Repeat C-sections and deaths?

[seili]

I am trying to decide whether or not to attempt a VBAC. I have to admit that I am now leaning towards the repeat c-section, though, which surprises me.  I've been posting my concern on a some message boards in hope of more information, but I just don't know if it is out there.

I have one child and he was born by c-section. It started as natural labor, but then he became stuck in my pelvis, apparently. 

At first I was really considering a VBAC, but now I am leaning more towards the elective, repeat c-section because I have read so many terrible stories about VBAC ruptures. And it is so strange...maybe I am doing something wrong...but I cannot find one story on a repeat c-section where the healthy baby died. 

It's strange because I know that the given statistics are that repeat c-section are more dangerous than a vaginal birth for both mom and baby. But I haven't even found one person saying 'their friend's baby' or 'their sister's baby' , etc. I know it doesn't necessarily mean anything because there must be some, but it kind of alarms me and makes me think the statistics for repeat c-section are also including unhealthy mothers and babies.

Now granted, I have found posts about the mother's dying during repeat c-sections, but I am particulary looking for information for the babies. I only ever see people giving the statistics that have been reported. 

Does anyone have any ideas about this? 

I am truly kind of puzzled. 

PS-

Oh, I should mention while I'm thinking about it, that while I am having a hard time find any personal stories about RCS death of a healthy baby, I have read all the statistics and I do still think that VBAC is an excellent choice for some people. I don't think it's crazy at all for some people to try it.  I'm really just questioning it for me because of my last labor. I know that even with my history, I still could succeed, but I just don't know that I'm willing to take that chance.- especially because of the stories that I have read- I feel I might be in more danger of that happening than some other people.

My last labor, I got to 10cm and was at the pushing stage, but felt no urge- only a terrible, unrelenting feeling in my back that was inescapable. The doctor said it was because my son was stuck in my pelvis. She is supportive of either VBAC or c-section, but says that it is probably more likely to repeat with me than with someone who didn't have that problem or who has had a previous vaginal birth. 

Someone mentioned to me that if you are looking for horror stories, you will find them. And that is just it. I have been looking and looking on both sides and I haven't come across any horror story deaths from RECS for a healthy baby- you would think someone would be talking about. But I have run across the VBAC horror stories and sometimes it upsets me even more because some of the mothers do not regret their choice and even go on to say they had a successful VBAC because the baby eventually emerged- though not alive. I guess I am just disturbed right now...the more I read, the more disturbed I get. But, I should also add that I have never felt a desire to need a vaginal birth- I know some do feel that strong urge.

[Ms. B. Sprout]

Comprehensive risk comparison: NIH VBAC risk white paper from March 2010

Edited by Ms. B. Sprout - 4/10/11 at 6:54pm

[LiLStar]

Your story is CLASSIC. Dilating to 10 with no urge to push and severe back pain that just doesn't go away indicates a baby who was probably malpositioned. Since my c-section in 2007 and being involved in ICAN and hearing loads of women's stories.. it seems to be one of the more common ones. Of course, everyone's details are different, but dilating, trying to push, and not being able to move a stuck, malpositioned baby is one of the more common c-section stories I hear. Thats what happened in mine as well. There's no reason that your history would increase your rupture risk (I'm assuming you had a low transverse incision?) and, regardless of vaginal vs c-section, 2nd time moms are less likely to have problems with a malpositioned baby simply because after pregnancy, our uterus is more "apple" than "pear" and its a little easier for baby to rotate around to an ideal position. There are also things you can do to help encourage your baby into an ideal position, such as exercises recommended on spinningbabies.com, or seeing a chiropractor who specialized in pregnancy. 

As for "horror stories".. there are a lot of rupture horror stories online in which the mother was induced. Induction is well known to significantly increase the risk of rupture. Rupture also occurs without induction, and even without labor! Even if you're the unlucky 1 in 250 non-induced vbac women who ruptures, rupture does not always, or even most of the time, mean a dead or damaged baby. 

quoting from http://vbacfacts.com/vbac/ (removed some text to shorten the quote, see link for full text)

...the rate of uterine rupture in a spontaneous labor with one prior cesarean is approximately 1 in 250 (0.4%), 1 in 2000 (0.05%) VBAC babies will have a bad outcome.

However this rate is inflated as Landon (2004) included women who had pre-labor stillbirths in this statistic.  In other words, women whose babies passed away before labor, had VBACs rather than repeat cesareans, and so those deaths were counted towards the 0.05% statistic. 

Landon (2004) stated that from 114 ruptures at term, 7 (6.2%) babies had...(oxygen deprivation), 2 (1.8%) died

I do have a friend who, while she had a live baby from her ERCS at 39 weeks, he had to spend 10 days in the nicu because his lungs just weren't developed enough. He was a 39 week "preemie", and spent much of the first 2 years of his life regularly needing hospitalization for breathing treatments and such. 

[labortrials]

I'm sorry you're feeling so much fear.  I think too much focus on the horror stories (either way) is not going to help you prepare for another birth.  Planned ERCS can be a great experience for some mamas.  However, there are risks to consider for sure and then even other factors that aren't scientific.  Like in my case . . . if I end up with another c/s, how will I keep 2 22-month-old twins off of me while I'm healing from major abdominal surgery?  Rupture risks are fairly low esp. w/o induction, augmentation, or epidurals, and it's my understanding that there are often 'signs' that it's happening.  Of course, not everyone can discern those signs.

The NIH held a VBAC consensus-building session in 2010.  You can read the entire report . . . you should read the report, actually.  I think it'll make you feel better about at least considering the risks and benefits of VBAC.  And a GREAT source of information is Childbirth Connection.  I'd also recommend getting involved with ICAN.

Good luck on your journey!!

[kltroy]

This is definitely a personal decision and many factors will go into it, including your own previous experience.  Some things to consider:

*  family size.  If there is even a remote possibility that you may want a third child, you may want to attempt VBAC, since the risks of RCS go up quite a bit with each subsequent repeat surgery

*  your own liklihood of success.  You seem quite convinced that you are unlikely to succeed, and I understand your hesitation, based on prev. experience.  However remember that regardless of what the reason was for your first c/s, about 3/4 of all women who attempt VBAC will succeed.  As others have said, baby getting "stuck" was probably just poor positioning (a chiropractor and a look at www.spinningbabies.com during this pregnancy can help with that).  Or it could be some goofy pelvis thing.  You will probably never know unless you try. 

* your fears.  You should try to work through these before your next birth, regardless of what you decide as a mode of delivery.  Telling your birth story can help.  Going to some local ICAN meetings can help (really).  Speaking with a councellor who works with birth trauma, PTSD, etc, can help.  Speaking with other women who have been there can help.  Sometimes you can find emotional healing workshops that can be very helpful in identifying your fears and helping you move past them.  Remember, this is a new pregnancy and a new birth.  It has nothing to do with your last one.

If you are a facts and figures person, (and we all are to some extent) here are some brief facts:

* about 3 of every 4 women who attempt VBAC will be successful

* around 1 of every 200 women will experience some form of uterine rupture.  About 20% of these result in the baby dying.  This is 1/5.  Multiplying these numbers out, roughly 1/1000 VBAC attempts will end in the baby dying.  To put this in perspective, the risk of losing your baby due to amniocentisis is around 11/1000.  The risk of losing your baby for CVS is 15/1000. 

*  The risk of a mother dying during childbirth during a VBAC is 4/100,000.  The risk of mother dying during a repeat CS is 13/100,000. 

*  Another perspective:  around 1/200 women will experience a placental abruption.  Or a complete previa.   

*  While rupture is an obstetric emergency, it is about as likely to happen as any other obstetric emergency.

I know these numbers are difficult to wrap your brain around (anything with lots of 0s is), but hopefully it puts some things into perspective.  I also think the resources at www.childbirthconnection.org are excellent.  The links on the left will lead you straight to a page that has a comparison of risks to mom and baby for VBAC vs RCS, and it is very helpful. 

Another good decision-making resource is:http://givingbirthwithconfidence.org/2-2/a-womans-guide-to-vbac/weighing-the-pros-and-cons/

The facts and figures in the above-mentioned guide are straight from the NIH Consensus statement that was drafted and finalized in 2010. 

If you decide to have a RCS, there are many excellent resources you can find on planning a family-friendly cesarean section, and this is also something that your local ICAN chapter can assist with.  Best of luck with your decision and your pregnancy!

[roadfamily6now]

You have some great replies.

The statistics deal with fractions of %'s the number are so small.

C-sections are more risky for the MOM then the baby which is probably why you have not heard of any tragic baby death stories with c-sections.

I'd still try for a VBAC. It is the safest way to birth.

[seili]

Thank you all for replying.

I checked ICAN and I think all of the other sites mentioned and I lots of books, too. I think it's a hard decision. Right now, I still am thinking that basically:

VBAC is best for most people, but more dangerous for the baby if it goes wrong,

ERCS is more dangerous for mom and future pregnancies.

It's just still weighing the possibilities in those two choices.

I know this is the best time to decide, though, because if I have another c-section and then want a VBAC later, that is possible, but not as easy to find a provider and may up the risks.

I have a low transverse incision on my ueterus, so the doctor says I am a candidate for VBAC, if I would like to go that route.

I do wonder if part of me will always wonder if it was possible, but I don't know if I wonder enough to take the chance, if that makes sense. But then also, I think I already said it, but I really don't feel sad or a loss from c-sections, I just think anything done the most natural way, when possible, is always best. (And I hate needles, etc!)

[jenniro]

"VBAC is best for most people, but more dangerous for the baby if it goes wrong,

ERCS is more dangerous for mom and future pregnancies."

You know, I thought this too, but I've found some research that doesn't support this.  Most ruptures are not catastrophic, so even if the dreaded uterine rupture occurs, it does not mean death, or even harm, to the baby.  There is also evidence that babies are more likely to die in the first year of life if they were born by elective repeat c-section.http://www.news-medical.net/news/2006/09/05/19919.aspx?page=2  The chance that something will go wrong in a VBAC or a RCS is small, so the good news is that whatever you decide, the odds are overwhelmingly in your favor for a healthy mom and babe. 

I am struggling with this decision as well, but we aren't TTC until this summer.  I truly believe I can give birth, and I do want to experience natural birth.  I was in a car accident in '93, so there is the slight posibilty that I have true CPD.  I really don't believe I do.  I think my pelvis healed just fine.  But there are medically necessary c-sections, and with my luck, I'd prepare for a VBA2C, and end up with placenta previa or something that schedules me for a section.  So, I am trying to have absolute faith in my body and "know" I can VBAC, and also prepare for a c-section.  Because, really, there is only so much I can control. 

Right now, I am planning to have a homeirth, HBA2C.  I've tried to labor in the hospital twice now, and my long start-and-stop labors are not tolerated in a hospital.  I am not any more concerned with uterine rupture than I am about cord prolapse or any other unlikely complication with any pregnancy.  I have an experienced midwife that I trust, and I know that she is quite capable of detecting problems and transferring to the hosptal in a timely manner.  That is how I feel today, anyway.  I am usually a total science geek, looking at the studies and stats, trying to find the absolute safest choice, but the truth is, there are risks no matter what I decide.  So, I am following my gut on this one.  The frustrating aspect of following your gut, though, is that there is never a deadline to decision making.  I could be in early labor, decide that something is not right, and opt for a 3rd section.  I don't see myself doing that, especially after my last TOL, but if I have learned anything in this journey of pregnancy, birth and motherhood, it's that:  I am stronger than I give myself credit for and although the only thing I can control is my attitude, that's sometimes all it takes.   

[MsFortune]

Elective, scheduled c-sections have the best outcomes for babies. Better than standard vaginal birth.

However, risk for mother is increased. So I think that's the balance you have to consider.

If you are interested in a VBAC, what does your OB say? Some women are better candidates than others. If the OB thinks you are a good candidate, and you have a hospital birth (in case of rupture) then the risk is somewhat managed.

Either way, congrats on the baby!

[jenniro]

Originally Posted by MsFortune 

Elective, scheduled c-sections have the best outcomes for babies. Better than standard vaginal birth.

However, risk for mother is increased. So I think that's the balance you have to consider.

If you are interested in a VBAC, what does your OB say? Some women are better candidates than others. If the OB thinks you are a good candidate, and you have a hospital birth (in case of rupture) then the risk is somewhat managed.

Either way, congrats on the baby!

If the only goal is a breathing baby right out of the womb, then sure, elective, scheduled c-sections have the best outcomes, but when looking at the first year of life, and maybe beyond, not so much.  The study excluded women with complications in pregnancy, so they tried to limit to the method of delivery.  And what about the issue of prematurity.  Scheduled c-sections are based on an ESTIMATED due date.  There is evidence that even the last few days of pregnancy are important to the developing fetus.  My doc scheduled my c-section for 6-10-10, and my due date was 6-19-10.  I went into labor and had my son 6-23-10.  If I had continued with the section, my son would have been born almost 2 weeks early.  I would be interested in my OBs opinion, but it wouldn't be a deciding factor.  At least half of women, and upwards of 70% in some studies, with diagnoses of CPD and FTP go on to have healthy vaginal births when OBs told them they could never do it.  OBs are immersed in a medical model that teaches them to be on the offensive for something to go wrong, which is wonderful when something does go wrong, but the excessive use of unnecessary interventions on healthy moms and babies is contributing to unnecessary c-sections.  They also have insurance and legal considerations that sway their decisions.   

This is not an easy decision, and very personal.  No one solution is the safest because it depends on so many factors, physical, emotional, and spirtual.  That is why I disagree with blanketed statements like, "Elective, scheduled c-sections have the best outcomes for babies. Better than standard vaginal birth."  It's not that it's a wrong statement, it just simplifies a complicated issue a little too much.


 

[KempsMama]

There is a rupture birth story on here somewhere that I found to be pretty typical, mom and baby are just fine. 

[Storm Bride]

Originally Posted by jenniro 

And what about the issue of prematurity.  Scheduled c-sections are based on an ESTIMATED due date.  There is evidence that even the last few days of pregnancy are important to the developing fetus.  My doc scheduled my c-section for 6-10-10, and my due date was 6-19-10.  I went into labor and had my son 6-23-10.  If I had continued with the section, my son would have been born almost 2 weeks early.
 

This.

I can't remember exactly what ds2's EDD was, but I do remember my family doctor and OB wanting to schedule a c-section for July 4th (I'm in Canada, so that's not as far out as it probably sounds to American posters!). I was pushing for a VBAC and put them off until an ultimatum from the OB. (FWIW, I've regretted giving in every day since it happened, and the nerve damage from the surgery still affects my daily life, to some extent - ds2 is almost six.) I went into labour the night before the surgery and was just starting to dilate when I got to the hospital, so ds2 did end up choosing his own birthday (to within a day or so, anyway - don't know how long I'd have laboured). That birthday? July 26th. The doctors wanted to take him three weeks before he was ready to be born. That scares me.

Oh - and the OB said he was "overdue" and there could have been trouble...but he had the highest initial apgar of any of my babies, including the first two, both of whom were taken through my abdomen, because they were breech - no concerns about their health, only about their ability to be pushed out without injury.

[kltroy]

To the OP:  i understand your aversion to risk and wish for a healthy baby.  Of course, this is everyone's wish.  I think the question you need to ask yourself is, what lengths are you willing to go to reduce your risk by a fraction of a percent? 

To flip things around and instead talk about success rates, take the following perinatal death statistics, which are from the NIH VBAC consensus statement:

For planned VBAC:  130/100,000

For ERCS:  50/100,000

To reword this, 0.13% of all babies will die after planned VBAC, versus 0.05% after ERCS.  Or to flip it around, the odds of your baby NOT dying are:

99.87% with planned VBAC versus

99.95% with ERCS. 

When you look at it this way, I think this particular difference is rather trivial.

Now let's flip around the statistics for mom:

Risk of deep vein thrombosis (throwing a clot - can be bad)

the risk of NOT having this is:

99.96% with VBAC

99.90% with ERCS

Hospital Stay length for mom is HALF the length of time for attempted VBAC versus ERCS (2.55 days versus 4.5 days, and this does include unsuccessful VBACs)

Anyway, my point is, the risks to the baby are present for both scenarios, but they are so very very small that you should think seriously about whether the reduction in risk is worth having major surgery for YOU.

It's a very personal decision, and only you can say what is important for you.  Best of luck.

[~~Sarah~~]

Forgive my intrusion, I'm not a VBACer (by some miracle) but I am a VBAC supporter.

seili, the horror stories that you are looking for from ERCS are few and far between. I'm sure they do happen (freak accidents where the cord is cut accidentally by the scalpel and such) but they are rare because the main issues that arise from ERCS happen later. They are not birth stories so much as they are neonatal stories. There can be problems (and even death) due to prematurity and other lung issues, but the baby is whisked away and is cared for in the NICU so it does not happen, catastrophically, at the time of birth. There are also the "first year" morbidity and mortality statistics that are often quite removed from the birth (and likely most people would never even make the connection). There are also stories of the hazards (maternal and fetal) of pregnancies that happen after c/sections - risks increase with each c/section. These too are not ERCS horror stories. because they happen before the birth.

Please also consider the much greater risks to yourself - after a second c/section (or VBAC) you will have two children depending on your wellbeing.

[seili]

Yeah, I definitely have concerns with both choices. Still the immediate dangers of VBAC still weigh on me, but my next step is to research if many of those cases were induced.

I'm sure no matter what I ultimately decide, I will still have concerns because that is just the nature of living and definitely can be more apparent when you are pregnant. And I do tend to over-analye.

I am sure if I choose the repeat c-section, that I will be a nervous wreck! Sometimes I get nervous just walking into a doctor's office. ha! My c-section with my first-born was so different because I was in so much pain that I could not wait for them to get the epi started again and get the c-section. It was almost heavenly.

I do wonder if any of the interventions caused me to stall, but I am really scared of what might happen if I try again. I do wonder if breaking my waters and the pitocin caused him to not position correctly. He was posterior the whole time, but he did try to turn. But for some reason, I am just rather scared of trying, even though I will be beyond nervous for surgery, I think I am more worried about what could go wrong during a VBAC. For me.

I don't mind not ever having a vaginal birth because even though I love the idea of a natural birth, when possible, I think that death is also natural, so in some situations, it is better to abandon natural and reach for life. It saddens me that so many women that have had c-sections feel so despondent, though...so despondent that they have a hard time celebrating their child's birth. I know not everyone is like that, but of course, through all of my reading, you see a lot of that utter depression over it, that I usually don't understand.

[roadfamily6now]

but the Dangers of a VBAC are the same dangers you face with ANY vaginal birth.

Any women that is pregnant can experience a Uterine Rupture. In fact UR's can happen even before labor starts so even those women planning an Elective C-section are not without risk.

Besides the risks, what kind of Birth Experience would you want?

[roadfamily6now]

And for what it's worth, I have no hard feelings about my first birth which ended in c-section.  I still choose to have a VBAC. :)

[seili]

Isn't uterine rupture more common in women who have had abdominal surgery, though?

It seems that most uterine ruptures during VBAC's were often because of induction, though, so that is something to ponder. But I am still leaning towards the c-section, which kind of still surprises me. Oh, how I hate needles and procedures! I will be a nervous wreck!

It's strikes me funny to realize I am almost equally naturally-minded and surgically minded. I was thinking about other women in my family before me and I realized that I think they probably should have had c-sections. My mom had a terrible birth with me. She had a partial placenta previa that they didn't know about, she had to have x-rays, she was in labor 36 hours or so. But we both ended up okay, but I am surprised to find myself thinking that she still should have had the section. Both of my grandmothers had terrible births, too. One of my grandmothers had 4 boys in 4 years (one set of twins) and the doctors have no idea why she didn't die with the last boy....they did have to do a hysterectomy, though.

At this point, it is still just a feeling I have.....that even if it doesn't end up terribly, it will end up bad again or I will be able to birth him, but barely, with lots of tearing and lots of fear for a baby that is stuck and barely coming out. Or that I will be exhausted and then end up with another section. But I do know that are feelings can steer us the wrong direction, so while I have time, I am still pondering!

I'm glad that you do not have lots of emotional trauma from your surgery! There are lots of people like that, too, thankfully, but I was just suprised at how many seem deeply disturbed and traumatized by their lack of vaginal births.

[MsDolphin]

Originally Posted by seili 

... I definitely have concerns with both choices.

Thank you for the great thread. I seem to have alot of the same concerns as you. I have issues with both options. We are still TTC, right now I am just trying to do research and have a thought of what I want to do, IF we have another.

[lawmama1984]

I think it's really wonderful that you are pondering both decisions so carefully.  I will say that if you do decide to VBAC, I think it takes very real commitment on your part.  I think you will find this post on The Unnecesarean very helpful.  I really loved reading it:

http://www.theunnecesarean.com/blog/2011/6/5/vbac-vs-repeat-cesarean-try-on-both-choices.html#comment13118899

For me, personally, I am one of those people for whom having a vaginal birth is very important.  I have no negative feelings about my cesareans, but it is very much a goal of mine to have a vaginal birth.  Additionally, (and I am not sure how to word this without it sounding terrible), VBAC is statistically safer for me, while slightly more risky (and I mean, very, very slightly) for the baby.  I do have two other children to consider as well, who need a mother.  I do believe that I can safely (safely for me and the baby) VBAC our next baby, which is why I am making that choice--I trust my midwives, literally, with my and my baby's life, so this makes the decision a little easier for me (although it is a difficult one no matter what choice I would make).

Anyway, best of luck to you! I am sure you will make the right decision for your family. 

Edited by lawmama1984 - 6/15/11 at 7:50pm