hbac risks

[coltynsmom]

hello. I have posted on here before about having an hbac with a wonderful and supportive midwife. my sister in law is planning a vbac at the hospital and has questioned me about why I decided to do the hbac. I know in my heart that I want to be at home and I feel the safest here but what do I tell people that ask about the risk? I know that the risk of uterine rupture is very low but if it does happen I have been told that it can be life or death. Is this true? What exactly happens during a uterine rupture and what can be done about it? Could I get to the hospital fast enough? I will also be asking my midwife all of these questions on my next visit. THANKS!

[moonglowmama]

Well, I'll summarize what I've learned about it. My midwife says the risk of uterine rupture is the same in vbacs as it is in any other women. Increased risk is caused by augmentation of labor, which you are more at risk of in a hospital setting, since pitocin is commonly given to a large portion of laboring women there.

Also, there is a wide range of what is considered "uterine rupture." Most of what is termed uterine rupture are small tears that heal on their own, and are mostly unknown about because they heal fine on their own. The reason those are even known about is from the days of women being routinely manually examined following birth.

It is highly unlikely your uterus would actually burst open completely in some fashion. If it did, that would be a true emergency and you'd be lucky to keep your life. My midwife has been practicing for about 30 years and has done 200+ vbacs at home and has never had a uterine rupture. It's VERY uncommon, especially at home.

[Amynf1]

I am planning an HBAC with my home birth OB. He worked in the hospital system for 14 years, attended about 3000 births, had a bout a 25 % c/s rate and has seen rupture first hand. He is still comfortable attending a HBAC. As for risks, it would take over 7100 elective repeat cesareans to prevent one fetal death from rupture during a VBAC attempt. The overall risk of rupture is 0.05% and the risk of fetal death from that rupture is 0.08%. I'm not saying it doesn't happen, it does and babies do die from it but like my doc said, being in the hospital does't guarantee that the outcome would be any different. I think for any of use planning to HBAC there are going to be a certain amount of nerves involved but at some point you just have to let go. It's probably a continual work in progress even as late as in labor. Another thing to consider is that most ruptures are small windows not full on fetal expulsion into the abdominal cavity type ruptures.

[cathicog]

Originally Posted by coltynsmom

my sister in law is planning a vbac at the hospital and has questioned me about why I decided to do the hbac.

You will be more likely to have a VBAC than she will, statistically, cuz there's little chance your labor will be augmented or tinkered with)

I know in my heart that I want to be at home and I feel the safest here but what do I tell people that ask about the risk? I know that the risk of uterine rupture is very low but if it does happen I have been told that it can be life or death. Is this true? What exactly happens during a uterine rupture and what can be done about it? Could I get to the hospital fast enough? I will also be asking my midwife all of these questions on my next visit. THANKS!

The risk after one c/s is less than 1 %, only 3% or less after 2 c/s. {Silent Knife (and its successor) by Nancy Wainer Cohen, the VBAC companion by Diana Korte, and Obstetric Myths vs. Research Realities are excellent sources of material to tell people of home VBAC safety. So you are still more likely to have your VBAC at home, cuz no tinkering is done.That's a 99% success rate. Instead of using the word rupture, which sounds cataclysmic, you might use the more correct word, "deheisence", which is a pulling apart, rather than an explosion, and most unmedicated women will feel thier uterine scar pulling apart.(it's painful!) One of the dangers in hospital VBACs is both the pit augmentation(which according to ICAN, should not be used) and epidural(because the pit causes stronger, more painful ctx) which interferes with the mom's ability to be able to feel if the scar is opening. If you are at home and the scar deheises, you can feel it, the baby's heartrate may drop a little, and you will know it is time to head to the hospital, and the midwife will call and let them know, so the OR can be ready when you get there. It usually still takes 20 min, even if you are in the labor room in the hospital. To increase the chance of vaginal birth after c/s, Have a Home birth. If you have to transport, most likely you will be close to birth then anyway. But VBAC successes are much more likely at home.

[CookAMH]

Originally Posted by moonglowmama

Well, I'll summarize what I've learned about it. My midwife says the risk of uterine rupture is the same in vbacs as it is in any other women. Increased risk is caused by augmentation of labor, which you are more at risk of in a hospital setting, since pitocin is commonly given to a large portion of laboring women there.

Also, there is a wide range of what is considered "uterine rupture." Most of what is termed uterine rupture are small tears that heal on their own, and are mostly unknown about because they heal fine on their own. The reason those are even known about is from the days of women being routinely manually examined following birth.

It is highly unlikely your uterus would actually burst open completely in some fashion. If it did, that would be a true emergency and you'd be lucky to keep your life. My midwife has been practicing for about 30 years and has done 200+ vbacs at home and has never had a uterine rupture. It's VERY uncommon, especially at home.

I agree with this (esp the low, low risk part and that it doesn't have to be catastrophic if it does happen) except that in Henci Goer's book (Obstetric Myths vs Research Realities) she found that prostaglandins, not pitocin, increased the risk of rupture and that pitocin is actually ok (though not ideal).

[sattygirl99]

I want to correct the pp...

Risk of ur is .5% for 1 prior section and 1.2% for 2 sections. That's per ICAN.

Ur can happen in pregnancy. It can happen in moms with no prior sections at all. It can happen to a ftm. There's no real precident since so many births are controlled with pitocin and cervidl/cyotec.

[ktmeyer]

If your uterus ruptures along your scar, and your placenta is over your scar, it will cause a lot of bleeding and in most cases the baby won't make it. Honestly, in this scenario it is unlikely a hospital could respond fast enough to save the baby. So no real benefit to being in a hospital there. However, if it is determined that the placenta is NOT over the scar, then even if the scar were to open up, there would be minimal bleeding, and plenty of time to get to the hospital. Hope that helps.

Katie

[coltynsmom]

thank you so much ladies. my mind is at ease again. i also never knew about the ICAN website so thanks for that too. I forwarded it to my sil.

[MsBlack]

Originally Posted by moonglowmama

Well, I'll summarize what I've learned about it. My midwife says the risk of uterine rupture is the same in vbacs as it is in any other women. Increased risk is caused by augmentation of labor, which you are more at risk of in a hospital setting, since pitocin is commonly given to a large portion of laboring women there.

The risk of uterine rupture is NOT the same for a VBAC as for any other woman, sorry. Your mw has not done her homework on this one. Others have posted stats per ICAN research, which is what I respect the most as a VBAC source of info. Per ICAN stats, in healthy moms, the risk of UR in a VBAC is .5% (1 in 200). The risk for uterine rupture in someone who has never had a csec or other uterine surgery is FAR LOWER than 1 in 200 (look it up), and is always associated with either medications such as cytotec or pitocin (excessive pitocin can indeed rupture a uterus, tho 'normal doses' rarely do), OR, a mom with severe nutritional deficiencies or other underlying health problems. If we just want to talk about normally healthy moms, uterine rupture is extremely rare and occurs mainly in the presence of certain birth medications as noted.

It is however important to note that the stat '1 in 200 VBACs rupture' is referring to VBACs IN HOSPITALS, in part because of medications along with other restrictive or interfering practices that do not allow a woman to birth freely and well fed according to her own instincts. We don't have good stats on UR at homebirth (no good stats in the USA on anything homebirth related, because so few of us have homebirths). From my own experience as well as talking with many other hb mws, I believe that UR rate for HBAC is far far less than 1 in 200. Way far less-because generally speaking, homebirth mws are helping moms be very healthy, and they are NOT interfering with birth in ways that are likely to promote UR. But HBAC moms still do have UR more often than 'any other mom'.

For the greatest part, I treat VBACs as normal birthers, as being women who need mostly the same kinds of support and info to have a normal birth as anyone else. BUt a VBAC is NOT just any woman--she does have a prior uterine surgery, and however small, there are still greater chances of either UR for her than a non-surgery mom, or of having placenta accreta if placenta implants over the scar.

I work to normalize HBAC--and most passionately believe that for normally healthy survivors of csec, home is the safest, best place to birth. And I still think that we do women no good at all to claim things like "the risk of uterine rupture is the same in vbacs as it is in any other women." It is simply not true--and I will not work with a HBAC woman that does not understand that there IS an increased risk of rupture for her--however small that increase of risk for the woman who does all in her power to be healthy and work pro-actively toward, and with, healthy normal birth.

But I agree with all else you posted, moonglowmama!

[Romana]

In the unlikely event you were to have a catastrophic rupture at home, it is likely the baby would die, and possible (but less likely) that you would die. However, catastrophic ruptures are rare. I do know one woman who had a a couple natural births, a c-section, a hospital VBAC, and then an HBAC with a rupture where the baby died. It's quite rare but it is a possibility, and one that you should be aware of when choosing to HBAC.

I recently researched this issue and there is simply no comparison between VBACs and women with unscarred uterii. Absolutely no comparison. The risk of rupture is many times higher for women attempting VBACs and this has been clearly demonstrated.

Anytime you give birth at home you take a few homebirth-specific risks. They are small enough to not really show up when you study a very large group of homebirthing vs. hospital birthing women, hence the "just as safe" line we often use. But the fact is that there are some homebirth-specific risks, and a catastrophic uterine rupture is certainly one of them, as well as a catastrophic placental abruption. In either case, the chance of the baby surviving during a homebirth is not good. In some of those cases, the baby would also die in the hospital, but if it was caught immediately in the hospital they might be able to save the baby with a crash c/s under general.

I do also know a woman whose baby died during a hospital VBAC attempt. She tried to tell her care providers that something was wrong, but she was disregarded (and she had midwives!) since it was her first unmedicated labor and it turned out she was rupturing. By the time they figured it out, it was too late for the baby. So I'm not saying home = dangerous and hospital = safe - just that in a rare and catastrophic event like that, I'd want to be in the hospital, no question. The risk of a situation like that occurring are are very low, but I certainly take it into consideration when choosing homebirth.

[moonglowmama]

Originally Posted by MsBlack

The risk of uterine rupture is NOT the same for a VBAC as for any other woman, sorry. Your mw has not done her homework on this one. Others have posted stats per ICAN research, which is what I respect the most as a VBAC source of info. Per ICAN stats, in healthy moms, the risk of UR in a VBAC is .5% (1 in 200). The risk for uterine rupture in someone who has never had a csec or other uterine surgery is FAR LOWER than 1 in 200 (look it up), and is always associated with either medications such as cytotec or pitocin (excessive pitocin can indeed rupture a uterus, tho 'normal doses' rarely do), OR, a mom with severe nutritional deficiencies or other underlying health problems. If we just want to talk about normally healthy moms, uterine rupture is extremely rare and occurs mainly in the presence of certain birth medications as noted.

It is however important to note that the stat '1 in 200 VBACs rupture' is referring to VBACs IN HOSPITALS, in part because of medications along with other restrictive or interfering practices that do not allow a woman to birth freely and well fed according to her own instincts. We don't have good stats on UR at homebirth (no good stats in the USA on anything homebirth related, because so few of us have homebirths). From my own experience as well as talking with many other hb mws, I believe that UR rate for HBAC is far far less than 1 in 200. Way far less-because generally speaking, homebirth mws are helping moms be very healthy, and they are NOT interfering with birth in ways that are likely to promote UR. But HBAC moms still do have UR more often than 'any other mom'.

For the greatest part, I treat VBACs as normal birthers, as being women who need mostly the same kinds of support and info to have a normal birth as anyone else. BUt a VBAC is NOT just any woman--she does have a prior uterine surgery, and however small, there are still greater chances of either UR for her than a non-surgery mom, or of having placenta accreta if placenta implants over the scar.

I work to normalize HBAC--and most passionately believe that for normally healthy survivors of csec, home is the safest, best place to birth. And I still think that we do women no good at all to claim things like "the risk of uterine rupture is the same in vbacs as it is in any other women." It is simply not true--and I will not work with a HBAC woman that does not understand that there IS an increased risk of rupture for her--however small that increase of risk for the woman who does all in her power to be healthy and work pro-actively toward, and with, healthy normal birth.

But I agree with all else you posted, moonglowmama!

Thanks, MsBlack- I always like reading your posts!

I want to clarify a little about my midwife- just because I love and respect her so much! Although there is statistically a larger risk, I think she would say that because of her emphasis on nutrition combined with her own experience and listening to that of other midwives, the risk pertaining to homebirth is still small enough that no difference in care is required. Meaning, she strongly encourages us all towards excellent prenatal nutrition and we fully go over what all the risks are for homebirth, what our options would be in each case, so that as couples we can decide for ourselves which route of care we'd like should X happen. As I said, she's never had a rupture in her practice, nor an abruption. She attributes that to nutrition. When she worked at the county hospital she would see things like placentas that would nearly disintegrate upon delivery, but these were moms who were on drugs, had received no prenatal care and were heavy smokers, etc. Which is why nutrition is such an emphasis in her practice.

I think what it comes down to, is that we have to look at what the risks are of being in a hospital setting as well as out of the hospital. Then, looking at the specific risks, decide what course of care we would decide upon should a particular risk present itself. In a home birth, we largely have to know what can be done at home, what would be done at a hospital and at what point would wisdom dictate a change in location or care. At the hospital, we have to look at what can we do to minimize risk and have the best outcome possible. Well, of course that true no matter where you are, but at the hospital we're more likely to have to refuse interventions that could be harmful whereas at home, it's about knowing what can and can't be done in a variety of situations.

To the op, I'm glad you found ICAN and I hope it will help your sister get the outcome she wants as well.

[MsBlack]

Hey Moonglow--glad not to offend too much by dissing your mw

I know for myself, there are times I have to be careful not to dismiss ALL idea of risk from hb, which is generally my inclination (especially compared to my perception of the inherent grave risks to healthy women and babies *in the hospital*). I think your mw and me have a lot in common! But one of the things I do to keep myself from promoting hb in TOO rosy and risk-free a light is to keep Informed Consent docs for clients to sign...one is specific to HBAC...and there is the place that I name ICAN stats on rupture, for instance.

I do agree in general that nutrition makes a huge difference for any mom--and I believe that good nutrition as a foundation of mom's self-care is one reason that homebirth sees so few problems like UR in HBAC, serious placenta problems of any sort for anyone (hbac or 'regular'), postpartum hemorrhage, newborn problems....and so on. Not just nutrition, of course--it's the holistic approach in general, the high degree of connection between mom and mw and the sense of trust and safety generated thereby, so important to the birth process proceeding well and straightforwardly....

And I heartily agree that wherever a woman wants to birth, she should note the risks inherent in any setting. As Romana says, there are 'homebirth specific' risks, and 'hospital specific' risks, too. Well, in life we get no guarantee of externally provided safety anywhere, with any kind of choice...so we have to just do our homework and then rest with whatever options help us to *feel* the safest. Because at birth, feeling safe and relaxed is such a major element of birth proceeding well and normally.

[coltynsmom]

Originally Posted by MsBlack

And I heartily agree that wherever a woman wants to birth, she should note the risks inherent in any setting.

That exact point is what I was looking for. There are risks involved in any situation. I guess I just needed to put it in perspective. The thought of losing my baby because I chose to have a hbac scares me but I have to remember that there is risk at the hospital too if I elected to have the c-section.

Thank you for your input and even your little "debate" I need to hear all sides and not just the "rosy" homebirth stories. (though those are greatly appreciated too!) THANKS

[redvlagrl]

We were planning an HBAC, but have ultimately decided to VBAC at the hospital under the care of our MW.

I have spoken to 2 MWs, and one of them I really trust. She said that in this community there is a lot of nervousness about HBACs because some years ago there was an HBAC UR and the baby didn't make it. She pointed out that because of this if you have to transfer to the hospital for any reason you will likely be sectioned right away simply because of the fear surrounding HBACs. This was from my secondary MW. My primary is not comfortable with an HBAC (though she would do it if we insisted), but we felt that *she* should also be in her comfort zone for us to have the best chance at VBACing.

From the reading (peer reviewed studies) I have done, the risks of UR are indeed 0.05% after one c section. BUT what was interesting to me was that 80% of women do *not* feel the rupture as pain and that the only really reliable way to tell was through fetal monitoring. I am not comfortable with CFM, but we will have the MW check more frequently.

Also, UR can happen any time in active labour - early or while pushing. So it also doesn't make any sense to us to labour at home for as long as possible. If we were going to do that, then we may as well just HBAC.

So, even though I desperately want a HB (we had planned one with DD), we are going to do the hospital route with a MW.

[CookAMH]

Originally Posted by redvlagrl

From the reading (peer reviewed studies) I have done, the risks of UR are indeed 0.05% after one c section. BUT what was interesting to me was that 80% of women do *not* feel the rupture as pain and that the only really reliable way to tell was through fetal monitoring. I am not comfortable with CFM, but we will have the MW check more frequently.

I was just rereading a part of Henci Goer's book (thinking womans guide to a better birth) and she basically seemed to say that CFM was a reasonable measure in a VBAC because the hr being a good indicator of a rupture problem, and it can be missed with intermittent. That works for me as long as I'd be able to be mobile, were I to end up in the hospital instead of HBAC.

This may have been said, but many of the ruptures occur before labor even begins, in late pregnancy.

Originally Posted by cathicog

The risk after one c/s is less than 1 %, only 3% or less after 2 c/s. {Silent Knife (and its successor) by Nancy Wainer Cohen, the VBAC companion by Diana Korte, and Obstetric Myths vs. Research Realities are excellent sources of material to tell people of home VBAC safety.

Can you point me to where in the Obstetric Myths book that it talks about HBAC? I was reading some of that book last night and read VBAC and homebirth info but not HBAC specifically. But I was skimming parts and didn't read all the abstracts.

[sattygirl99]

Tje risk isn't 3% after 2 csections. Its 1.2%. risk with 1 section is .6%. That's a 99.4% rate of sucess without rupture after 1 section and 98.8% sucess after 2. Remember as well that the risks are based on hospital vbacs. Hospital vbacs aren't as successful as home vbacs because they are often tinkered with. I personally believe the risk rate mayh be slightly scewed becaused of this. That's just based on my own personal experience with a hosptial vbac that was truly ripped away from me.

I prefer to look at sucess rate over risk rate. I also believe birth has risk. Whether its first birth, 5th birth, vbac, hb. ALL birth has risk. IME, cfm can also cause a section that's not needed. I had that with dd, I transitioned so hard and fast her hr shot up and they didn't give her time to level. As we left the room for the or, her hr was normal. There was no sign of rupture or anything when they sectioned me. In fact the ob said my incision was amazing and had to ask me who did it because it was strong and wonderful. So cfm isn't all its cracked up to be.

While the hr changes do get 'missed' with ifm, in most cases the mom feels something isn't right. Mom doesn't have to feel pain to know something isn't right.

Just my 2 cents.