The real risks

[forestrymom]

I am facing EXTREME resistance to my second VBAC from the doctors. Long story but a homebirth isn't really an easy option for me, so its with an OB. And I want to know the REAL risks. Thanks!

[roadfamily6now]

Your second VBAC? Odd they are pressuring you after have already had one.

The real risk is a small % higher risk of Uterine Rupture.
All women have this risk, which is about 0.1% - 0.3% VBAC women have a 0.3% - 0.7% risk.
U/R can occur even before labor, so the theory that having a scheduled c-section before labor will protect a women from u/r is false. No one has a 0% risk.

Would you also like to hear about the risks of another c-section? Or about the risks that occur AFTER a c-section and in future pregnancies?

I borrowed this from a friend of mine's blog.

Here are a couple examples of the risk factors with increasing cesarean section surgeries.

2nd Cesarean
Risk of Hysterectomy : 0.42% (1 in 238)
Risk of Blood Transfusion : 1.53% (1 in 65)
Risk of Placenta Accreta : 0.31% (1 in 325)
Risk of Major Complications : 4.3% (1 in 23)
Risk of Dense Adhesion's : 21.6% (1 in 5)

3rd Cesarean
Risk of Hysterectomy : 0.9% (1 in 111)
Risk of Blood Transfusion : 2.26% (1 in 44)
Risk of Placenta Accreta : 0.57% (1 in 165)
Risk of Major Complications : 7.5% (1 in 13)
Risk of Dense Adhesion's : 32.2% (1 in 3)

[forestrymom]

The OB who is using scare tactics to attempt to persuade me into another surgery was open about the risks of another surgery. However, his point was that those rarely result in death to the mother or baby, while a uterine rupture often does. What are the risks of death of infant and mother when a uterus ruptures?

[John'sMama]

There's a great article on mothering under pregnancy & birth, then VBAC & cesarean, called Fighting VBAC-Lash: Critiquing Current Research. Here's a paragraph I pulled from it, but the entire article is worth reading.

Thus the risk of a baby dying in association with VBAC was 12 times lower than the risk of a baby dying from non-rupture-related causes. No amount of medical intervention can reduce the fetal mortality rate to zero; death will always be a part of birth. Using the very rare risk of fetal death to convince more women to undergo unnecessary surgery still cannot guarantee the parents a live baby."

Good luck with your journey to VBAC; is using a CNM an option for you?? If not, maybe you can hire a doula to not only support you but also fight for you during labor & delivery!

[forestrymom]

Originally Posted by John'sMama

There's a great article on mothering under pregnancy & birth, then VBAC & cesarean, called Fighting VBAC-Lash: Critiquing Current Research. Here's a paragraph I pulled from it, but the entire article is worth reading.
Good luck with your journey to VBAC; is using a CNM an option for you?? If not, maybe you can hire a doula to not only support you but also fight for you during labor & delivery!

This is very useful. The OB told dh and I that the risk of maternal death with a ruptured uterus was 50% and the risk of infant death was 80%. How can his numbers be so far from these? I guess I should've asked where he got his numbers. This is so confusing.

[turnquia]

Originally Posted by forestrymom

This is very useful. The OB told dh and I that the risk of maternal death with a ruptured uterus was 50% and the risk of infant death was 80%. How can his numbers be so far from these? I guess I should've asked where he got his numbers. This is so confusing.

I"m also a part of another birth board and we've had a few mom's do HBAC, hospital VBAC as well as a couple of rutpures. No mother died or baby.... actually in both instances I recall the ruptures they were both small partial ruptures. There was one recently who had a fairly large rupture and yes the mother needed some blood transfusions and had a longer recovery however all is fine.

Your OB's numbers maybe higher if he's talking about full ruptures (Your entire CS scar and then some rupturing).

I suggest getting a hold of ICAN and seeing if you can get some information from them to take to your next appointment and ask your doctor for the same thing. You want to see VALID and CURRENT research that is in a medical journal (not via a google search) and see what type of discussion that will open up.

What about finding another more supportive OB?

GOod luck!

[kltroy]

Risk of UR is around 0.5% for first VBAC, more like 0.3% if you've already had a successful VBAC. Risk of death to the baby is around 1/10. This makes your ABSOLUTE RISK of death to baby = 0.5%*10% = 1/2000 or 0.05%.

I would ask your OB for the reference for his numbers, since they conflict greatly with the research I've seen. O

Here's a ref that might be helpful to you - brand spankin' new:
Zwart J, Richters J, O¨ ry F, de Vries J, Bloemenkamp K, van Roosmalen J. Uterine rupture in the Netherlands: a nationwide population-
based cohort study. BJOG 2009;116:1069–1080.

[snip from abstract] Results There were 210 cases of uterine rupture (5.9 per 10 000 pregnancies). Of these women, 183 (87.1%) had a uterine scar,
incidences being 5.1 and 0.8 per 10 000 in women with and without uterine scar. No maternal deaths and 18 cases of perinatal death (8.7%) occurred.

[roadfamily6now]

Emily and Kltroy gave you some most excellent stats! Those numbers are similar to ones I have found.
Why is your OB trying to scare you? Perhaps he himself has had 2 VBAC mom's rupture and one of the babies died? I dont know. It does sound to me like he is not as supportive as he says he is. It also says to me (if he in deed has had mom's rupture) that perhaps he likes to induce VBACs or use Pitocin on his VBAC moms.

[forestrymom]

Originally Posted by roadfamily6now

Emily and Kltroy gave you some most excellent stats! Those numbers are similar to ones I have found.
Why is your OB trying to scare you? Perhaps he himself has had 2 VBAC mom's rupture and one of the babies died? I dont know. It does sound to me like he is not as supportive as he says he is. It also says to me (if he in deed has had mom's rupture) that perhaps he likes to induce VBACs or use Pitocin on his VBAC moms.

He says he had a very large window just this past weekend, and that he has had babies die as a result of vbac, but I didn't ask for details, nor do I feel he is entirely telling the truth. He does not induce. I asked about that. I was induced with my first vbac, with pitocin. He said that the fact that I had a previous vbac, with induction, is no indication that my scar is strong enough to sustain this birth--that its random when it comes to scars rupturing. He did say he was willing to see me past 41 weeks, which is likely to happen.

[kltroy]

Well to be perfectly honest, I would feel very comfortable having a doc who had actually *seen* and *dealt with* a UR for my VBAC. Think about it: the first time you see something you (a) don't quite know what you're looking for and (b) aren't quite sure how you would react even though you know how you should react. He's BTDT and to me that's reassuring because the second (or third, or fourth) time around he will feel more confident in his ability to recognize a rupture and deal with it effectively.

I think this may be a case where personal experience and anecdote are more powerful than statistics. If this guy happened to see a few unlucky women then that is going to stick in his mind much more vividly than all the statistics in the world. Anyway, it sounds like you need to continue to have a discussion with him and take it from there. I wish you the best of luck.

[Realrellim]

Originally Posted by forestrymom

He says he had a very large window just this past weekend

From what I understand, a "window" is not necessarily a rupture. Apparently it's possible to have those for a large part of a pregnancy, and they don't necessarily pose any threat to the baby or mother. I can't remember if I read that in Silent Knife or in Natural Birth After Cesarean: A Practical Guide, but one of them included information on that.

[MommyDOK]

Originally Posted by forestrymom

This is very useful. The OB told dh and I that the risk of maternal death with a ruptured uterus was 50% and the risk of infant death was 80%. How can his numbers be so far from these? I guess I should've asked where he got his numbers. This is so confusing.

As the ob how many ur he has had. All ob's have had ur (if they've been in practice for a big)...what I'm saying it is not just vbac moms that ur. Ask him how many vbac's he has done and how many of those had ur. Ask him how many died.

My ob (the one I switched from) told me he did 80-100 vbac's a year and I had a 4% rate of ur (never ever has a study shown that in a low transverse scar) BUT he's only ever seen two ur. Huh,his math was way off. I knew I was switching so didn't show him his mathematical errors, but now I wish I had.

[GOPLawyer]

You've stated that you don't feel he's telling the truth so from that I will take that you don't trust him. That being the case, why don't you switch to a different OB or a CNM?

[DocsNemesis]

Also think about this. First off, the chance for a catastrophic uterine rupture is much smaller than the UR rate. I can't remember exactly what, but its very very small. There is a very small chance you could have a UR, yes-but its much more likely to be a small rupture, which doesn't pose a huge risk to baby and mom, provided its caught.

In a catastrophic rupture, I believe the risk is higher for the baby. Its still possible for both to come through ok, but not as likely. Oddly of the 10 or so catastrophic ruptures I've read about, 3 occurred before labor even began. And one occurred in a mom who hadn't had a cesarean.

I'd also question his belief that having a previous VBAC, especially one in which pitocin was used, means nothing. From what I've seen, the chances of UR go down even more when mom has already had a successful VBAC. Yes, it doesn't guarantee you're safe, but birth never does.

Finally-in regards to catching UR's-I'm making an assumption here, but if you are not using pain meds, your chances of catching a UR quickly go up by leaps and bounds. Think about it-with an epidural in place, a mom will most likely not be able to feel anything, maybe pressure or something being off, but not pain. Now think about how many moms get epidurals. A LOT. The vast majority. Its entirely possible that the baby/mom would've been ok had they caught the rupture early. With mom not being able to recognize a rupture, all they have left to rely on is fetal heart tones and sometimes bleeding/odd contractions (which aren't guaranteed to happen). By the time the fetal heart tones are getting whacky enough to notice, they're already in some serious trouble. Then with all the time it takes to get to an OR, get surgery started, etc....yeah, it can be something like 5, 10 minutes, fast, but when a baby is in major distress, that may not be fast enough.

I personally wouldn't attempt a VBAC with pain meds in place. I WANT to feel the pain and everything else. I want to be able to say "WHOA, that's not right" and get attention immediately. I can't imagine not having some major pain with any sort of UR...although I admit thats an assumption. I should see if I can find anything on that specifically, from moms that have been there. Knowing what to look for yourself can make all the difference!

And also, as pointed out above, cesarean doesn't come without risks. Babies are more likely to die after a cesarean as are mothers, versus a vaginal birth. Another cesarean increases the risk to any future babies. And cesarean babies are much more likely to have respiratory problems.

Nothing in childbirth comes without risks.

[MsBlack]

Originally Posted by forestrymom

This is very useful. The OB told dh and I that the risk of maternal death with a ruptured uterus was 50% and the risk of infant death was 80%. How can his numbers be so far from these? I guess I should've asked where he got his numbers. This is so confusing.

If you understood him correctly, then he's just giving you numbers off the top of his head--NOT referencing any actual research. Could it be you misunderstood him...? The only thing I can agree with him on at all, is that babies do die more often than moms in case of UR. But not a lot more often--so many variables play a part, such as how bad the rupture, how far from a hospital that can do csec, other. Otherwise, his numbers are just crazy....either you somehow misunderstood, or he just made that up!

I don't want to call him a liar--but I've known many women who were straight-out lied to by their OBs for various issues (not all vbac related) "for her own and her baby's good".

But in any case of being presented with numbers/stats, I always ask just how those numbers were generated, what factors were taken into account. For instance, in studies of vbac/ur, how many of those women were in a really healthy state during their labors, and how many had really poor diet/lifestyle habits? How many were induced--and with what? How many had to labor with continuous EFM, pretty much in bed, on their backs? How many had doula support, and stayed home til the last minute, vs those who went in the second they thought they were in labor? Other questions come to mind as well.

As far as I can tell from info gathered from homebirth mws I know, for instance, the rate of UR is very low for most of us. Very much lower than any of the studies indicate--and the studies are all about hospital births, because that is where most births happen and it is easy to get a sample of hospital births. Not saying you should have a homebirth (tho I generally do favor it!), only that as a homebirth professional, I tend to think about the differences btwn home and hosp stats--in terms of variations on the norm, especially-- such as breech, vbac, mulitples, group-B strep infections, lengthy rupture of membranes. There is just not enough research done that is homebirth based. Anyway, just something else to question--and I'm just saying that we *should* question all stats, and we should assume that in any group of women/births studied, there are women who may well have all been categorized as 'lowest risk' yet there are still great differences in their relative states of well-being, preparation, the kind of care they receive, etc. We can't 'see' those things in the studies/stats, but I think they do matter very much.

[forestrymom]

I did not misunderstand him. I was taken aback because the numbers I'd heard previous to that were not nearly as dramatic, but I thought maybe I had misinterpreted the stats I had previously heard. I am not eligible for a homebirth because of my distance from a hospital (80 miles) and that hospital does not have an OB or an anesthesiologist on staff 24 hours, so they won't allow a vbac. I'm already traveling a long distance for this OB, and plan to have a midwife attend the birth as well. He is the OB recommended to me by her, because none of the OBs in any community close to mine are happy about doing vbacs. I had my first vbac before the rules changed, by a midwife and OB who are very supportive (and still are, but not allowed to do them for insurance reasons) of vbac.

Thank you all for your responses!

[MsBlack]

Well....just so you know, some people have 'homebirth'/hbac in someone else's home or even a hotel, close to a surgery-ready hospital. Something to consider while you're considering options.

[schreiberwriter]

I interviewed 3 professionals when searching my provider for my VBAC. I heard 3 different perspectives, practices and attitudes. A reminder that doctors and midwives are people who are influenced by their experiences.

It doesn't hurt to talk to a few other physicians and see how they view and handle VBACs.

[katelove]

According to the research cited in this article http://www.medscape.com/viewarticle/573948_3 the risk of uterine rupture actually decreases after one sucessful VBAC.

[mamatolevi]

My VBAC happy ob who attended my first VBA2C, has seen three ruptures over the cuorse of nearly 25 years. One of those was in a first time mother. None of them resulted in a dead baby or dead mom, nor a hysterectomy.