Talked to OB about VBA2C-don't do it/midwife HB-do it- what to do?! Updated :)

[*farmergirl*]

 I talked to our local midwives who said- ok to a home birth after 2 c-sections as the cause for the c-section isn't likely to happen again....

so I figured I might as well talk to my OB that I've seen for all of my pregnancies and who also did the c-sections to hear what she had to say and find out if there was anything about the incision I should know about.oh and i didn't even mention I was thinking of home birth. Also I had call them a couple weeks ago to get a copy of my records send to the hospital about an hour away who says that they will do a VBA2C. I still have to meet with them to know what they really think.

Well I don't even know what to think! Everything she said was basically don't do it. She mainly focused on uterine rupture- said it was 5% for two for more previous. she told me that if anything went wrong  they would literally have seconds to save my life and that the babies life won't even be a concern because it would be dead or possibly have cerebral palsy. Apparently she and her partner have both seen a rupture during their residencies at a large hospital and hers ended in death of the baby and his ended with the baby having cerebral palsy. And after seeing that they just don't recommend it. Now I know what 5% is but i guess for illustration she gave the example of having 100 people in a room and knowing 5 of them would die- would i want my child in that room. She then went on about the hospital I might transfer to saying it' too small to offer the standard of care & she couldn't believe they said yes because if anything went wrong we'd have an automatic lawsuit case.They should have an OR on the same floor as the labor room and an OR ready and waiting just for me. Also that one Dr there is 80 something years old and another Dr is really new and they aren't going to be as fast as she and her partner could be if needed. This hospital has midwifes and she said that they're willing to let natural labor go on longer cause they can't really do anything and then when things go wrong they just step back and page in the Dr. my OB said if I was her sister she would forbid me but since she can't forbid me she recommends I consult with the even larger hospital 2 hours away and continue seeing her with her sending important info to them and then once labor starts come in and if under 4 centimeters go in an ambulance to said hospital 2 hours away and if over 4 I'd stay at our local really small, doesn't do vbacs at all hospital and we'd all look at each other and hope for the best & she'd get the OR ready jut in case. I asked her if the risk on continued c-sections was less than the risk of vbac and she wasn't quite willing to say that but said that the risk with c-section is mostly with later pregnancies having placenta problems but she's done thousands of c-sections and plenty of c-sections after 3,4,5 kids. 

I don't know about the hospital 1 hour away but i know she would want IV, continuous internal mointor etc. And really if I had to labor in our hospital again I'd rather have a scheduled. And the idea of riding for 2 hours in an ambulance during what was at least during my first labor and very intense fast labor just sounds horrible.

I feel like I've been told the opposite things and in a way both the MWs and the OBs are like the voices in my head- yes i can do it & it should be a natural uncomplicated birth and then ah things go wrong that have a really low rate as we found out with ds1 & what if....

[purslaine]

I  would do my own research and identify what the risk is.  The article I just read said it was 1.95% - still not a great number, but not 5%.

there are other risk factors as well - including maternal age, and whether or not you are induced (do not go for induction if trying the VBAC)

I would also look into the probability of catastrophe with a rupture.  I know it is high - but what are the stats?  Then stick them together what is the probability of a rupture and if it happens what is the probability of something catastrophic?  What is the risk over all?

Even if both of you live, a rupture is no walk in the park, it might well be that the risk of it happening is the risk you would have to live with.

Personally, if 5% is correct, it is too high for me. I would have an elective Csection.   I reduce it down to 1 in 20 and I am not comfortable with those odds.

[jenniro]

The uterine rupture rates for VBA2C in these studies was 0.9% and 1.36% (see below).  So, I am not sure where your doc gets her stats.  It is a difficult decision and it should be yours to make without scare tactics .  There are a ton of things to consider.  First, independent midwives and OBs have different philosophies about birth.  The midwives believe in the natural process of birth and have confidence your body will do what it was made to do.  OBs tend to medicalize the process of birth and have legal and insurance considerations.  I obviously have a bias but I think both believe they are doing what is best for their patients.  The important question in all of this is, how do you feel?  Do you trust the midwives?  Do you feel comfortable with homebirth?  If you want a homebirth but worry something may go wrong, what is the midwives transfer plan?  As far as responding to an emergency, I always wonder, how do they respond to a FTM that needs an emergency c-section?  If they can do that, they can respond just fine to any obstetrical emergency.  There are definately risks to a RCS, not just placental problems in future pregnancies.  Infection, hemmorhage, death.  ACOG even recognizes that VBAC, even VBA2C, is relatively safe and should be an option for most women because of the risks of repeated c-sections.  So, I guess the point of all this rambling is that statistically, VBAC and RCS are relatively safe, the chance of something going catastrophically wrong in either is low.  But you have to be informed and decide what risks are acceptable for you to take.  Because either way, something could go wrong.  That is a risk of birth.  The last link is info from the NIH consensus comparing RCS and VBAC side by side, might help put things in perspective.

http://medicalcenter.osu.edu/viewer/Pages/index.aspx?NewsID=2835

http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2009.02351.x/abstract

http://givingbirthwithconfidence.org/2-2/a-womans-guide-to-vbac/weighing-the-pros-and-cons/

[douladianne]

It really does depend on the reasons for the other 2 c-sections. As a doula, I've assisted with many VBAC's including two VBA2C's. All were home births except one and she was successful because of several positive factors...VBAC friendly doc, VBAC friendly hospital and she had a doula. I would say if those factors are not there for you and you are set on having a VBAC, your greatest environment is your home.

If someone told me that I had a 98% chance of being successful at something, there'd be no stopping me! Feel free to email me if you have any questions or would like additional info.

Take care!

Dianne

[*farmergirl*]

Thank you for the replies and links. I'm trying to think it all through and find out what the FACTS are. I realize either way there are risks that something could go wrong  I also have never heard 5% before and I should have asked her where she got that from but between her spiel and two toddlers acting up cause they noticed i was distracted and being raised with Dr knows best mentality  I had a hard enough time questioning her. 

I'm 26 BTW and ds1 was an emergency c-section due to fetal distress because of the cord being wrapped 4 times and he couldn't descend into the birth canal. ds2 was 2 years later and was an elective mostly cause at that point I didn't have anyone here to help with ds1 and my OB pretty much scared me into it and said she didn't think i could make it to the 1 hour away hospital in time- oddly enough this isn't a concern this time. 

I really just want a healthy child and if there are future children for them (and myself of course) to be healthy too. if the risk of rupture really is low then I think the best way to have a healthy mom and baby is a vaginal birth. While i love the idea of a home birth I've been leading towards the hour away hospital because while the midwives seem competent we're 20 minutes drive from the tiny hospital and there's no way in the middle of labor I'll be running to the car and hoping in so figure in time to get in the car and time is stretching on in an emergency situation. also that hospital has midwifes and is more like a birth center but with an OR right there which my DH really wants especially after the labor of DS1. I really want to labor in peace no continuous mo niter no drugs. I'm really against the idea of inducing especially with a VBAC.  I hadn't really considered the two hour away hospital because two hours in the car is a long time especially if i have to wait for DH to get home. My first and only labor was 6 hours start to pushing and figuring things go faster...well id' rather stay home than birth in a car. I really need to talk to the hour away hospital and see what they say. I know it has to happen one way or the other but I really hate trying to predict the future.

[konayossie]

Originally Posted by jenniro 

http://givingbirthwithconfidence.org/2-2/a-womans-guide-to-vbac/weighing-the-pros-and-cons/

Thank you so much for posting this link! I have been looking for something that would give me exactly these side-by-side comparisons of VBAC/VBAC. GREAT resource!!

[cagnew]

I'm going for my first VBAC and I thought I would share my plan with you :) Your risks aren't that much more than mine. 

I spent most of this pregnancy NOT thinking about the VBAC or the birth. Frankly, my last birth was so traumatic that I just couldn't think about it. I knew I wanted a VBAC, but that was it. The only thing I did was interview a few OB's to find one that would be supportive of my decision and allow me to labor w/ as little intervention as possible.

I started thinking about the whole thing around 30 weeks, mostly because the fear was becoming something I couldn't ignore. I started reading VBAC info and birth stories and what-not. I went to an ICAN meeting. But I couldn't get up confidence. I couldn't bring myself to think that I would actually have a successful VBAC. All I could think was that I wasn't going to go into labor, and would be forced to c/s (my OB won't do inductions because of the risk increase). I figured that even if I DID go into labor, I would never make it because of all the interventions. I would have to be on the dumb monitors and that would just start the whole downfall for me. 

Around 33 weeks, after talking more to the ICAN director, I decided to consider getting a doula. We had had one with my last birth and wans't really impressed, so we weren't going to consider it this time. I didn't want to bring it up to my DH because money is tight and hiring a doula is expensive... especially since there was only one that I would consider- a doula that was also a midwife. Sooo... I did some more reading and learned how dangerous multiple c/s can be (meaning 3 or more... we are Catholic and don't use birth control, so we will most likely have a lot of kids... which is fine with me :) ). That did it for me. I talked to DH and explained things and he agreed to hiring the midwife to be our doula.

So this is the plan. Our hospital is an hour away and, if it's during rush hour, it takes forever to get there. When I go into labor, I will call the midwife and she will come to my house and make sure I really am in labor. Then we will go to a hotel near the hospital and labor until I am about ready to push. Then we will go to the hospital and have the baby. I am at peace with this plan (well... I REALLY want a home birth, but DH isn't ready for that yet). I believe I will go into labor, and my OB is willing to let me go to 43 weeks if everything is going okay. Laboring in the hotel isn't as good as home, but at least I won't have to deal with nurses and doctors and interventions. The midwife will monitor the babies heartbeat and let me know when I am close enough to pushing to go to the hospital. She knows all the tricks for handling pain and changing baby positions (my last baby was posterior). I have confidence in her.

If my OB gets all weird and starts pushing for a c/s or some form of induction (I don't know what that would be... she said she wouldn't induce unless it was absolutely necessary... which doesn't make sense), I will just stay home. DH won't have a say at that point (but don't tell him...).

There are some things I can't control and I accept that. I feel completely in control of everything else though, and that helps. I've read some very good books that have helped me keep things in perspective. Any future babies will be born at home, which is where I think it's safest for mom and baby. Yes, even a VBAC or a VBA2C.

Good luck! Make the decisions that best fit you and have peace that it's all going to be okay :) Have confidence! Read, read, read. I highly recommend "The Cesarean" by Michel Odent. I disagree with some of what he says, but the rest is good. Also, if you haven't already, read "The Thinking Womans Guide to Better Birth" and "The VBAC Companion." Many people like Ina May too.

[courtenay_e]

In considering the relative danger of a VBA2C, I would also look VERY carefully at the relative danger of a CESAREAN after 2C's.  There is a preponderance of evidence that shows that it's not the first cesarean that is as dangerous as the repeat ones, and the level of danger increases with each surgical birth.  If they are going to use scare tactics, they should at least scare you about BOTH paths you could take! *angry eyes*  The newest studies show that increased risk of rupture starts after the third or FOURTH cesarean and a vaginal birth, NOT after the second cesarean.  So, if you respect the abilities of the expert in normal birth (your homebirth midwife) who says that they are willing to take on the risk of your labor and birth, I would listen to her skills.  Remembering always that the OB is a surgeon who is trained in the PATHOLOGY (to look for what could possibly go wrong) of pregnancy, labor, and birth, and trained to CUT (again, she is after all a surgeon).  It will always be a surgeon's first impulse to cut, as that is the path they are accustomed to taking.  But the midwife, though she IS trained to make sure she keeps homebirths safe, is also trained in how to notice things that may preclude a woman from homebirth.  Trust me, she isn't taking you lightly.  She does NOT want a poor outcome on her records.  If she thought, from the preponderance of studies, that it was not safe, she would not take you on.  There are a few mavericks out in homebirth world, but not as many as the medical establishment would have us think.  We are not heros, we are not looking for trouble.  We want good, safe, happy outcomes, and will work to get them...or ask women to consider other options if we don't think it is possible at home.  Just a thought...

[jenniro]

Originally Posted by konayossie 

Originally Posted by jenniro 

http://givingbirthwithconfidence.org/2-2/a-womans-guide-to-vbac/weighing-the-pros-and-cons/

Thank you so much for posting this link! I have been looking for something that would give me exactly these side-by-side comparisons of VBAC/VBAC. GREAT resource!!

Your welcome!  Farmergirl, I really hope the hospital an hour away works out.  KUP!

[douladianne]

Hi Farmergirl ~ Thinking of you and the tough decisions you have to make. Unfortunately, if you're in a hospital and "attempting a VBAC" (as the hospital calls it), you will be required to be continuously monitored either with an external fetal monitor or an internal one. They typically like to use an internal one and will insert an IUPC (Intrauterine Pressure Catheter) at the same time so they can monitor the strength of the contractions. This requires breaking your water first...now you're already at 3 interventions.

If you were having a home birth and there was a need to transport,  911 would be called to transport you in an ambulance.

I really like Cagnew's plan for her VBAC and have heard many others do it that way as an alternative to a home birth. Often times, labor goes very smoothly and baby comes quickly because mom feels safe and is extremely relaxed! Baby is either born at home or in the hotel. You can't go wrong with having a midwife for a doula but no matter where you give birth, you deserve to have a doula...Of course I'm a little bias :0)

Take care!

Dianne

[neveraim]

Oh dear God!!! I'm so sorry that you were exposed to all that misinformation!!!  Doctors know how to just scare the bejesus out of you!  I had a VBA3C in June with a wonderful OB who's been doing VBACs for over 30 years.  He also catches breech and twins...and VBAMC and VBAC after special scars...vertical incisions, etc.

The risk of catastrophic uterine rupture is 3 out of 1000.  50% of those are caused by induction or augementation of labor with pitocin/cytotec, etc.  Yes, when this happens it is very serious...http://www.ican-online.org/vbac/uterine-rupture-a-10-year-population-based-study-uterine-rupture 

You need to talk to a provider who is supportive of VBAC.  Your doctor is not up to date with the current ACOG guidelines that say that VBAC and VBA2C is safe.  Who knows what the conditions were surrounding the uterine ruptures they 'saw'.  Could have been cytotec inductions...

If you are healthy and your baby is healthy, you should be able to move towards whatever birth you want. 

Edited by neveraim - 1/29/11 at 4:00pm

[channelofpeace]

FWIW, when I was pregnant with my third and I went to my OB, he just assumed I would be trying for a VBA2C and had no problem with it.  I am not sure there was even a discussion about it?  That birth was my first VBA2C and I have had another since then.  

Good luck making your decision!

[douladianne]

@Channelofpeace...You were one lucky woman and sounds like you had a great (but atypical) OB :)  I love that you're now becoming a midwife!

[Lisa1970]

My last doctor tried to claim a 30% rupture rate on vbacs. Then I had a csect and almost died. I had a complication that had a 90% death rate. 

[*farmergirl*]

I finally got in to see the other hospital- wow we like them sooo much better. They said I am a good candidate for a VBAC! Other than a hep-lock they don't require anything for a VBAC no continuous fetal monitor. I can still use the birth tub even. Apparently they have had several other people come from my former OB who had similar experiences. I feel so much better about it now and have actual answers to my questions no just OMG your baby will die and you might too!!

[jenniro]

Yay!!  I am so excited for you.  It is so nice to be somewhere that you are supported instead of scared, right? I mean, come on, you're just a woman having a baby, and it is a wonderful time.  Enjoy the rest of your pregnancy and I look forward to your birth story!

[Lisa1970]

I had a doctor try to tell me the death rate for vbac was 1/3rd. Obviously, that is wrong. You need to find out where she gets her 5% from. Chances are, that is just a made up number. The only baby I have ever known to die from uterine rupture was an initial birth, not from a vbac.

Another thing to consider is that the ruptures often happen before labor even starts. With each additional csect, you are at a higher risk of things such as placenta problems and rupture and so on. If you are planning more children, you need to seriously consider that.

Regardless this is not a doctor to stay with. She clearly is not supportive of vbacs and you need someone who is supportive.

[Lisa1970]

I bet you were with the same doctor I am with now. Dr C.
 

Originally Posted by neveraim 

Oh dear God!!! I'm so sorry that you were exposed to all that misinformation!!!  Doctors know how to just scare the bejesus out of you!  I had a VBA3C in June with a wonderful OB who's been doing VBACs for over 30 years.  He also catches breech and twins...and VBAMC and VBAC after special scars...vertical incisions, etc.

The risk of catastrophic uterine rupture is 3 out of 1000.  50% of those are caused by induction or augementation of labor with pitocin/cytotec, etc.  Yes, when this happens it is very serious...http://www.ican-online.org/vbac/uterine-rupture-a-10-year-population-based-study-uterine-rupture 

You need to talk to a provider who is supportive of VBAC.  Your doctor is not up to date with the current ACOG guidelines that say that VBAC and VBA2C is safe.  Who knows what the conditions were surrounding the uterine ruptures they 'saw'.  Could have been cytotec inductions...

If you are healthy and your baby is healthy, you should be able to move towards whatever birth you want. 

[labortrials]

I think a lot of your success (in a hospital) is dependent on how the hospital staff and the delivering OB react to VBA2C.  IMO, you have more "control" over what happens to you in other birth settings.  I'd be sure that the OB(s) who supports your choice of VBA2C will be there for you at the time of delivery!!

Also, there's a good chart in Dr. Marsden Wagner's book, "Born in the USA."  The most consistent UR risk rate I hear is for primary VBAC - UR risk is @ .5%.  It's my understanding that the risk rises with the number of cesareans, but by how much, we don't really know.  The best guestimate is about 1%.  I'm not thrilled with that statistic, but knowing that we don't know how many of these ruptures were caused by induction or aumentation, for instance, makes me think it's probably lower.  Last time I looked into weighing the risks of VBA2C vs. RCS, the risks were about even.

I don't think it's fair to scare you into thinking that being in a hospital would save you from a bad outcome.  They may (or may NOT) be able to respond to an emergency quickly.  Again, based on what I've learned these past few years, there is a certain amount of time from decision to perform surgery until the surgery can take place.  It's also my understanding that the risk of a catastrophic complication from a UR is 6%. 

It seems like you probably just need to do more research so you can feel comfortable with your needs and wishes.  You can always provide that OB with links or hard copies of better studies.  Quoting a 5% rupture risk to you (or anyone else) is NOT good . . .

Oh, and my favorite place for getting good childbirth info is http://childbirthconnection.org.  It's an independent non-profit organization, and I think it has the best consumer-digestible and reliable info out there.  Other places (ICAN, Lamaze, etc.) are great (I'm an ICAN leader), but I don't think, not that I'd know for sure, med pros are going to look on that stuff as favorably.  JMO!

[*farmergirl*]

Thanks Jenniro! Until you said it I had forgotten that yes indeed this time I will have a birth story :joy 

This new OB is very supportive of VBACs and has full faith in the midwifes who work at the hospital. The OB is more in the wings and while the OR will be on stand by once I go into labor they're both there JIC. I just Love when they look at the facts and work with you so you can make your own decisions. Seems like of course thats the way it should be but sadly it seems that it's rather rare in the medical field.