VBAC with T cut?

[grcelizabeth]

I realized maybe I should post this here instead of professionals or both. Anyhow, my friend has had 2 C/S (1 was twins) with "T" incision. I know there are many things you have go thru to consider if a VBAC is possible in her situation, but I'd like to know your thoughts.

[Amynf1]

I'm planning to VBAC with an inverted t incision in July. There is also another inverted t mom that posts here. She will probably chime in. She has already VBACd with one and is planning to have 2nd VBAC after inverted t in May. I have some information about it on my website...

http://doulamomma.wordpress.com/2009...-presentation/

[AlexisT]

There aren't good statistics on the rupture rate. I've seen guesstimates ranging from 2-12%, with the most common cited statistic being 4-9%. The Landon study gave the 2% figure, but the absolute numbers of women were small. 107 had an inverted T incision, 2 ruptures.

The number of providers who will do a VBAC with an incision that extends into the fundus is very small, and it will almost certainly be at home. I've also read comments from midwives and OBs that if a vertical scar does rupture, the outcome is more likely to be catastrophic, but there were no statistics (even guesswork) to back that up--probably because a small percentage (ruptures) of an already small number (VBACs with an incision other than lower transverse) is just not reliable.

[kitkat5505]

My mom had 3 vbacs after a T incision c/s, but for myself I'm not sure if I would be comfortable with doing it.

[Amynf1]

Originally Posted by AlexisT

There aren't good statistics on the rupture rate. I've seen guesstimates ranging from 2-12%, with the most common cited statistic being 4-9%. The Landon study gave the 2% figure, but the absolute numbers of women were small. 107 had an inverted T incision, 2 ruptures.

The number of providers who will do a VBAC with an incision that extends into the fundus is very small, and it will almost certainly be at home. I've also read comments from midwives and OBs that if a vertical scar does rupture, the outcome is more likely to be catastrophic, but there were no statistics (even guesswork) to back that up--probably because a small percentage (ruptures) of an already small number (VBACs with an incision other than lower transverse) is just not reliable.

I just wanted to note that the studies done that quote a 4-9% rupture rate for inverted t's are lumping inverted t's, j incisions and classical incisions all together. The Landon study does as well but like you said, only find's a 1.9% rupture rate for a small absolute number. Classical scars have a higher rupture rate than inverted t's as most of the vertical portions of the inverted t scars do not extend into the fundus. Classical incisions do extend into the fundus (unless is the incision was low vertical). Typically, the operative report will indicate if the vertical portion of the scar extends into the fundus, sometimes they will indicate the length of the scar in centimeters and sometimes they will only say 't'd secondary to XYZ, extending into the contractile portion of the uterus' like mine does. Extending into the contractile portion of the uterus does not necessarily mean into the fundus (which is riskier), my scar doesn't go that high per my OB (who will be attending me as a homebirth). I know it seems like pulling teeth but when trying to decide if VBAC with one of these scars is right, all this information matters.

[GOPLawyer]

It is also important to note that dehisences (just a thin spot/window and not a true UR) were included in the study that shows the higher rate of UR which skews the stats improperly.

I've had 2 c/s...one w/ a J incision that went up into the contractile portion of the uterus. I felt perfectly comfortable planning a HB (it turned into a hospital birth when I went into premature labor @ 30 weeks...still had the VBA2C w/ a vertical incision). A 98-99% chance of NOT having a UR was ok for my comfort level.

Amyfn1 - Would you mind pointing me to where you found the discussion of the incision going up into the fundus? I'd love to read up on that further. Thanks!

[jessica_anne010]

I replied to this on the birth professionals board, but I'll repost here too.

I had a VBA2C after 1 Inv T. There are a lot of things to consider VBACing after a special incision. Were any of her c-sections premature? How many of those were Inv Ts? Were they Inv Ts or upright Ts? How high did the vertical incision go? How long ago was her last c-section?

These all factor into her risks. I'd be happy to talk to her about it. She can either join my yahoo group Special Scars ~ Special Women or email me personally Jessica @ jessicas-haven.com.

Speaking to the ruptures being more likely to be catastrophic - There is no evidence of that either way. I do know one momma who ruptured while trying to VBAC after an Inv T, but it was not catastrophic.

Hi Amy! *waves*

[Amynf1]

Originally Posted by GOPLawyer

It is also important to note that dehisences (just a thin spot/window and not a true UR) were included in the study that shows the higher rate of UR which skews the stats improperly.

I've had 2 c/s...one w/ a J incision that went up into the contractile portion of the uterus. I felt perfectly comfortable planning a HB (it turned into a hospital birth when I went into premature labor @ 30 weeks...still had the VBA2C w/ a vertical incision). A 98-99% chance of NOT having a UR was ok for my comfort level.

Amyfn1 - Would you mind pointing me to where you found the discussion of the incision going up into the fundus? I'd love to read up on that further. Thanks!

I'll have to get it together. I read it in obstetrical textbooks that discuss how incisions are done. I verified it with three OB's as I was curious since my operative report didn't specify the length of the vertical incision. The OBs I talked to were Dr. Tate from Atlanta, if you are familiar with him, the Army OB that released me from care from the hospital here as risked out for VBAC and also my Korean OB. My Korean OB is primarily a HB doc now but when he was a hospital doc he performed about 750 c/s so he has a good bit surgical experience. They all three said that in an inverted t situation that typically the bikini incision is first (as was mine) and the t extension is secondary and that they try to keep the cut to a minimum if possible as scar tissue in the contractile portion or the fundus can be more problematic in pregnancy than scar tissue in the lower segment. It's not as much about preserving the ability to VBAC within the recommended guidelines as is it to avoid things like dehisences or placental attachment issues or to minimize adhesions and healing and repair time.

Anyway, the texts that I read had diagrams of the uterus with incision location and technique in the description. I'll see if I can find it for you. It's all pretty fascinating really. Not from the perspective that I'd like to actually DO surgery but knowing the methodology that was used on me is kind of interesting. Plus, feeling confident that they didn't cut my uterus from one end to the other is kind of nice too


Hi Jessica! I knew you'd pipe in at some point