress than if it were for other reasons such as breech or fetal distress, and this study found that one-third of women who had repeat cesareans for delayed progress or failed induction had them before 5 cm dilation, which means many women were still in latent labor. These findings highlight the importance of finding a care provider who encourages VBAC, not just agrees to it. If that is not possible, forewarned is forearmed. Women should be prepared to refuse a repeat cesarean based only on exceeding an arbitrary time limit.
As for your question on the length of pregnancy, a lot of water has flowed under the bridge since I wrote TWGBB. I have additional data on pregnancy length which can be found in my new book for professionals Optimal Care in Childbirth: The Case for a Physiologic Approach (c) 2012, co-authored by Amy Romano. Here is the relevant excerpt from the book:
How Long Is Normal Pregnancy?
The 40-week due date was set by fiat in the early 1800s by a German obstetrics professor who declared that pregnancy lasted 10 lunar months (10 months of 4 weeks each) from the beginning of the last menstrual period, hence the eponymous Naegele’s rule (Baskett 2000). Two modern-day studies of pregnancy duration with reliable dates found that the true median length (half of births before, half after) is longer and varies by parity, falling at 284 days in nulliparous women and 282-283 days in parous women (Bergsjo 1990; Smith 2001). A third study also found that after adjustment for other factors, nulliparous women beginning labor spontaneously averaged pregnancy durations three days longer than similar multiparous women (Mittendorf 1993). One of the studies establishes that a 41 week (287 d) definition of “postterm” is not physiologic. Investigators found that, depending on age and parity, at least 25% of women had not given birth by 41 completed weeks, (287 d) whereas by 42 weeks only 10% remained undelivered (Bergsjo 1990). Ten percent is a defensible definition for postterm; 25% or more is not, and there is more: by curtailing pregnancy, induction confounds duration. The same study found a dip in gestational length in pregnancies ending in December, which investigators attributed to elective inductions before the Christmas holidays (Bergsjo 1990), and an analysis of U.S. data between 1989 and 1998 found that large increases in the percentages of induced labors at all periods of gestation over the decade had shifted the distribution curve of pregnancy duration to the left (MacDorman 2002). None of these studies establishes the length of normal pregnancy in healthy women because the inclusion of preterm births and complicated pregnancies also pulls the distribution curve to the left (Mittendorf 1993). The only study we have on pregnancy duration in uncomplicated pregnancy at term reports a median of 288 d in nulliparous women and 283 d in parous women, longer than the other two studies, but still within their possible ranges (Mittendorf 1990).
Baskett TF, Nagele F. Naegele's rule: a reappraisal. BJOG 2000;107(11):1433-5.
Bergsjo P, Denman DW, 3rd, Hoffman HJ, et al. Duration of human singleton pregnancy. A population-based study. Acta Obstet Gynecol Scand 1990;69(3):197-207.
MacDorman MF, Mathews TJ, Martin JA, et al. Trends and characteristics of induced labour in the United States, 1989-98. Paediatr Perinat Epidemiol 2002;16(3):263-73.
Mittendorf R, Williams MA, Berkey CS, et al. The length of uncomplicated human gestation. Obstet Gynecol 1990;75(6):929-32.
Mittendorf R, Williams MA, Berkey CS, et al. Predictors of human gestational length. Am J Obstet Gynecol 1993;168(2):480-4.
Smith GC. Use of time to event analysis to estimate the normal duration of human pregnancy. Hum Reprod 2001;16(7):1497-500.
Q: I have been told that I will need to be continuously monitored during labour as I am attempting a VBAC and I also have gestational diabetes. I understand why they want to monitor and am ok with that but I am petrified of ending up strapped to the bed like with my first labour. I had PROM and then was induced unsuccessfully. 3 days later I ended up having a cesareanw and unable to really move about. Is it unreasonable to ask that I be given 3 periods of 10 minutes every hour where I am completely free to move about or something similar? The midwife I have already tried to talk to this about basically told me that I would be putting my baby’s life at risk if they couldn't monitor the whole labour.
Is there some reason that monitoring is more important in a VBAC and in gestational diabetes?
A: First let's get the gestational diabetes issue out of the way. There is no evidence that what should more properly be called "carbohydrate intolerance of pregnancy" in an otherwise healthy woman increases the likelihood of fetal distress in labor.
Having had a prior cesarean delivery is a more complicated issue. The two studies we have on the topic agreed that the most reliable symptom of uterine scar rupture is a profound slowing of the fetal heart rate (FHR) either continuously (bradycardia) or during contractions (decelerations). Theoretically, then, continuous EFM could improve outcomes by shortening the time between recognition of the problem and delivery. The studies disagreed, however, on whether continuous EFM would improve outcomes. One found more newborn morbidity with delivery in after 17 min when abnormal FHR was the only symptom while the other did not. (Often, although less reliably, scar rupture is accompanied by other symptoms such as heavy bleeding and severe pain.) Still, the benefit was minimal even in the study claiming to find it. Of the 5 infants delivered after 17 min, 4 required mechanical ventilation, but within 24 hrs, they had recovered. The 5th, delivered 32 min after diagnosis, had "asphyxia," which sounds awful, but is a catch-all term for low blood oxygen. No information is given on the eventual outcome for this baby. What we don't know, though, is whether the infants delivered by 17 min in good condition would have developed problems with further delay or whether the infants delivered after 17 min likewise would have had more serious problems with additional delay. Even so, if continuous EFM had no harms, it would make sense to use it as a precautionary measure, but that isn't the case. Several other harmless events can cause FHR decelerations such as rapid descent during pushing or maternal positioning or epidural analgesia causing low blood pressure, and these false positives could lead to unnecessary surgery. In addition, trials of continuous EFM in the general population have shown that EFM increases the likelihood of cesarean and instrumental delivery.
Where does that leave you? I think your best bet is to find a solution you can live with and that won't get you labeled a "difficult patient." EFM needn't confine you to bed nor does being in bed confine you to one position. You can stand, "slow dance" with your partner by rocking from foot to foot, sit in a chair or on a birth ball, kneel upright in the bed or on get on all fours in the bed with a birth ball supporting your upper body and head, etc. I searched on "positions for labor" and picked the Mayo Clinic one, but there were others as well. And it wouldn't be unreasonable to insist on being detached for brief periods so that you can use the toilet or take a turn or three around the room. A doula could be a big help with ideas, and I strongly recommend hiring one. She can also help you and your partner with some of the emotional issues that may arise in a VBAC labor.
Guise JM, McDonagh M, Hashima JN, et al. Vaginal birth after cesarean (VBAC) Report/Technology Assessment No. 71. Rockville, MD: Agency for Healthcare Research and Quality; 2003 March 2003. Report No.: AHRQ Publication No. 03-E018.
Hi, I am really hoping that I might be able to find some sound, evidence-based advice on a tricky situation.
My first child was born via emergency cesarean in 2009. My doctor wanted to induce on my due date and I managed to negotiate 3 more days but it still wasn't enough. My cervix was long and closed and baby was not engaged. I did not know much about induction or how much it increased the likelihood of surgical intervention. My baby was not ready and went into fetal distress. Meconium was then found in the amniotic fluid and I had an emergency cesarean. I was thrilled to have a healthy baby boy but devastated to have had a cesarean. In hindsight, I wish I had been more comfortable questioning the advice of the doctor. Now that I have done more research and see that the average gestation for first time mothers is 41+ weeks, what I agreed to seems crazy! I think I knew this at the time but felt like I didn't have many options.
When I became pregnant the second time, I was very clear that I wanted to VBAC. My doctor (same one) agreed but said he would only let me go 3 days over. I sought a second opinion and was told the same thing. I live in the Bahamas and there are not as many birthing options here as there are elsewhere and again, I felt like I had little choice. All the way along, I have just hoped that I might go into labour spontaneously before the 40 weeks +3 days that my doctor is suggesting. So, I am 40 weeks tomorrow and a cesarean will be scheduled for Thursday if nothing is happening naturally. Again, baby has not decsended, cervix is long and closed.
So, my question is... what can I take to my doctor tomorrow in terms of research that might help me beg for more time to go into labour spontaneously?
PS - I should add that there were no medical complications in either pregnancy.
A: It may be difficult, but it is every person's right to decide on medical care, which means the right to refuse treatment as well as agree to it. The research evidence is very clear that inducing labor in a woman with a prior cesarean and an unfavorable cervix not only substantially reduces her chance of vaginal birth but increases her chances of having a scar rupture. Here are the data from my forthcoming book, Optimal Care in Childbirth: The Case for a Physiologic Approach, now in press:
Seven studies comparing scar rupture rates in inductions involving prostaglandin E2 (trade names: Cervidil, Prepidil), a cervical ripening agent, with inductions not involving PGE2 all reported an increase in scar rupture rates with cervical ripening (Delaney 2003; Kayani 2005; Kwee 2007; Landon 2004; Ravasia 2000; Taylor 2002; Zelop 1999). Differences amounted to 2 to 20 more scar ruptures per 1000 women. Even without use of PGE2, risk of scar rupture with induction is higher. Nine of ten studies comparing scar rupture rates with labor induction not involving PGE2 with spontaneous onset of labor reported higher scar rupture rates with induction (Ben Aroya 2002; Bujold 2004; Delaney 2003; Hoffman 2004; Kayani 2005; Kwee 2007; Landon 2004; Lin 2004; Ravasia 2000; Zelop 1999). Differences amounted to 2 to 19 more scar ruptures per 1000 women. As for chances of vaginal birth, all ten studies comparing VBAC rates in induced labors with labors of spontaneous onset reported fewer vaginal births with induction (Delaney 2003; Elkousy 2003; Gonen 2004; Goodall 2005; Grobman 2007; Gyamfi 2004; Kwee 2007; Locatelli 2004; Ravasia 2000; Srinivas 2007). Seven to 14 fewer women per 100 had vaginal births with induction. Some studies have found higher scar rupture rates when women go past their due date, but differences disappeared when investigators controlled for increased use of induction (Hammoud 2004; Zelop 2001).
I should add that the book doesn't cover studies of misoprostol (trade name: Cytotec), another cervical ripening agent, because scar rupture rates with its use in VBAC labors are so high that some years ago it was banned. (It should be banned, period, VBAC labor or not, but that is another story.)
Reply from sender: My doctor and I have actually already agreed not to induce for this second birth because of the danger of uterine rupture. The issue is really more that he feels that I should have a planned cesarean at 40 weeks and 3 days (this already required some negotiation on my part... he would prefer to induce on due date today), whereas I would prefer to wait for spontaneous labour. Is there any evidence to suggest that uterine rupture is more likely for VBACs (without induction) beyond 40 weeks?
Henci’s response: As I wrote in my previous reply, some studies reported an increase in scar rupture in postdates pregnancies but the difference disappeared after the researchers adjusted for induction. In other words, the excess risk of scar rupture after 40 weeks is iatrogenic, meaning "caused by doctors." It is due to doctors being more likely to induce labor once the woman reaches her due date, not to anything intrinsic to longer pregnancy duration.
2nd reply from sender: I appreciate your clarification of the research re. postdates as I missed the significance in your original response. The great news is that I just saw my doctor and after hearing my perspective, backed up with real research thanks to you, the Lamaze site, ICAN and other great resources I found, he agreed that I seemed to be fully informed and he respects my decision to wait a week. When I first walked into his office today, he said ccesarean in 2 days and now I have a whole week! May not be enough but still feels like a huge victory... thanks for your help! Now, to get labour started...
Henci’s 2nd response: I suggest a compromise if you can't get labor started on its own: if the cervix is favorable, you will agree to the induction, but if it isn't, you will keep waiting. With a ripe cervix, and therefore, no need for cervical ripening agents, the risk of scar rupture is much lower than when cervical ripening is involved, and VBAC rates once the cervix is ready to go are similar to those with spontaneous onset. In addition--and this is a bit trickier than a straight "yes or no" agreement because it may be perceived as telling your doctor his business-- this study found that the risk of scar rupture is dependent on maximum dose of oxytocin and length of time at maximum dose, not length of labor per se. Many doctors use unphysiologic levels and increase the dose before the current one has had a chance to take full effect. The recommended (and I may say evidence-based) dose regimen mimics oxytocin levels your body would produce naturally. It is part of the Pitocin (alternate trade name: Syntocinon) label information.
3rd reply from sender: I am still hoping for spontaneous labour but I'm not sure that I can convince my husband and doctor to go any further than 41 weeks. I just came back from another appointment and baby is nowhere close to engaged. A cesarean has been scheduled for Monday and I am pretty devastated at the thought. I think I could convince them to maybe wait another day or two but I feel like I would be all alone, out on a limb, and then if something did happen because we waited, I would feel responsible. It just feels like I worked so hard to get an extra week of waiting. Anyway, maybe a miracle will happen on the weekend and I will go into labour.
Henci’s 3rd response: I feel for the difficulties of your position. Here's what I recommend: Sit down someplace quiet and review everything you know about the pros and cons of your options. Figure out what you would prefer to do and why you feel that way. Next, sit down with your husband and share what you are thinking and feeling. See what he has to say and listen to his thoughts and feelings. Then find a quiet time to seek inner guidance as to what you believe is best, whether that be in prayer, meditation, or reflection. Once you have made your decision, own it, and don't let yourself second guess it. Move forward in peace knowing you have done the best that you can for yourself and your family.
Q: What is your opinion on the safety of double vs. single layer suturing and VBAC?
A: 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.
Q: I am 41 years old and have had 3 cesareans in the past, the last being 13 years ago. I have a midwife that is willing to do a VBAC with me. Just yesterday we had our first visit with her and while looking through my records from my cesareans we noticed that the last 2 were done with single layer closures. I trial labored with my first 2, having been induced probably too early, and never dilated past 5 or 6. So consequently had 2 cesareans, then my 3rd was scheduled. I need to research and talk to some different docs.
A: Here's what the research has to say: a systematic review (a study that "studies studies" on a particular issue) of scar rupture reported a pooled rate of 1.4% in 16 studies comprising 1666 women. A study looking at scar rupture in women laboring after three or more cesareans found none, but there were only 89 women, way too few to have confidence that the odds with three prior cesareans is similar to two. However, the likelihood of scar rupture is increased by some factors, notably induction or oxytocin (Pitocin or "Pit") augmentation of labor and, yes, single-layer uterine closure. The largest study reported a rate of 3% with single-layer suturing versus 0.5% with double-layer. On the other hand, it is decreased by other factors such as longer interval to next pregnancy and midwifery model care, which a study shows both decreases scar rupture rates and increases VBAC rates.
In my opinion, your best VBAC option would be midwifery-style care in a hospital prepared to handle the need for urgent cesarean 24/7. Unfortunately, the odds of your finding a hospital-based care provider willing to agree to a VBAC at all are very low, and the odds of finding one willing to be patient and supportive during labor are even lower. On the other hand, signing up for another cesarean exposes you and any future babies to the escalating risks of severe complications with the accumulation of cesarean surgeries as well as to the risks attendant on any individual surgery. (The increasing risks, as you may know, arise from increasing likelihood of placental attachment abnormalities and of dense adhesions, which can be problematic not just during cesarean surgery but in any future pelvic surgeries.) As you say, you need to see what hospital-based options may be available to you. If a hospital-based VBAC is possible, you'll have to see if its parameters are acceptable to you. If not or you have no hospital option, it's not an easy decision, and only you can decide what is best.
Reply from sender: Thanks for your response. Our local hospitals that offer midwifery will only allow trial labors after 2 cesareans - not 3. Although that's just the midwifery section. Some of the doctors will consider it. You just have to go in for an individual evaluation. I will have to do that to get a consultation to see what they think. The midwife that is willing to do a home birth with me lives about 10 minutes from the hospital. Do you think that would be sufficient if that ends up being my only choice to try a VBAC
Henci’s response: That makes sense. Here's my analysis of the situation: There are three possibilities that would require hospital transfer:
- Non-urgent situation such as slow labor: in this case, it wouldn't matter whether you were at home or at the midwife's house.
- Urgent but not emergent situation: baby not happy, symptoms that suggest possible scar rupture such as unusual pain or bleeding, or both. Being at the midwife's house would be an advantage.
- Emergency situation: in this case, the midwife's house would be better than your house, but it is possible that it wouldn't matter how close you were to the hospital or even whether you were in the hospital itself.
Two missing pieces are:
- Can the hospital handle an emergent situation 24/7?
- How good a relationship does the midwife have with the hospital staff? If she were to call and say I'm bringing a woman in who will need a cesarean stat when we arrive, would the OR and OR staff be waiting for you when you came in the door? Unfortunately, this is often not the case.
2nd reply from sender: My records from my past 2 cesareans show that I had first a running locked suture followed by an imbricating suture.....would this be a double layer closure?
Henci’s 2nd response: I am, of course, not a clinician, but I remembered that I have Gretchen Humphries' talk on uterine closure techniques at ICAN's 2007 conference, and, yes, you have double-layer closure. (Gretchen's day job is as a veterinarian. She has performed cesarean surgeries, just not on people.)
Medical & Physical Conditions Affecting VBAC
Q: I have 6 children. My first were vaginal births and easy enjoyable experiences. Then I became pregnant with twins. I went into labour at just under 34 weeks and was forced into a cesarean.(too long to explain here but hospital has since admitted there was no medical need for section). I found this very distressing. 6 years later I was pregnant again and developed pre-eclampsia that my doctor and midwife ignored. I struggled for about 8 weeks with swollen hands and feet and other symptoms and repeatedly being told I was worrying too much. After my last appointment with my midwife I took myself to hospital and pre-eclampsia was diagnosed. I had my baby a couple of days later by cesarean at 35 weeks and 2 days. In was told I couldn't have a vbac because they could not induce me because of previous cesarean. Again, very distressing. 3 years later I became pregnant by surprise, everything seemed to go well physically but I could not accept the pregnancy emotionally at all. Then at 24 weeks I had sugar in my water and was put on insulin . I had hypos nearly everyday. I lost 2 stone in the last 3 months of my pregnancy. When I had the baby I weighed less than I did before I got pregnant. Any way, when I got to 36 weeks this time I began to believe I was pregnant and got excited. I agreed to a plan to be induced at 38 weeks and have a vbac. At 37 weeks The baby was scanned and appeared to weigh just under 6 lbs. So I was offered a cesarean. I refused as I still wanted to have a vbac. I agreed to come in to have a trace each day and to come back in to be induced later in 38 the week. One day before I turned 38 weeks I had a trace and both me and the baby were fine. I was about to leave when a doctor who didn't know me (it was the weekend) asked why I was having a vbac. I told him was because I thought it was safer. He said because I was having hypos (which I had been having throughout time on insulin) that my placenta was probably failing and should have a section that night. I should stay in hospital and be constantly monitored because if I fell asleep I might not notice the baby stopped moving. I was distraught. I called my midwife and she arranged for me to have my waters broken on the unit to try for my vbac. Despite contracting almost straight away and having them about every ten minutes and the baby remaining fine I could not cope with the fear. I could not sit, stand or lie down. I could not rest believing that my baby could die any second. I just gave in and I think I went a little mad. I had a cesarean and my baby practically roared at the surgeon. She weighed 6 lbs. She is now 18 months old and wonderful and still breast feeding. I however suffered severe PTSD and have been having counselling. I still suffer flashbacks and it was many months before I believed she was not going to die any second. I have read a great deal since her arrival. I feel I didn't need insulin and that's why I lost so much weight and had hypos all the time. I did think the healthy eating plan was good. I am 5 foot 7 and wear size 16 clothes. Am I mad for thinking this? I feel that I have gone from a normal women to a wreck. If I were to have another child do you think I stand any chance of being treated like a normal woman? I would appreciate your thoughts. I had my first child at 24 and I will be 40 next week.
A: It sounds like you have been through some very difficult, frightening, and disempowering birth experiences. You are doing the right thing in getting help with the psychological aftermath. If you want another resource, I recommend Solace for Mothers, a peer support group for women who have had traumatic births.
I think that yes, you absolutely have a chance of changing this pattern should you decide to have another baby, but I think it depends first, on your working through the emotional issues so they don't come back to bite you in a subsequent pregnancy or labor, and second, on making thoughtful choices of your care providers and place of birth, and third, on preplanning for potential triggering scenarios so that you can handle things differently instead of reacting automatically. Your therapist should be able to help you with all of these.
You don't mention a partner or other loved ones as you told your story, but whoever would be with you during pregnancy and labor also needs to be on the same page you are and ready and willing to support you in your decisions, so you may have work to do in that arena as well. It isn't unlikely that if they have been with you during your prior experiences, they, too, have emotional issues to work through.
P.S. It sounds like you may be a woman of size. If so, I recommend the blog The Well-Rounded Mama.
Q: I have a friend who is trying for a VBAC, 2+ years after a cesarean for breech presentation (footling). No breech present this time.
Waters broke, but no contractions yet. Just wondering if there is some sort of 'best practice' policy out there for how long is generally allowed between waters breaking (no meconium/baby stable, etc.) and repeat cesarean? At 40+2days. No underlying conditions, mother and baby are both healthy. We’re dealing with a “shroud waving” doctor.
A: Hopefully, your friend has begun labor spontaneously by now. According to the introductory section of the Cochrane systematic review of PROM at term, 79% of women will begin labor by 12 hours and 95% by 24 hours. The same systematic review makes clear that awaiting spontaneous labor does not increase newborn infection rates despite few babies in the biggest trial being tested or treated for GBS. Endometritis rates are modestly higher with awaiting labor (6 more per 100), but infection rates correlate with number of vaginal exams, so one wonders whether this excess is iatrogenic. The review concludes: "Since planned and expectant management may not be very different, women need to have appropriate information to make informed choices," which means "shroud waving" is not in order. Should your friend exceed 24 hours or wish to agree to induction, giving Mother Nature a gentle nudge with a physiologic oxytocin regimen should have minimal, if any, effect on her risk of scar rupture. Among 9 studies (I can provide a list if you need it), 2-19 more women per 1000 induced without involving prostaglandin E2 experienced scar rupture compared with women with spontaneous onset. Doubtless, the oxytocin regimen was an important factor.
Q: I am actually sending this on behalf of a friend's sister... She was hoping for a VBAC for this pregnancy. Her first pregnancy ended in a cesarean because of 'failure to progress'. She was told it would be unwise to attempt a TOL because she has android hips... My understanding is labor can be more difficult & pushing can take longer but vaginal deliveries are possible with this shaped pelvis. Is this a reason to submit to a scheduled cesarean for this pregnancy? Are there any studies available to confirm or debunk the thinking that a pelvis with this shape will not allow a baby to pass?
A: Let's start with the four basic shapes of the female pelvis. This link is the best I could find showing them without spending too much time looking.
It is true that the android shape is considered less favorable for childbirth as this article attests, but vaginal birth depends many factors. Even those that appear to be unalterable such as the size and shape of the woman's pelvic opening and the circumference of the baby's head are not fixed. The pelvis can flex open and the skull bones can mold to fit through it. I am not aware of any research specifically on pelvic shape and VBAC likelihood, but Lamaze's "A Woman's Guide to VBAC" can help your friend's sister make an informed choice about planning VBAC or repeat cesarean surgery. As the booklet makes clear, neither planned VBAC or cesarean guarantees a problem free birth nor need a woman be an ideal candidate to have a good probability of vaginal birth.
If she decides to plan a VBAC, I recommend that she find a caregiver who encourages VBAC, not just reluctantly agrees to it. If her care provider doesn't think she is able to birth vaginally, it is likely to become a self-fulfilling prophecy because it will affect her care provider's judgment. For example, I have a study that found that women were given less time in the VBAC labor if their prior cesarean was for delayed progress that if it was for a reason such as breech or fetal distress. Your friend's sister should ask what percentage of his or her patients with prior cesarean plan VBAC, and what percentage of them birth vaginally. The answers should be "most of them" to the first question and at least 70% to the second one. If she can't find such a person--or even if she can--I strongly recommend hiring an experienced doula. A doula can help with physical support such as ideas to help labor progress and with emotional support as well, which can be especially important for women and their partners in VBAC labors who are more than ordinarily likely to experience feelings of anxiety or discouragement. (More about doulas and how they can help can be found here.)
VBAC And Uterine Dehiscence
A: Have you had any experience with uterine dehiscence? I had a 10 cm dehiscence found upon incision after attempting a homebirth after 2 cesareans (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 cesarean 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 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.
A: 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.
Q: I am desperate 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 ccesarean. Five years later during my pregnancy. 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 30 hours 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 cesarean. What I was told was I had ruptured, and not to become pregnant 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 would need another cesarean around 38 wks but could become pregnant 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 Florida 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 layperson to search when I don't know where to even look.
A: 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 cesarean 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 cesarean, 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 cesarean 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 weeks, 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 cesarean 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.
Reply from sender: Thank you for the input. I did look at the site your recommended. One section said if there was separation of the scar that may not be a reason to have a repeat cesarean. Is my case somewhat different since mine opened all the way along? I was also thinking the use of a prostaglandin 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?
Henci’s response: 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 cesareans. 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.
2nd reply from sender:We are still TTC at this point, but, I have a question. You mentioned in your post that the recommendation 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 will try to Homebirth VBAC (HVAC) if I can find a provider. I felt so much stress just thinking about going in to another hospital. However, if it is recommended by a provider I trust (someone who supports VBAC and normal birth) that I should plan another cesarean I will give it serious thought. I am also wondering if mulitple induction drugs are given due to fact that 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?
Henci’s 2nd response: 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 cesarean 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
3rd reply from sender: 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 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)?
Henci’s 3rd response: I am not aware of any studies specifically on labor with a small window in the scar. What we have is indirect evidence: a number of papers and reviews from the 1980s found about the same percentage of women who have planned repeat cesarean prior to labor have an opening in the scar at the time of the surgery as have a scar separation during a VBAC labor. This implies that women must be laboring with these windows and not having a problem with them otherwise rates would be much lower in women having planned surgery. I could provide the citations for these papers, but your strongest argument is that the exact degree of risk or lack of risk is irrelevant. You should have the right to refuse surgery even if your doctor deems it inadvisable and still receive medical care just as it would be if you were not pregnant. That being said, because there may be a greater risk, it would probably be better to labor in a hospital that can perform an urgent cesarean at any time of the night or day and to avoid inducing labor with oxytocin or prostaglandins or augmenting labor with oxytocin because these agents increase the risk of scar rupture. It would also be better to avoid an epidural because it increases need for labor augmentation.
I have a 1992 study of dehiscence, which the authors defined as "silent separation of a scar incidentally 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 198-9 study distinguishing between dehiscence, which authors defined as "separation of the uterine scar with un-ruptured 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.
I have a related question. I was "diagnosed" with a thin lower uterine segment (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 contractions 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. Vaginal birth after 2 cesareans (VBA2C) is still in the standard operating practice 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 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.
A: 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.
How Many VBACs Can I Have?
Q: I am wondering if there is any literature you can point me to regarding the safety of a vaginal birth after a VBAC. I have heard a physician stating that the risk of uterine rupture increases, and I am wondering what the research on this subject says.
A: Oh, my. The facts are exactly the reverse. Having a VBAC greatly decreases the risk of scar rupture and increases likelihood of vaginal birth in subsequent pregnancies. Among the three studies on this topic, 3 to 17 fewer women per 1000 with a prior VBAC experienced scar rupture compared with women with no prior VBAC. Among the seven studies reporting VBAC rates, six of the seven reported rates of 90-97% with prior VBAC vs. 70-76% with no prior VBAC. The seventh study reported a rate of 81% with prior VBAC vs. 60% with no prior VBAC. Once a woman has a VBAC under her belt, so to speak, she is almost certain to go on having uneventful VBACs.
Q: Is a VBAC nuts if...
1. cesarean : failure to progress
2. VBAC 8.8 lbs.
3. VBAC 9.6 lbs.
4. VBAC 8.6 lbs.
5. cesarean: fetal distress
6. VBAC 9.3 lbs.
7. VBAC 9.15 lbs.
8. cesarean: breech
Am I crazy? or irresponsible?
A: Absolutely not! The fact that you have had VBACs means that you will almost certainly have another uneventful VBAC. By contrast, each cesarean comes with risks attached to having surgery, including greater likelihood of injuring internal organs because of internal scar tissue (adhesions), and accumulating additional cesareans escalates your risk of life-threatening placental attachment complications* in future pregnancies. Not to mention the easier recovery with vaginal birth, which is no small thing with your large family. Since you already have three prior cesareans, though, I would recommend VBAC in a hospital staffed and equipped to handle urgent cesareans 24/7 because you are at higher risk for those placental attachment problems.
* placenta previa: placenta covers the cervix partially or completely; placenta accreta: placenta grows into the uterine muscular wall and sometimes through it; placenta previa and accreta in combination
Reply from sender: What hospital will let me VBAC after 3 cesarean? It was a nightmare to VBAC after 2. They told me the "climate" had changed since my previous VBAC, which was the previous year and the hospital wouldn't allow it. (This was with #7.) I fought to be allowed and was successful, but it was awful. Do you have a suggestion? I am trying not to freak out. My recoveries from the natural births were nothing. The cesarean recoveries were very difficult and I'm pretty tough.
Henci’s response: I was hoping VBAC access wasn't going to be a problem for you since you have managed to obtain VBACs despite multiple cesareans. Fortunately, you've got some time to see what can be done. The International Cesarean Awareness Network has a page with recommendations on what to do if a hospital refuses VBAC. Here is a quotation from the Joint Commission's consumer pamphlet "Speak Up: Know Your Rights" that should be helpful. (The Joint Commission accredits hospitals.
- You have the right to be informed about the care you will receive. . . .
- You have the right to make decisions about your care, including refusing care. . . .
- You have the right to be listened to.
- You have the right to be treated with courtesy and respect.
Finally, here is a quotation from the current (2010) VBAC guidelines put out by the American Congress of Obstetricians and Gynecologists:
Respect for patient autonomy also argues that even if a center does not offer TOLAC [trial of labor after cesarean], such a policy cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery.
This statement is followed by:
When conflicts arise between patient wishes and health care provider or facility policy or both, careful explanation and, if appropriate, transfer of care to facilities supporting TOLAC should be used rather than coercion.
Nonetheless, the language is there, and you can use it to politely but firmly insist on them either providing you VBAC services or find you a facility that will that is nearby enough that it will not create undue safety (distance to drive in labor) hazards or financial barriers (won't take your insurance).
Please let me know how things work out for you.
2nd reply from sender: Thanks for your help so long ago. I am going in tomorrow to get an amniotomy at 39 weeks because of PIH. My doctor is letting me do a trial of labor (ToL). I hope this VBAC is successful!
Henci’s 2nd response: I hope all goes as you would wish, and I look forward to hearing from you. If you will forgive the liberty, I'm going to suggest reframing the language around VBAC you have picked up as it may help you feel more empowered. "Letting" you do a "trial of labor" implants that the decision is your doctors', when, in fact, the choice to agree or refuse surgery is yours, and "trial of labor" implies that this is an "iffy" proposition and not the norm, when, in fact, labor is what happens at the end of pregnancy and with optimal care, the vast majority of women will birth vaginally. "Successful" VBAC is problematic because it suggests that a labor that ends in a cesarean is a failure. I think you would be better off thinking that you have chosen to plan a VBAC that will probably end in a vaginal birth but may end in an unplanned cesarean.
Q: I'm 36 1/2 weeks pregnant with my 3rd child. I really want to have a natural birth with this child as I did with my second child. But my doctor says that she will not do a second VBAC with me. My 1st son was an emergency Cesarean because he was breech and my water broke.
My doctor is a different doctor from my 1st 2 children. I feel my body is in good condition to go natural. The doctor also said the hospital is not equipped to do a VBAC. It has been almost 7 years since my last child was born. How can I get around having my child natural, and can I refuse a cesarean at my local hospital?
A: Planned VBAC is not only safe, but having had one already, absent a new indication for cesarean, a second planned VBAC is your safest and best option. The likelihood of VBAC is greatly increased and the likelihood of scar rupture is greatly reduced once you have a VBAC under your belt, so to speak. On the other hand, planning an elective repeat cesarean exposes you not only to the risks of any individual surgery but to the risks of accumulating cesarean surgeries. In other words, your ob is not practicing evidence-based medicine--not to mention denying you every person's inalienable right to refuse surgery. Moreover, if the hospital is "not equipped to do a VBAC," by which she presumably means it isn't equipped to handle an emergency, then your hospital isn't equipped to handle any laboring woman, period.
Your best bet is to find another doctor or midwife and possibly another hospital if there is one within reasonable distance. If there is an International Cesarean Awareness Network (ICAN) chapter in your region, they will know who is doing VBACs. If not, try the local doulas or call hospitals in your area and ask which clinicians are attending VBACs. Other options are, (1) as you suggested, refuse a repeat cesarean, but the disadvantage is that you will be under the care of a physician and possibly nursing staff who disagree with your decision and aren't happy with you for making it, or (2) planning a home VBAC with a qualified home birth attendant. Disadvantage is that while you are at very low risk of scar problems (2-4 per 1000), the risk is not 0. If you stay with this ob and hospital, I recommend hiring an experienced doula so that you and your partner have someone in your corner. Also, barring an emergency, do not agree to any intervention without understanding its potential benefits and harms, your alternatives--including doing nothing, and the potential benefits and harms of your other options. Again, barring an emergency, take time to consider your options without medical staff present so that you do not feel pressured. I would also be alert to attempts to manipulate you. You can tell if this is happening if you are getting feelings instead of information.
Reply from sender: May I follow up with a related question? Does the lower risk of rupture apply for the 2nd VBAC if the cesarean was an inverted J incision? The first VBAC was successful with a 10 + lb baby at home. ( There was no doctor to be found who would consider a VBAC with a classical incision.) Would you think that a repeat home birth would be tempting fate, or would the calculated risk be lower now that we have a "proven" scar? And if lower, do you have a percent risk?
I am a midwife that has always felt that the risk of VBAC after an upper uterine segment incision is too risky at home. Is there more to consider here?
Henci’s Response: First, let me clarify. So far as I understand it, an inverted J incision is not a classical incision. A classical incision is a straight, vertical incision on the body of the uterus. A J-incision is a transverse incision that has been extended up into the body of the uterus. (Here is a page, where, if you scroll down, you can see an image of the various types of cesarean incisions.) That being said, any incision into the uterine muscle is thought to increase the risk of scar rupture to an unacceptable degree, which means no one is doing VBACs in these women. The best data we have on risk of the scar giving way with an unconventional scar type comes from a large, multicenter U.S. study in which a mixed group of 105 women with inverted-T, J-shaped, and classical incisions managed to slip through the net and labor. Two percent had scar ruptures versus a rate (when labor was not induced or strengthened with I.V. oxytocin) of 0.4% in the overall planned VBAC population. That population size is too small to make a judgment on safety. For example, if one more woman had had a scar rupture, the rate would jump to 3%, nor do we know whether risk differs among the scar types. All of this is to say that there is no research that could help guide you. Since I doubt that the obs in your community will be any more willing to agree to a VBAC--although it might be worthwhile to check around--it comes down to you and your client deciding which set of risks she prefers to run: the risks of cesarean surgery and of accumulating another cesarean scar or the risk of scar rupture in an environment unprepared to deal with it. In a functional maternity care system, of course, she wouldn't be faced with this kind of choice.
VBAC With Classical Incision
Q18: Can I have a vaginal birth after a classical incision for myomectomy
Q: I am looking for a second opinion. I am 35yo, first time mother, approximately 33weeks. I have been seeing a group of midwives since the beginning of this pregnancy and planned for a natural, un-medicated labor and birth. 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 cesarean 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.
Q: 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.
Q: I had a classic cesarean in 2006 (inverted-T incision) and a prior vaginal birth 4 years ago. I am now 13 weeks pregnant and have found a maternal-fetal medicine specialist at a local teaching hospital that is open to me having a VBAC. I am so excited. He suggested continuous fetal monitoring - external and/or internal. He said no drugs would be used (Pitocin, Cytotec) and recommended against having any pain medication. Can you offer any other suggestions for a woman in my position?
My goal is a healthy baby and mother. My son who was born in 2006 passed away at 4 days old. Not because of the cesarean, but because he had a large sacrococcygeal teratoma that required surgery to remove it.
A: Let me start by saying that I am neither a midwife nor a doctor, so, I don't give medical advice. That being said, I am aware from the research that all of the medications used to induce labor have been shown to increase the risk of scar rupture in at least some studies, likewise, making contractions stronger with oxytocin. The effect on the scar almost certainly depends on who is considered eligible for labor induction or augmentation and what medications, combinations of medications, and dosages are used. Since he doesn't want to induce you, you may wish to discuss the reasons he might normally recommend induction and your alternatives. In many cases, you will want to weigh the potential benefits and harms of awaiting labor vs. a scheduled cesarean. For more information on making an informed decision, go to Informed Decision Making, Informed Consent or Refusal on the Childbirth Connection website. I would guess that your care provider just wants to take a cautious approach in your case.
I'm not sure why he wants to avoid pain medication -- although there are some good reasons for avoiding it in general -- but I could speculate that the use of epidural analgesia increases the likelihood of needing oxytocin to make labor stronger, which, as just mentioned, may increase the chance of having scar problems. A fairly common side effect of epidurals is episodes of slowing of the unborn baby's heart rate (bradycardia). Such episodes are also the most reliable symptom of scar problems. He -- and you -- may wish to avoid a "false alarm" leading to an unnecessary cesarean. However, if his concern is that an epidural may mask the pain of the scar opening, you should know that pain is not a reliable symptom.
I strongly recommend that you hire a doula. This is likely to be a more than usually anxious labor for you and your partner, and continuous support from a trained and experienced woman can be helpful. If you are trying to avoid pain medication, a doula can really help you out there. For more information on doulas, go to Options: Labor Support, also on the Childbirth Connection website.
Continuous electronic fetal monitoring has been shown to be the most reliable way of picking up scar problems as the most common symptom is, as I said, a substantial, sudden drop in the fetal heart rate. What is less clear in the research is whether picking it up via EFM actually improves outcomes. You may wish to discuss the pros and cons of external vs. internal monitoring. At one birth I attended as a doula where there was concern about the baby, the doctor compromised on using external monitoring as long as they were getting an accurate enough recording.
You may also wish to know whether your care provider wants to put any other restrictions on you. For example, will he set limits on the estimated size of the baby? Set time limits for making progress in labor? The informed decision making page will help you here as well if you want to make informed choices about other elements of your care.
You didn't ask me this, but you may be interested in knowing what the odds are of the scar opening and causing problems with a cesarean uterine incision that is not the standard type (low, transverse). A large recent study of 17,900 women planning VBACs reported a rate of scar rupture of 2% (2 out of 105) in women with classical (vertical), inverted T, or J incisions. This is compared with a rate of 0.4% in women with the usual type of uterine incision who labored spontaneously (no induction, no augmentation). Keep in mind, though, that while a scar rupture is serious and will almost certainly require an urgent cesarean, the baby is almost always fine. Here is the citation for the study in case anyone is interested:
Landon MB, Hauth JC, Leveno KJ et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med 2004;351(25):2581-2589.
Because you are at somewhat increased risk, you will probably want to labor in a hospital capable of handling an urgent cesarean 24/7. You describe your care provider as a "maternal-fetal medicine specialist," so you probably have that base covered, but it might not hurt to double-check. Hospitals in this category have obstetricians, anesthesiologists, and pediatricians in-house at all times, have at least a level II nursery (capable of handling fairly sick babies and stabilizing very sick babies for transport to a level III nursery -- a neonatal intensive care nursery), and 24-hr blood banking.
As you ponder your choices, be sure to take into account whether there is any chance at all that you will have another pregnancy. The risks of a number of serious, life-threatening complications escalates for the next baby with each successive c/sec. There is also increasing risk of dense surgical adhesions, which poses increased risk to you of surgical injury, should you ever need abdominal or pelvic surgery in the future, as well as increasing your risk of experiencing chronic pain and the possibility, although still rare, of experiencing a twisted bowel at some time in the future.
Reply from sender: The hospital where I plan to birth is highly capable of handling emergency situations and the maternal-fetal medicine specialist/OB has done much research on VBACs and the use of induction/augmentation agents. I do plan to hire a doula and my former midwife has also asked to attend the birth. So, I feel very comfortable being with them.
The uterine rupture rate you specified sounds even better than the statistics I've read (upward to 7%). I feel OK with those odds (over having a repeat cesarean).
The MFM recommended no pain medication for both reasons you stated: it could mask uterine rupture pain (although this is not reliable) and it could affect the baby's heart rate. I do not want any "false alarms" which may contribute to a cesarean. I personally would rather have a drug-free birth as well (for many reasons).
I plan to talk to the MFM about using external fetal monitoring if everything is going smoothly. I do not want internal monitoring (for infection reasons and personal reasons) unless the external monitor is not picking up accurately.
I do not know if we plan to have another pregnancy after this one but it is a possibility. Just another reason to avoid a repeat cesarean.
Henci’s response: It sounds like you are in good hands and well on your way to planning the safest possible birth. You are also wise to take into account that another pregnancy, intended or not, is a possibility if you are not planning to do something permanent about preventing it.
The rate that I have seen bandied about in the literature for scar rupture of a classical incision is even higher than 7%. After reading the Landon 2004's statistic, I looked up the sources for the higher number. Turns out it came from two older studies from back in the days when a fair number of classical uterine incisions were still being done, but these studies did not distinguish between scar dehiscence (a harmless window) and scar rupture (the scar opens completely and causes symptoms). Landon 2004 did, as do all of the more recent studies and reviews.
2nd Reply from sender: I just wanted to update this posting to report that I had an intervention-free vaginal birth after classic cesarean on 3/29/2007. I labored at home for less than 6 hours and arrived at the hospital 26 minutes before our daughter was born. I was complete upon arrival and she came out with 3 contractions. I will say this birth was the most rewarding event in my life. It was significantly empowering. I am quite thankful that I didn't experience uterine rupture and found a supportive provider who respected my wishes to VBAC (although he didn't make it to the birth because of the brief time I was in labor there).
Henci’s 2nd reply: I am absolutely thrilled for you! I know personally that an empowering birth experience can be a life-changing event--and that the reverse is also true.
I am sure your hands are full with your new baby and your older child, but if you can find the time, it might help others if you would write the hospital telling them how much it meant to you to have a flexible care provider who was willing to work with you and who respected your right to make informed decisions about your care.
Q: I am 37 weeks pregnant with our third child. We have 2. 5 year old twins. Our son was born vaginally and our daughter was born by emergency cesarean. My cervix closed on the doctors arm and when she pulled her arm out, my cervix tore and her umbilical cord came out. Somehow I ended up with a low transverse incision with a curve up one side (j incision). I've been fighting doctors left and right. We are military and don't have 100% control of the care that I've been getting. I've decided to attempt a medicated free VBAC. It is hard to find anyone out there with a VBAC under their belt that is not from a low transverse incision. I am trying to find others out there to help with the moral support. It is hard when it feels like you don't have much support. My husband and family are 100% behind me; I just wish more doctors and hospitals were more supportive. Luckily for me I have found a great midwife who is behind me, but a hospital that is fighting me tooth and nail.
Q: Please could someone give the contacts of any caregivers in the USA or Canada that is willing to handle VBAC after a Classical Incision? I am pregnant and don't want to go through the traumas of a CS again.
A: I hope someone out there responds, but I have to say that it's a long shot. I suggest you get in touch with people at the International Cesarean Awareness Network (ICAN). If anyone would know who might be willing to take you on, they would. The ICAN website might have helpful advice too. It should be your absolute right to give informed refusal to surgery, but unlike any other patient, it is a right denied to pregnant women. Here are some agencies that affirm that right:
Office of Personnel Management HIPAA Consumer Rights and Responsibilities. Appendix A. Consumer bill of rights and responsibilities. Chapter four: http://www.opm.gov/retirement-services/publications-forms/benefits-administration-letters/1998/98-203.pdf
“In order to ensure consumers' right and ability to participate in treatment decisions, health care professionals should:
Provide patients with easily understood information and opportunity to decide among treatment options consistent with the informed consent process. Specifically,
- Discuss all treatment options with a patient in a culturally competent manner, including the option of no treatment at all. . . .
- Discuss all risks, benefits, and consequences to treatment or nontreatment.
- Give patients the opportunity to refuse treatment. . .
- Abide by the decisions made by their patients . . . consistent with the informed consent process.”
Department of Health and Human Services. Chapter IV -- Centers for Medicare & Medicaid services, Department of Health and Human Services: Part 482--Conditions for participation for hospitals. In: National Archives and Records Administration; 2005.
“A hospital must protect and promote each patient’s rights. . . . The patient’s rights include . . . being able . . . refuse treatment. . . . The patient has the right to be free from all forms of abuse or harassment"
The Joint Commission. Speak Up: Know Your Rights. Note: "The Joint Commission" is formerly "Joint Commission on Accreditation of Healthcare Organizations"
- "You have the right to be informed about the care you will receive. . . .
- You have the right to make decisions about your care, including refusing care. . . .
- You have the right to be listened to.
- You have the right to be treated with courtesy and respect.”
Q: I have a 10 and 8 year old both vaginal deliveries no complications, labor started on it's own at home with my water breaking. I had another vaginal delivery, Jan. 2009 at 14 weeks due to a large fibroid, which I never had before or since. The fibroid was found at 7 weeks with me complaining of right side pains at that time it was the size of an orange. By 14 weeks the pain was 24/7 and I was put in the hospital and 3 days in I went into labor with my water breaking. In 2009 I had a myomectomy with the Da Vinci Robot to remove the fibroid that grew to the size of a cantaloupe it was NOT inside my uterus it was on top of it but not on a stalk. My doctor and my OR notes state "a skin flap was pealed back and fibroid completely removed and skin flap tacked back down". They did NOT go into uterine muscle or puncture through uterus. I was shocked when I was told yes I had to have a cesarean for any future pregnancies. One reason I got was because it was on top of my uterus and the other because the hospital and or my insurance did not practice "VBACS" and since i had a uterine surgery it was considered that. I conceived in 2009 with no complications BUT was a scared wreck through whole pregnancy from fears told by doctors that women can have uterine ruptures during pregnancy from any uterine surgery and I quote, "you would bleed out within ten minutes and the risk of death is high for mother and child if that occurs" So I had a cesarean in 2010 to a healthy baby boy with no problems. I asked my doctor during the cesarean IF my uterus looks bad or at risk then I need my tubes tied. Her exact comment was it looks perfect I can't even see a scar where we did the myomectomy. GREAT so is this a cesarean for NOTHING. We have a strong faith and believe in having a large family and repeat cesareans NOT the way we want to go unless it just has to be and NOT because of liability reasons. So I would like your opinion as much as you can just hearing my story and not seeing my chart. I do have my complete medical records and since all this we have moved from FL to VA and although I'm not pregnant I would like to find an ob or midwife - someone that would listen and at least look at and research my chart and give me a chance for a VBAC.
A: I am not a midwife or doctor, so I cannot give you an opinion. I can, however, tell you what the research says and apply logic. If your doctor said she couldn't even see a scar from your myomectomy, then you are essentially a woman with a history of a single cesarean and two prior vaginal births, which makes you an excellent candidate for VBAC. I have 10 studies of women planning VBAC with a history of vaginal birth, and the VBAC rate was 90%, give or take a few percent in all 10. I have five studies reporting percentages of the scar giving way. In all cases, it was substantially lower (2 to 6 per 1000 VBAC labors) than in women in the same population without prior vaginal birth. And it must be remembered that in all but a few, rare cases, scar rupture means no more than having an unplanned cesarean. Mother and baby are fine. On the other hand, each cesarean surgery increases the likelihood of having life-threatening placental attachment complications in the next pregnancy, and you say you want a large family. I suggest you get in touch with the International Cesarean Awareness Network people closest to your new home. They'll know who is doing VBACs.
Q: There are women very regret for have tried VBAC after cesarean because their losses. , I will suggest not have VBAC at all because you don't want take risk with you and your baby life.
A: 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 escalating 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.
I just want to let all those ladies out there know that unless there is a medical reason for having another cesarean that a VBAC is possible! My first son, the result of rape, had a huge head and the kid just wasn't coming out the right way. His heart rate kept dropping and the cesarean was just inevitable.
I was told that because of my strong stomach muscles and the fact that I was young (23 at the time) that I should have no issues with having a VBAC. I got pregnant after getting married about 3 years later. I had to really search for a doctor who believed in the VBAC process. She was not only informative, but extremely supportive. She was not just interested in how my pregnancy was doing, but how I was doing as well.
I signed a consent form and had one false labor. I will not lie, I was scared! Now it seems ridiculous because the chances of rupture are less than 1%, but I was taking that chance. Totally worth it. I would recommend that anyone attempting their first VBAC be very near (less than 10 minutes) or birth in a hospital just to be on the safe side. But, after one VBAC take a glance at this article: http://www.medscape.com/viewarticle/573948_2 and you'll be amazed how much easier and safer a subsequent VBAC can be.
While not all VBACs are successful it is a good idea to do your research and be prepared for everything. Find out what you can do to prevent another cesarean - exercise throughout your pregnancy, go as long as you can without an epidural (painful but worth it), and try not to birth on your back.
I wish everyone who is attempting their first VBAC blessings. It is so much different than a Cesarean and you will be wonderfully surprised at how much energy you have and just the whole process!
A: Thanks for sharing your story. The research shows that it isn't how easy or hard the labor is or whether it ends in vaginal birth or cesarean surgery that makes for a positive birth experience but whether the woman was a full participant in and agreed with the decisions that were made and whether she was treated with respect and kindness by her caregivers.
Here are two good sources of VBAC information, "A Woman's Guide to VBAC" on the Lamaze website and "VBAC or Repeat C-Section" on the Childbirth Connection website. You can also find information on the International Cesarean Awareness Network's (ICAN's) website and at VBAC.com
Response from a blog reader: Thank you so much for the information. My first was a natural birth turned c-section (no meds until I was on the operating table - I walked to the OR!) so I'm looking for anything and everything I can find about VBAC. My midwife agreed that my pelvis was adequate and I am healthy. I was 2 weeks overdue and induced (via cervical balloon) which I firmly believe caused the need for surgery. I wish I had been given just a couple more days, but our medical system panics at anything out of the normal.
I love reading successful VBAC stories! Thank you so much.
Q: I am in the process of writing a protocol for my home birth practice and VBAC. In my reading of various sources I have seen mention of history of infection of a previous incision with cesarean as well as extension of the incision being cited as reasons to risk out a client for VBAC. I haven't been able to find any evidence regarding these findings and increased risk for uterine rupture in labor. Do you know of any such evidence?
A: I just skimmed the systematic review that underpinned the 2010 NIH VBAC conference, and the reviewers did not look at infection after the previous cesarean as an influence on scar rupture rates. I know it has been proposed as one, but I haven't run any searches on the issue myself. If you want to try and haven't already, this is PubMed's gateway, and there is a link to tutorials on that page on how to structure searches. I know that VBAC is not recommended for inverted T and J incisions, but I have not seen any research on incision extensions. The best data we have comes from an analysis the big Maternal Fetal Medicine Units Network cohort in which a mixed group of 105 women with classical, inverted T, or J incisions labored, among whom 2, or 2% experienced scar rupture. I would think this is high enough to contraindicate home birth, but I don't know if this should be extrapolated to incision extensions. Maybe you can find something in PubMed as well.
Q: A friend of mine had a planned CS for a breech baby which she now regrets. She wants to try for a VBAC with her next one, but she is worried the baby might be breech again. If that would be the case, she would still like to try for a VBAC and has asked me for some statistics. Unfortunately I couldn't find any.
A: Well, her biggest problem will be finding a care provider willing to do VBAC even if the baby is head down. That being said, I'm not aware of the statistics on how likely it is that her next baby would be breech. If it is, her best bet would be trying to get the baby turned. Here's a general article on strategies. Besides the various home remedies, the Webster technique--here's a video--a chiropractic technique, and moxibustion, a Chinese medicine option--here's a video- https://www.youtube.com/watch?v=K1jF8f981mA - should be harmless because neither involves manipulating the uterus. I also have a tidbit of data on the safety of external cephalic version, an obstetric technique, which does: A review reported on one study of 56 women with a cesarean scar who underwent ECV to turn a breech and none had a problem with the scar. This isn't enough to establish safety, but it suggests risks are probably not unduly high, and, of course, the risks of accumulating cesarean scars should be considered in the calculation. Lieberman E. Risk factors for uterine rupture during a trial of labor after cesarean. Clin Obstet Gynecol 2001;44(3):609-21.
Q: I have a couple of questions for you about my upcoming VBAC delivery. First of all let me give you a little bit of my background. I am currently 35 weeks pregnant with my 5th child. My first 2 were delivered vaginally at just over 39 weeks. My first was started when my water broke on it's own. After 12 hours of labor (without an epidural) and not much progression they decided to give me pitocin to help it along. At that time I asked for an epidural as I was very tired after laboring all night without any sleep. My son was born about 5 hours after I got my epidural. My second child was a scheduled induction after 2 days of inconsistent but constant contractions. When I was checked right after they started the pitocin I was already dilated to a 4 and was told I would have probably been in later that day to have the baby even without the induction. That labor lasted a total of 5 hours and I had an epidural. My 3rd child was born by emergency cesarean. My water broke and 4 hours later I was at a 9 1/2 but the baby's heartbeat was going down in between contractions. My doctor tried to finish stretching me but it didn't work. After being prepped for surgery my doctor again tried to stretch me in the OR but again it didn't work. After the baby was born we found that his cord was wrapped around his neck 3 times and the doctor figures it was hanging him in between contractions and not letting him descend enough to finish dilating. With my 4th child I was going to try a VBAC but due to unforeseen circumstances we ended up moving across the country when I was 37 weeks pregnant. My previous doctor (the one that delivered #2 and 3) would not attempt a VBAC since his office was at one hospital and my insurance would only cover the hospital that was across town (about 5 miles away). At that point I had been through enough emotionally and didn't feel I could find a completely new doctor and just decided to do a scheduled cesarean.
I have been fortunate to find a doctor with this baby that is willing and very supportive to try a VBAC. My question is this: my doctor has told me that I should definitely have an epidural since there is an increased chance of emergency cesarean if there was a rupture. My research tells me that the epidural might cause more of a chance of having to do a repeat cesarean. So which is it? Should I or should I not have an epidural? If it is better to not have an epidural can you tell me of some articles or research to back that claim that I can show to my OB? Also, my doctor says I will have to go into labor on my own (consistent with my research) but that if we need pitocin to help me along we could use it after active labor has started. What are your thoughts on that? Lastly, I have never used a doula but believe it would be advantageous if I don't get an epidural. How would I go about finding one at this point of pregnancy and how much would I expect to pay?
A: I am not aware of any research that supports or guidelines that recommend having an epidural in place for a VBAC. You may wish to ask your doctor for the evidence supporting this practice because you are right that epidurals slow labor, increase the need for oxytocin to augment labor, and interfere with pushing. In addition, one of its side-effects is an episode of slow fetal heart rate either secondary to a drop in maternal blood pressure, the most common adverse effect of epidurals, or just on its own. This could lead to a false-positive diagnosis of scar rupture because a slowing of fetal heart rate is its most reliable symptom. I would add, too, that your prior vaginal births greatly increase the odds of having an uneventful labor ending in vaginal birth. That being said, if you like everything else about your doctor or you have no other choice, you may wish to compromise on having the epidural set but not running any anesthetic through it.
Your ob is right to be leery of inducing labor as it reduces the likelihood of vaginal birth. However its association with scar rupture has to do with whether the woman was induced with an unripe cervix, whether cervical ripening agents were used--cervical ripening agents soften connective tissue in the cervix, but the scar is also connective tissue--and possibly both. You had better find out, though, if your ob is willing to wait for your labor to start on its own or whether your ob will insist on an elective cesarean if, say, you still haven't gone into labor by a certain date or the doctor thinks the baby will weigh more than a certain amount. If that is the case, you will have to see whether your ob will honor your right to informed refusal or find someone else.
So far as using oxytocin to induce or augment labor, not all studies find this problematic for the scar, but others do. I'm willing to bet that the reason for the difference is that in the ones that didn't, induction was only undertaken in women whose bodies were ready to labor and a physiologic oxytocin dosing protocol was used for inducing or augmenting labor. You may wish to ask your ob whether he or she uses an active management (high-dose/short-interval between dose increases) regimen or a physiologic regimen. (FYI: The recommended oxytocin dosing regimen is in the Pitocin package insert.)
I strongly recommend hiring a doula. The largest of the doula organizations is DONA International. The link will take you to DONA's home page. Look at the left of the page, and you will see a drop down menu to locate a doula. You will also find some good general info on doulas, including how to hire one.
I wanted to chime in and say that I also had a classical cesarean. My daughter lived for 3 precious days. The surgery and recovery period were considered to be normal but I couldn't bear to have another one. My husband and I chose to have a home VBAC in spite of potentially outdated statistics regarding uterine rupture. We know that is the path God paved for us to have a normal birth. We intentionally spaced the births 25 months apart to increase the likelihood of success. It also gave us much needed time for healing, both emotionally and physically. My son was born via VBAC at home with a midwife. During labor my baby and I were carefully monitored and would have transported to our closest hospital (10 minutes away) if the need arose. My son was born at home, weighing in at 10 pounds. :-) It was a healing birth in many ways.
Response: Thank you for sharing your story.
Q: I'm 40, 12.5 weeks along now, and my only child just turned 4. She was delivered by Cesarean after our homebirth didn't go the way we'd planned. Now as a hopeful homebirth after cesarean (HBAC) I'm finding very few options for a normal pregnancy and birth... especially since I believe I am carrying two babies.
I don't feel that early or routine ultrasound is safe, and will continue to deny this intervention until 20 weeks.
I was upfront with my prospective traditional midwives and they directed me to the local VBAC friendly OB. He's nice and supportive and believes in birth, but he's still a surgeon who delivers babies in a hospital setting. My whole heart and soul believes that babies should be born at home.
Most of the experienced midwives that I have talked to are encouraging me to plan a hospital birth. So considering that my intuition is correct, and there are two babies, and we plan a hospital birth... how do I retain the dignity of a normal pregnancy and birth?
I don't want ultrasounds every two or three weeks... I don't even really want a doppler. I don't want to spend my entire labor in a hospital and I don't want someone else to catch my babies. But what I do want is a normal, hands off pregnancy where I am allowed to connect with my babies... a waterbirth with darkness and privacy and only the people around me that I choose. And of course, I want us all to be safe and well.
How do I balance all of this? If I go in for an ultrasound at 36 weeks, and everything looks great for a homebirth, and I can miraculously find an experienced midwife who will assist me at home (or at my friends home, 8 minutes from the hospital where this OB that ultimately I do trust works) and we get into labor and everything progresses normally... is it foolish to stay home and let things unfold naturally?
Or, do you think that a twin VBAC should be continuously monitored in a hospital setting for everyone's safety?
A: So, as I understand your concern, you want the best outcome with the least possible medical intervention given your individual circumstances, a concept the American College of Nurse-Midwives has developed under the title "optimal birth," and you are trying to figure out how to obtain that. Fortunately, you seem to be in the enviable position of working with care providers who essentially have the same philosophy, which puts you way ahead of most women in the U.S.
The key point is making informed decisions based on complete and objective information about your options, including doing nothing. An acryonym, BRAIN, can help:
N o or not now
Childbirth Connection has a webpage with additional information on decision making. If you are working with practitioners who are prepared to respect your point of view, make decisions collaboratively with you and each other, and compromise, then it doesn't matter that one may be more inclined to see things from a medicalized point of view or, for that matter, the other may be more inclined to dismiss concerns about risks.
You may also wish to preplan a family-centered cesarean so that if cesarean becomes your optimal choice, you have already thought about and gotten agreement ahead of time. Here are some helpful resources:
From ImprovingBirth.org A Family-Centered Cesarean: Taking Back Control of My Son’s Birth
From You Tube: The Natural Cesarean
It seems to me, though, that a great deal hinges on whether you are carrying twins. If it's twins, you then have a set of decisions to make about place of birth and care in labor whereas if it isn't, given your preferences, the path ahead is much clearer--at least for the present; life can always pitch you a curve ball. You may wish to agree to a brief scan to establish this one way or the other.
Q: I have a question about the risks associated with a VBAC. I've been told by 3 different care providers (a midwife, A CNM, and an OB/GYN) that I will be unable to labor and birth in a way that feels right for me. I'd like to be able to labor without constant EFM, walking around, and perhaps birth in the water if I'd like to. I've been told that I can't do this because my combination of a premature birth (he was born at 24 weeks due to infection) and a previous Cesarean (due to my twins that were both breech at 36 weeks). I was told that I am majorly high risk, even though I've never had any other issues in pregnancy. I count both birth issues as isolated incidents, I feel like I do not have a chronic issue that would stop me from a VBAC. However, the birth of my first son was extremely traumatic to me, so much so that I've had to go through counseling to over come the effects of the emotional trauma (I was held down while a manual extraction was performed on me without my consent).
Well due to this situation I feel that my best option for my mental/emotional well-being is a home birth. However, I would like to do this knowing that the risks are acceptable. I've read the post about the chances of rupture when a VBAC is performed 24 months after the Cesarean without induction being 0.4% in recent studies. My question is how long it takes to bleed to death from a rupture. I am 11 miles away from the nearest hospital and I want to be sure that in the unlikely even of a rupture that I will have the possibility of surviving. Obviously, if the bleed out time on average is 4 minutes or something then this would be impossible for me to do. I also realize that the bleed out time is based on the size of the rupture and many other factors, I'm looking hopefully for resources and studies about this. I care the most for my child and want to do what is best for her while balancing my emotional needs.
A: I am not entirely clear on your history. I think that you are saying that you had a vaginal birth at 24 weeks for infection followed by a cesarean at 36 weeks for twins. If that is correct, then you are at very low risk of the scar giving way. If you are trying to do a risk calculation, though, it would help if you could verify the nature of the uterine scar and whether the incision was closed with single- or double-layer suturing. (Single-layer suturing increases the risk of scar rupture as do scars other than low transverse.) That information should be in the surgical notes. It might also be helpful to see if the most congenial of the clinicians you have spoken with can give you any further information on why you can't do things the way you would prefer. Is there something specific about you or is that just their standard practice for VBAC labors?
That being said, scar rupture in labor will require a repeat cesarean, probably fairly urgently, but only 6% result in the baby's death, according to a recent massive systematic review of VBAC, although, of course that percentage comes from pooled data from VBAC studies, most of which took place in university hospitals with 24/7 emergency cesarean capability. No woman died secondary to scar rupture in any of the studies included in that review, and, unfortunately, the same was not true of women having elective repeat cesareans. So this is to say that if you have a qualified home birth attendant, who follows the fetal heart rate (fetal distress being the most reliable symptom that something has gone wrong with the scar), and you and she were pay attention to other possible symptoms such as unusual pain or bleeding, then even with a scar rupture, in the vast majority of cases you and the baby would survive, and the baby would survive intact . There's no guarantee, though.
This brings me to your PTSD. Even if you plan a home birth, the reality is that you may end up needing to be in the hospital. I recommend going back to your therapist to come up with strategies for maximizing likelihood of a positive experience and minimizing likelihood of another traumatic one. You may find Solace for Mothers, an online peer support organization helpful as well.
Reply from sender: You are correct about my history. Also, I know I had a bilayer closure. It's good to know that my risk is very low.
This morning I read the following abstract: http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001192
The conclusion is different from what I've read so far even in ACOG's recommendation. It reads:
"Among women with one prior caesarean, planned ERC compared with planned VBAC was associated with a lower risk of fetal and infant death or serious infant outcome. The risk of major maternal haemorrhage was reduced with no increase in maternal or perinatal complications to time of hospital discharge. Women, clinicians, and policy makers can use this information to develop health advice and make decisions about care for women who have had a previous caesarean."
I would be very grateful if you could tell me what you think of the quality of this research. I would also be grateful if you could point at what you deem to be quality research on the topic.
A: I have written a blog post for Science & Sensibility that analyzes this study as well as another one. Here is the link.
Q: A Doula friend who has attended three VBACs after 2 cesareans (Vba2cs) in the past two months has observed that her Vba2c clients have had much longer labors, days of irregular contractions, and overall a much longer process than that of her non VBAC clients. Is there a reason for this? Physiological or Psychological? Any research on it?
A: I don't know whether VBA2C vs. VBA1C makes a difference, but we do have studies showing that VBAC labors tend to be longer compared with women who birthed vaginally the first time. Here is one, and here is another. I can think of both psychological (increased anxiety, for ex.) and physiological (women with prior c/sec would be more likely to be women who progress at a more leisurely pace, for ex.) reasons, but the take-home pay is that clinicians should expect VBAC labors to progress more like 1st labors than labors in women with prior births.
The questions and answers offered in this section are from evidence-based information, and archived from the Lamaze Ask Henci forum that was available through 2014. For medical advice, please see your care provider.