VBA2C success rate 30-40%?

[MissMaryMac]

Hello all,

Sorry for the long post... Just looking for some desperately-needed answers.

Yesterday I had an appointment at my current practice (will not be able to see them again since our family will be moving in the next month). It is a VBAC-friendly practice and the OB who would have overseen my birth met with me to discuss benefits/risks of trying a VBA2C. Unfortunately we don't have much information about my first C-section (it was in another state and very likely caused by too much intervention too soon), but she went over the details of my second C-section (which she performed after my homebirth hospital transfer 2 years ago).

The post-op reports stated that things are looking good in there: low transverse incisions, double suturing, no scarring or uterine thinning to worry about, etc. My OB told me that on the outside it looks like I'd be a good candidate for a VBA2C (she put my rupture rate at about a 3-4%, which I guessed she would say), BUT... Because my second labor was a failed VBAC (about 60 hours, mostly back labor, posterior baby), she is worried about my ability to achieve a vaginal birth at any point in the future.

Also, because I managed to dilate to 9cm but was unable to push the baby out (persistent cervical lip), she told me that this actually LOWERS my success rate to a 30-40%. She said that if I'd never dilated at all she might be more generous with percentages, but the fact that I dilated so far and "nothing came out of it" means that the problem is probably with me (inconvenient pelvic shape, etc.).

I'm not exactly sure what to think. Part of me wants to say that 30-40% is STILL a percentage, no matter how low, but could it really be true that I'm doomed to never experience a vaginal birth because of past history? Has anyone else ever been told something similar? Is there any way to confirm that there actually IS a problem with the shape of my pelvis? It might be too late to find out since I'm already pregnant, but... I don't know. I'd just like to get some answers, somewhere, because it's hard to stay motivated when I feel like I'm headed toward another failure.

[kltroy]

Well, look at it this way:  at the end of the day, your VBAC will either end up in a vaginal birth, or it won't.  Nobody can tell you ahead of time whether it will or will not, all they can do is estimate how often someone with your history ends up with a vaginal birth.  It still doesn't tell you how YOUR next birth will turn out. 

The question you need to ask yourself is whether data like a reliable estimate of success rate would influence your decision to TRY again.  The ACOG guidelines make the point that when VBACs are successful, it's best for mom and baby.  And when VBACs end up in RCS, it would have generally been better to have scheduled the RCS ahead of time and avoid the unsuccessful trial of labor.  The problem is that you cannot predict which VBAC attempts will be successful -- you can only know after the fact (ie either it worked or it didn't).  If you look at it in a strictly epidemiological (ie public health - what is good for the masses, not necessarily for the individual) light, the "tipping point" for benefits/risks seems to be around 50%.  That is, once your odds of successful VBAC dip below 50%, your risks associated with attempting a VBAC are probably greater than those associated with just having a RCS.  However, this does not account for individual preference and the other factors like having a supportive care provider, hospital, etc.  These things can increase your odds of successful VBAC but are difficult to assign a number to, and your preference can mean that you are willing to accept a higher risk for the shot at having a vaginal birth.

I would also consider how many additional children you are thinking about - are you really really done after this birth, or might you have another?  If you might have another, this is a good reason to go for a VBAC even if you feel your odds are lower.

There is a reasonably good success calculator here: http://www.bsc.gwu.edu/mfmu/vagbirth.html

that can help you with decision making.

I don't know for sure what your odds of success are, but I do think it makes sense to reason through the process in a logical way.  Also, the ACOG guidelines do have a fairly good number for risk of rupture after 2 cesareans -- it's under 1%.

Another thought:  Whatever you decide to do, I think the key to having a good birth experience is to feel like YOU are the one making the decisions, and you are making the best choices you can given the circumstances and the information available at the time.  I know that a CBAC is difficult no matter how you get there, but I do believe that if you feel as though it is your call and that you really gave it your best shot and that you were given every opportunity for things to work and they simply didn't, it can be a lot easier to live with this.  Similarly, if you simply cannot stomach the thought of another labor because of a previous experience, I think that's ok too and there are some really great ways to plan a family-centered cesarean.

[Ms. B. Sprout]

I really, really hear you. I had a failed VBAC attempt during which I dilated to 10 and never felt the urge to push. For 4 hours I was complete, baby was at -2 station, and she never moved down despite tectanic contractions. She was posterior.

I think OBs' predictions are worthless. I was told by an OB at the beginning of this pg that because I dilated to 10, he thinks I "beat the odds" and could probably VBA2C. Of course, he wasn't "allowed" to give me a trial of labor (his exact words were "they will come down on me if I let you try" ), so I am not using him. Just as well -- he also quoted me a 7% rupture rate and told me ACOG doesn't support VBA2C.

So, there you go. Different doc, 100% opposite "prediction." It's all smoke and mirrors. He only said that to me to throw me a bone because he wasn't letting me VBAC anyway. And your doc probably didn't want to have to deal with a VBA2C mom so she made that percentage up out of thin air to discourage you and get you to schedule the RCS.

But that's just my opinion, and I am pretty jaded about all this stuff after what I have been through with the OB world in the past 6 years.

I am going to order The Pink Kit to find out more about my pelvis. I haven't used it yet, so I can't really say how helpful it is, but I have heard other VBAC mamas rave about it. It's a thought. You might also want to consult with a midwife, even if you are not planning an HBAC, just to get another perspective on your pelvis. Here's a start: Pelvises I Have Known and Loved.

[AlexisT]

You're not doomed (and that 3% rupture rate is way too high--it's under 1%) but it is true that women whose sections were performed for FTP or CPD do, on average, have lower VBAC success rates than women who had either planned CS or emergency CS for fetal distress. These are considered "repeating" reasons (a bad term). 40% sounds low, however; usually, it's considered to be 80% when the initial CS was for a nonrepeating reason and 60% when it's for FTP/CPD. Without more details on your first, I can't say if that needs to be factored in (if you had 2 sections for the same reason, that might be significant).

That's the bad news.

The good news? That 60% is an average. It includes women who, for whatever unknown reason, have persistent and repeating problems in labor no matter what they do. That's a smaller group than some providers believe, but it does exist. There are women out there who have a bad birth, and try to do everything "right" next time, and once again, they have a slow labor that never really gets into a good rhythm, or a malpositioned baby who can't descend. We do not have the ability to identify who is going to have these persistent problems and why. We don't always know why labor goes wrong. We can say that, on average, FTP moms have a lower success rate, but it's dicey to take that statistic and apply it to an individual. I don't think there are good models for predicting an individual's VBAC success. An OB or MW may have experience or instinct, but that is not the same as putting a number on it.

To draw an analogy: I had preeclampsia in my first pregnancy. The quoted stats on preeclampsia that 5% of pregnancies will be complicated by it; 20% of mothers who have it in their first pregnancy will go on to have it again; and 25% of women with chronic hypertension will develop superimposed preeclampsia. These are basic statistics and they are true. Yet, I cannot apply any of those statistics to me, because calculating individual odds is dependent on many factors. An individual's odds of recurrence may be anywhere from 5-80%, and my MFM would not give me a number on recurrence in hypertensive women. An individual is not an average; she is a unique set of circumstances. Sometimes we can calculate the factors and draw up a personalized estimate, and sometimes we can't. Your OB may be able to explain her reasoning, and I would certainly ask her why her prediction is so low. You can decide for yourself if those reasons make sense to you or if they fail to satisfy. Experienced providers do have intuition, and it shouldn't necessarily be dismissed, but intuition isn't the same thing as statistics. Like I said, my MFM refused to give me a prediction, and he was right to do that, because he didn't have enough information (he didn't care for me during my first pregnancy, and the information I had available wasn't wonderful). My current OB is not confident that I will VBAC, but she explained her reasons to me and I agree. (She feels that my blood pressure will spike before I can go into labor.)

[jenniro]

There is no reason for me to succeed at a VBA2C.  I fractured my pelvis as a teenager, non-displaced and healed well.  My first labor was 19 hours, I dilated to 9, but never felt the urge to push.  My second labor was 13 hours, my water broke and contractions did not start.   I was dilated to 4 cm when I was admitted and was still a 4 when I had the c-section 7 hours later.  So, I have had c-sections for CPD and FTP with a history of pelvic injury.  Sounds like I should sign up for the RCS, right?  I know I may have true CPD and I have accepted that c-sections may be necessary for me, but I am still going for VBA2C for the individual reasons.

I was not educated about natural childbirth, just thought it would happen.  First pregnancy, labor started, got into a regular pattern, and then stopped.  I called the nurse at my OBs office and she said that I should come to the hospital as soon as labor started again b/c it would go fast.  So, I did, and then it didn't go fast.  They broke my water at 3 cm to "speed things along."  They gave me pit at 6 cm b/c I had "stalled."  I had to stay in bed on my back b/c that is the only position that allowed the monitors to work.  At 6 am in the morning, I was dilated but not feeling the urge to push.  Nothing was wrong with me.  My baby had tolerated labor like a champ, not one decel, but the doc said I just couldn't do it.  As I planned for another baby, I knew I wanted to VBAC, but didn't really educate myself about that either.   

My second labor was in a town 3 hours away b/c that is the closest hospital that allows VBAC.  My doctor seemed nice even though I only met her 3-4 times.  It was a bigger town than the small rural place I live, and it was different.  Everything I read suggested a doula.  I hired one in the town I was going to VBAC in b/c she was the only one available.  I met her twice.  I was not entirely comfortable with my providers, but it is all I had at the time.  Well, my water broke in the hotel room.  I called the doula and told her that I would call when things picked up.  Instead, she recommended coming over now and trying to "get things started."  She gave me cohosh, massaged my feet, and I did nipple stim.  All that did was make my early labor intense enough that I went to the hospital too early again.  My doctor was not available for my birth so I got the on call doc, who walked into the room and said, "You can't do this, you couldn't before."  My labor continued through the night, cervical checks galore, and the constant reminder that I was failing, not progressing fast enough.  At 6 am in the morning, again, I was crying and scared.  Why was I not progressing?  What is wrong with me? There was nothing physically wrong with me, again, and there was nothing wrong with baby, again.  Not even one decel.   Everyone in the room, including the doula, said, "You just can't do this."   

So, maybe they are right.  Maybe I can't, but I have never really been given a chance.  The risk of rupture is low.  I'm not worried about that anymore than I am worried about placental abruption, or any other birth complication.  I am worried about prematurity with a RCS.  The latest research suggets that even the last few days are important to the fetus, and I have a personal theory that some the of the conditions we are seeing skyrocket in children (ADHD, autism) could be attributed to inductions.  So, even if I decided to go the c-section route, I would wait to go into labor and then have the c-section, and if I am going to go into labor, then I might as well try for VBA2C because you just never know.  My babies have tolerated labor well, my uterus has tolerated labor well.  Even if I end up with a c-section, the benefits of labor for my baby are worth the risks to me from a "failed" VBAC. 

So, even though it doesn't seem likely to some that I will succeed, it is important to me to try. 

[labortrials]

Originally Posted by Ms. B. Sprout 

I am going to order The Pink Kit to find out more about my pelvis. I haven't used it yet, so I can't really say how helpful it is, but I have heard other VBAC mamas rave about it. It's a thought. You might also want to consult with a midwife, even if you are not planning an HBAC, just to get another perspective on your pelvis. Here's a start: Pelvises I Have Known and Loved.

I'm about to do the Pink Kit.  I started on it last time around but didn't really DO IT - maybe because I was having trouble with VHS?  Dunno.  Anyway, now I have a DVD copy of the tape.  Wahoo!  And Gloria's article is HUGELY encouraging.  Please do read it . . . and read it again every time you feel bad about your pelvis.
 

Quote:

Originally Posted by jenniro 

There is no reason for me to succeed at a VBA2C.  I fractured my pelvis as a teenager, non-displaced and healed well.  My first labor was 19 hours, I dilated to 9, but never felt the urge to push.  My second labor was 13 hours, my water broke and contractions did not start.   I was dilated to 4 cm when I was admitted and was still a 4 when I had the c-section 7 hours later.  So, I have had c-sections for CPD and FTP with a history of pelvic injury.  Sounds like I should sign up for the RCS, right?  I know I may have true CPD and I have accepted that c-sections may be necessary for me, but I am still going for VBA2C for the individual reasons. 

You go girl!!

UR rate - I think 1-2% is the conservative high (low transverse scar) for VBA2C.  The largest jump in risk is between 1-2 c/s.  It increases at 3 c/s but basically levels off.  However, we can't be certain that these studies incorporated the necessary limitations - no induction, no augmentation, especially.  And I think the success rate can also be impacted (positively and negatively) by induction, augmentation, and anesthesia.

I'm not a huge fan of those calculators, but I went ahead and did it.  My success rate prediction is anywhere from 52-67%.

Regarding FTP and CPD . . . those are pretty fluid diagnoses IMO.  And both blame the mother.  I'm not sure they're terribly predictive of failure in future vaginal births.  We have to try and figure out (to the best of our abilities) what factors may have lead to FTP or CPD that medpros just won't take any responsibility for.  Here's my 'for instance:'

12/29 am - visit with CNM; no remarkable dilation or effacement; baby still high; 40w estimated gestation

12/29 8:30pm - becoming violently ill from both ends; illness gets contractions going

12/29 - a bit later DH calls CNM who insists I couldn't possibly be in labor

12/29 before midnight - DH calls CNM and says we're going to the hospital anyway to treat me for dehydration

I must have been in transition b/c I couldn't understand WHY WHY WHY we were going to to the hospital; I didn't know how I'd get to the car; I didn't know how I'd keep from getting sick everywhere in the car.

12/30 early am - amazing that I didn't get sick ONCE in the car; arrived at the hopsital - found to be 9cm dilated with bulging waters

12/20 a little while later - CNM arrives suggests breaking my water, and I unfortunately consented

12/20 a little while later - complete and strong urge to push; baby doesn't descend; baby doesn't like upright pushing positions; I wasn't treated for dehydration; I quickly become exhaused

12/20 after 2 hours of pushing - CNM calls OB; OB thinks we can get baby out vaginally

12/20 later in the morning - c/s for CPD

Oh, and I'm 5'10+ with a large frame and had an 8lb1oz baby.  CPD MY ARSE!!!!!!  So, I refuse . . . downright REFUSE . . . to take that baggage in with me to this birth.

[Lynann]

I'm currently working through The Pink Kit with my DH in preparation for my HBAC in August. I think the information in there is awesome. Every woman should have this information during pregnancy. I found out from the Pelvic Mapping that I am long and narrow, and that some of the positions my m/w suggested last time during my "failed" home birth actually contributed to slowing down my labor, as squatting etc actually closes my pelvic cavity rather than opening it.

My timeline went like this:

Mon 12:40am - Waters break some (not huge gush, but as a first timer I thought it was complete)

Mon 1:00am - Contractions start at only 5-6 min apart.

Mon 10:00am (ish) - first check for dilation, only 3cm, still about 5 min apart for contractions.

Mon mid-afternoon - another check for dilation, at 4cm. MW stretches me to 5cm during next contraction while still doing exam.

Mon early-evening - this exam shows 7cm, again manually stretched to 8cm.

Mon evening - back labor starts, exam shows baby has turned and is now malpositioned.

Mon 10:00pm - still 8cm, MW begins to talk about transfer to hospital due to ROM 24 hour limit.

Tue 1:00am - Checked again, still 8cm, transferred to hospital for the rest of labor.

Tue 1:30am - check-in at L&D, nurses can't get a vein for IV, even though we tell them I have really bad veins they still assume I'm dehydrated, so they start pumping me full of IV fluids, which just causes my legs to look like tree trunks. Also put me on pitocin to strengthen contractions (doesn't work!!!)

Tue 2:00am - given some kind of pain med in IV after refusing epidural

Tue 3:00am - OB checks, I'm 9cm and finally making progress, although I'm forced to stay on my back due to CEFM which they keep loosing whenever I move.

Tue 6:00am - OB checks again before shift change, small cervical lip, he tells us I should be pushing within the hour.

Tue 7:00am - New OB checks me, 8cm, starts talking c/s. We finally agree to epidural so I can get some rest for the pitocin contractions that really hurt sooo much more than the natural ones, even though they aren't doing anything more.

Tue 8:00am - Epidural given

Tue Noon - Doctor decides I need c/s for FTP (stalled dilation)

Tue 2:00pm Taken to OR for c/s, DS born at 2:27pm I see him bundled up for a few seconds then he is whisked away and I don't get to see him again for nearly an hour, when DH brings him in to recovery. (DH stayed with DS that whole time, but I missed that important first hour, and nobody can give that back to me)

None of the interventions were medically needed, not even the transfer to hospital. The transfer was a law based decision so my MW could keep her license. I know my dilation reversed because of the exam by another complete stranger, as I had never met either OB before that night. I had a slow labor due to DS being malpositioned, so the pitocin didn't help because it couldn't change his position.

I've learned so much already from studying The Pink Kit, about how to work with my unique shape of body/pelvis and how to progress labor if it is slow again this time. It was recommended to me by a really good friend IRL who has had 4 HBACs with it, and is planning her 5th HBAC next month.

[konayossie]

Hey, I am no expert and have no answers for you, just sympathy, and I wanted to say that I am planning a VBAC in Sept after having been told flat out by my CNM and the OB who performed my c/s that "it's not gonna happen." I had a super-dysfunctional, very long labor (though not as long as 60 hours--phew!) at the end of which I actually started dilating backward and "un-effacing"  after feeling pushy for just a few contractions (never enough to have to push, though). DS had been having some nasty variable decels throughout most of the hospital portion of labor and his baseline was becoming ominous and then he had a prolonged (10 min+) decel that finally was enough to call it. What the OB found as the problem was my extremely prominent sacral promontory, which was effectively blocking his entrance into my pelvis. The OB had the CNM feel. As I said, both agreed that I could "try" for a VBAC in the future (I got double-layer suturing and all that good stuff), but "it's not going to happen." I was struggling to resign myself to a RCS, but eventually emailed the CNM who writes the blog The Midwife Next Door and asked if she had ever heard of my probem (I had scoured the inernet and these boards and couldn't find anyone else who had my particular problem). She said she actually had a client who had almost exactly the same type of labor with the same discovery at the c/s. She also thought to herself that her client would never birth vaginally with that anatomy (but she didn't TELL her client her thoughts). Well, she went on to VBAC in the next pregnancy! That CNM encouraged me to try VBACing (while also seeking chiropractic care to try to shift things around before pregnancy).
 

So, all of that to say, you can beat the odds--there are others who have done it. In my particular case, I am going into it knowing that my odds  of succeeding are probably lower than those of the average woman who attempts a VBAC, but a lower chance is still a chance, and I am not afraid of labor. I had a hard, long one before, I know I can do it again. Honestly I'm just scared of "failing" again, and the possible emotional cost of that is worth it to me to chance and try again since the benefits of a successful VBAC will outweigh the possible negatives of failure.

Originally Posted by MissMaryMac 

I'm not exactly sure what to think. Part of me wants to say that 30-40% is STILL a percentage, no matter how low, but could it really be true that I'm doomed to never experience a vaginal birth because of past history? Has anyone else ever been told something similar? Is there any way to confirm that there actually IS a problem with the shape of my pelvis? It might be too late to find out since I'm already pregnant, but... I don't know. I'd just like to get some answers, somewhere, because it's hard to stay motivated when I feel like I'm headed toward another failure.

[~~Sarah~~]

Wow, your doctor likes to pull numbers out of her %ss? Seriously though, the statistics on VBA2C are no where near 3 or 4% - they are at less than 1%. And since no one has studied the specifics of *you* and your case, the 30 - 40%, is by definition, completely made up.

I would read your story completely differently (granted, I'm sure I don't have the full details).

1 c/section due to mismanagement. Sucks. Happens to too many.

2 c/section after successful 1st stage to near full dilation. This tells me that your body has the memory, and capability to get there again even more easily next time. Again, I don't know the details of what happened at this point. Did you have an urge to push? Were you told to push against the cervical lip? How long were you at that point before the c/section was called? Was there some mismanagement involved here too? If the lip doesn't move, the baby won't descend... This likely has nothing to do with your pelvis.

Are you happy with your team of doctors? Are they truly supportive if they make up numbers like this? hmmmmm...

[cairomama]

The maneuvers in the PInk Kit are very helpful for creating space in birth. The Pelvic Floor Release and Walcher's Position are incredible in birth for helping baby engage and move under the pubic arch. It has worked in seemingly hopeless situations. If it doesn't work with waters in tact, try again after water breaks or is broken.