Just trying to get my facts straight..........

[nugget's mommy]

Hello Ladies!  I am newly pregnant for a third time and will be seeking a VBA2C.  I am going the hospital route, so I know my chances are not great, but that is what I am comfortable with.  With both of my boys, my water broke and then nothing happened (was going for a vbac with ds2 - even took lots of vitamin C to help strengthen the amniotic sac).  I have never even had a contraction on my own (not even braxton-hicks).  Hopefully this one won't follow the same pattern.  Anyway, I am going to call a provider that I have found quoted (within an article in my insurance provider's website, no less) as saying that "We believe that many women should have an opportunity to give it a try".  I know that doesn't mean she is a raving VBAC supporter, but it is at least a start.  So, assuming I can get an appointment with her, I want to make sure I have some facts right..........

1.  The rupture rate for a first VBAC is about 0.7% and then for a VBA2C is about 0.9%.  I want to make sure these numbers are correct and, more importantly, are these numbers.......

                     a.  reflective of ALL ruptures, not just catastrophic ones (so then the "catastrophic rate" would be even lower).  AND........

                      b.  do these numbers include all ruptures, even ones that were augmented with pitocin/cytotec (so non-augmented labors would probably have lower rates, too). 

2.  I will probably sound a bit blunt/cold here, but my main tactic is going to be that I don't want a c-section because it is safer for ME to not have a third c-section.  Is this true?  Any cold hard numbers supporting this?  I would be completely devastated if something happened to this baby, but the fact is, my boys need their mommy and that trumps everything. 

If anyone can answer these questions - great!  And any nifty links would be even better!

Thanks everyone and I will be thinking of all the VBAC mommies on this board trying in the coming months  . 

[nugget's mommy]

Just wanted to clarify that I would not avoid a c-section at all costs.  Obviously, if babe were in danger, I would have another section in a heartbeat, but I wanted to bring that up to the doc to show that I at least want a TOL and I don't want to be scheduled for a section on my due date.  I want my baby to pick his/her birthday, not be picked by some arbitrary ticking time bomb timeline.

[jenniro]

Here is a great study:  http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2009.02351.x/abstract

It should have great info and stats to take to your doc.  I printed the full article because it has some great tables.

[MsBlack]

In general, the ONLY person who is 'safer' with planning a RCS is the DOCTOR.  Of COURSE you'd permit RCS if your baby or yourself showed real signs of needing that kind of help during labor!

There is nothing cold about knowing, and saying, that you are putting your own health at the top of priorities in making a birth plan.  No one should try to make you feel otherwise; not to mention that vbac is safer for you and baby separately AND together, than RCS.  Not to mention that you and any future babies are also much safer with vbac than RCS. 

Here is a link to my essay on vbac/hbac, including information and links about both vbac and RCS.  While the site is homebirth oriented, the research is hospital birth based--there's just no real research yet on hbac since the number of hbac families is so very low.  Sounds like you have your info at hand, but you could take look to see if my page offers anything new or expanded you'd like to see (or share w/your doc).  There are other pages there you might find interesting as well.

Otherwise, you go woman

http://womynwisespeaks.wordpress.com/informed-choice/hbac/

[buckeyedoc]

I don't believe Cytotec is included in those numbers, because it is contraindicated in VBACs and I think results in a rupture rate in the single digits. Pitocin is probably included because it can be used at low levels. Catastrophic rupture resulting in fetal death happens in about 6% of ruptures, which is one in several thousand VBAC attempts.

The NIH conference and government evidence reports have a lot of good, very recent data accepted by scientists and doctors:

http://consensus.nih.gov/2010/vbacstatement.htm

http://www.ahrq.gov/downloads/pub/evidence/pdf/vbacup/vbacup.pdf

[labortrials]

You might like the "best evidence" info from Childbirth Connection - http://www.childbirthconnection.org/article.asp?ck=10210&ClickedLink=293&area=27.

I *think * that the 1% UR rate for VBAmC is hard to assess.  I'm not sure enough factors were ruled out to come up with that statistic, but I can't tell you for sure.  You know that ACOG came out with a statement revising their position on VBAC and VBAmC?  That should give you more confidence as you prepare for your hospital VBAC!

[nugget's mommy]

Thanks for the links everyone!  I really appreciate it  .  And thanks also for the support.  I'll need every last bit of it! 

jenniro - definitely some good stuff in there - if I read it right, it looks like the risks to mom between a repeat c and a vbac are about the same - there goes that argument .  All I know is that 3 years ago, a coworker had a vbac and her doc told her it was safer for her to have a vbac, so I'm sticking with that in my head. 

MsBlack - Ain't that the truth!  So frustrating that most of this is driven by litigation.  Thanks for the link and encouragement!

buckeyedoc - Well look at that - the doc I was talking about, that I was going to contact this week, was on the concensus development panel for the NIH thing.  That should be a good thing - just wish they weren't so careful to keep mentioning that their recommendations are for women with 1 uterine scar.  So I guess she is a pretty big whig.  If she's not taking new patients, hopefully she will at least have time to talk to me so I can get some recommendations. 

labortrials - yup - I lurk in the vbac subforum every now and then, even though I wasn't sure if dh and I were going to try for a third.  So I saw when ACOG revised their position.  That was a huge relief to see and can only help my cause.  Is it too soon to tell yet if the climate is starting to change from this, or if it is just words and had little impact?  Maybe this has been discussed, but I missed it?  Thanks for confidence boost! 

[MsBlack]

Originally Posted by nugget's mommy 

- if I read it right, it looks like the risks to mom between a repeat c and a vbac are about the same - there goes that argument .  All I know is that 3 years ago, a coworker had a vbac and her doc told her it was safer for her to have a vbac, so I'm sticking with that in my head. 

The risks to mom between RCS and VBAC are NOT about the same!  You have to remember that your risk includes your future health and future pregnancies--the risks of RCS cannot adequately be measured simply by comparing 1 RCS and it's immediate outcomes/risk with 1 VBAC and it's immediate outcomes and risks.  Check out the ICAN link to their White Papers--keeping in mind that the risks of RCS go on forever, into the rest of your life and most certainly the rest of your pregnancies.  Anyone who claims that the risks of RCS and VBAC are 'about the same' is taking a very narrow view...so narrow as to exclude very important information...which is always part of the Statistics Game.  Your own health, and the health of future pregnancies, is too important to accept such narrowly-guaged stats as adequate.  Read ICAN's White Papers, please!  Or otherwise find good information on the real and ongoing and constantly-elevating risks of CS and especially RCS.

Your coworker's doc is right, absolutely right--for otherwise healthy vbac candidates, vbac is definitely safer than RCS.

good luck!

[nugget's mommy]

Thanks MsBlack!  I can't get that link from jenniro to come up right now, so I can't even confirm that I read it right, but even if I did, you're right, I'm not sure what they accounted for in the figure that I may or may not have misread.  Anyway, I will check out the white papers - I think I read through them years ago but it is definitely time for a refresh. Thanks for reminding me - I joined ICAN 3 years ago, but the whole yahoo thing or whatever they use was too overwhelming for me to keep up with.  I mainly lurk at work, and don't feel too comfortable even posting here on MDC at work, but at this point I'm pressing my luck on purpose because we are pretty slow over the holidays, so I'm seeing what i can get away with .   I think the ICAN thing would still be too much, though, and I'm glad you don't have to be a member to look at the white papers.  Good to know in case a doc throws a similar figure out there. 

[jenniro]

Hopefully, this is readable, I copied the results section of the study.  This is just one study, and I have seen other studies that show a statistically significant increased maternal morbidity with RCS vs VBAC.  It is comparing only the immediate risks and results of RCS and VBAC as Ms Black states.  This doesn't mean it is useless info, though.  Sometimes, you have to speak the doc's language if you want to get their attention, and using evidence-based facts to support your decision is helpful.    For the record, I am an RN with a degree in Zoo/Physiology and Chemistry.  I look at as many studies as I can find and gather as much evidence as I can, then I listen to my heart and my gut, and make a decision.  I will be attempting a VBA2C with my next pregnancy.  I attempted a VBAC this summer that ended in a c-sec.  Anyway, here is some limited info from the study, but the full article can be found several places.

 

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

S Tahseen¹,

• M Griffiths²

^{Main results VBAC-2 success rate was 71.1%, uterine rupture rate 1.36%, hysterectomy rate 0.55%, blood transfusion 2.01%, neonatal unit admission rate 7.78% and perinatal asphyxial injury/death 0.09%. VBAC-2 versus VBAC-1 success rates were 4064/5666 (71.1%) versus 38 814/50 685 (76.5%) (P < 0.001); associated uterine rupture rate 1.59% versus 0.72% (P < 0.001) and hysterectomy rates were 0.56% versus 0.19% (P = 0.001) respectively. Comparing VBAC-2 versus RCS, the hysterectomy rates were 0.40% versus 0.63% (P = 0.63), transfusion 1.68% versus 1.67% (P = 0.86) and febrile morbidity 6.03% versus 6.39%, respectively (P = 0.27). Maternal morbidity of VBAC-2 was comparable to RCS. Neonatal morbidity data were too limited to draw valid conclusions, however, no significant differences were indicated in VBAC-2, VBAC-1 and RCS groups in NNU admission rates and asphyxial injury/neonatal death rates (Mantel–Haenszel).}

[MsBlack]

thanks for clarifying, jenniro!

[dlm194]

Dr. Mark Landon did 2 studies looking at VBAC outcomes.  His studies included 17,898 women who attempted a VBAC vs 15,801 who had a RCS. 

In the first study, published in the NEJM (http://www.nejm.org/doi/pdf/10.1056/NEJMoa040405), he looked at the rates of uterine rupture in ALL VBACs and separated them out based on scar type and whether the women had their labors induced or augmented.  In this particular study, he did not separate out based on whether they were VBA1C or VBAmC.   In looking at ALL those VBACs, he found a UR rate of 0.7%.   He found that the rate of uterine rupture in a completely spontaneous VBAC (including VBAmC) was 0.4%. 

You can look here to see how UR rates break down according to scar type and whether the labor was induced/augmented.

Of the 17,898 VBAC attempts, there were 124 symptomatic URs.  2 of those babies (out of the 124 UR) died.

In his 2^nd study, published in Obstetrics and Gynecology (http://journals.lww.com/greenjournal/Fulltext/2006/07000/Risk_of_Uterine_Rupture_With_a_Trial_of_Labor_in.5.aspx), Dr Landon took the same data and evaluated the rate of UR based on whether it was a VBA1C or a VBAmC (2, 3 or 4 c-sections).  Of those 17,898 women attempting VBAC, 16,915  were VBA1C and 975 were VBAmC.  The women who had 1 previous cesarean had a UR rate of 0.7% overall and the women who had more than 1 prior cesarean had a UR rate of 0.9% overall.  Keep in mind that about 25% of the women in each group had their labors induced and/or augmented with pitocin (which increases the risk of UR).

As far as maternal safety goes, 3 women out of 17,898  attempting VBAC died (0.02%) and 7 women out of 15,801 who had a RCS died (0.04%).  It would be interesting to know how many suffered significant morbidity (hysterectomy, extreme blood loss, infections, etc) as well!

[MsBlack]

Great, thanks for this info.

[nugget's mommy]

Thanks dlm194!!!!