OB recommends repeat CS what do you think?

[mythik]

Ok, so the MW practice I chose with DS has a 10% CS rate and I was one of those 10%...go figure.  Pregnancy normal, labor normal: 14hrs natural/no meds hypnobirthing, then broke down for epi, started pushing at 28.5hrs, at 31hrs had ER CS due to baby not descending/coming out.  We tried vacuum (he was still too high and lodged in there), forceps didn't work.  He was born at 40wks5days weighing 7lbs3oz.  They told me that my pelvis was too oval and the baby was not shaping.....ok.

I am 25wks preggy and going for a VBAC this time.  Per my MW practice rules I had to meet with the OB in the practice due to my previous CS with my son, well he of course recommended a repeat CS.  Mind you this is the OB that performed the CS so I also met him as I had questions on what happened.  I really didn't get why he just mentioned the repeat in the end...simply stating that the same thing would happen again - whatever. 

I had my regular monthly MW apt yesterday and she gave me more info on why the OB wants a repeat CS.....she said that his notes show that he cut my uterine artery during the surgery which is why there was so much blood loss...and he is worried that my uterus didn't heal as well due to the lack of blood getting to the uterus post surgery due to the surgical injury there.  They did a specials suture/fixing of the artyer but the OB thinks that the laceration mistake may up my risk for 'possible' uterine rupture.

Does anyone have experience with this and did you still go for a VBAC?

Thank you :).

[kltroy]

Well, I think it comes down to risk and what you're comfortable with.  So the general risk for UR is around 0.7%.  Let's say your risk is 1.5% (so double).  Are you ok with that?  How about if it were 2%?  5%  My point is, it's difficult to draw a line, although at some point we would all say it's not worth it. 

One idea would be to discuss with your OB maybe a "careful" VBAC.  Ask him when he thinks UR would be most likely, and work together to come up with a plan to minimize the risk that you both feel comfortable with.  Maybe this means you head to the hospital a bit earlier in labor than you would otherwise plan.  Maybe they do an ultrasound measurement to see how thick the uterus is over the scar?  Maybe this means that you decide to have a RCS at 42 weeks rather than inducing at 42 weeks.  Maybe it means that you agree up front (ie before labor starts) at what point you would call it quits on a VBAC attempt.  I think if you present a case that you are strongly motivated for a VBAC and that you have done your research and are comfortable with the risks and want to work with him to find a solution, this can work well. 

The other thing I would ask is whether the OB has any evidence that nicking an artery would impair healing, or would increase rupture risk.  The answer is probably no, but if he can explain to you, in a way that is satisfactory, why he thinks that may be the case, then you can decide how much of a risk increase it really is.  I would definitely have this discussion and try to nail down exactly how "bad" this is.  For example, a classical incision has a UR risk of around 4%.  Is this that bad?  I'm guessing not.  Best of luck - keep us posted on how this goes.

[mythik]

Thank you so much for that insight!  I have an apt with another OB that my MW practice recommends in three weeks for a second opinion on the laceration and healing questions I have.  My MW practice is very supportive of a VBAC but I really want all the information on this just so I know.

Thanks again!

[ablepearl]

I have to agree.  What is your comfort level?  If your risk is even as high as 10%, that means you have a 90% chance of NOT rupturing.   Regardless of the actual risk, the results are the same, right?  If you rupture you will either deliver quickly vaginally, or you will have a c-section.  If you are the less than 1% that ruptures in a standard VBAC, or the theoretical 10% that ruptures in a more 'risky' VBAC, does it matter at that point WHAT the risk level was?  No, the response by the providers is the same, get the baby out safely.

Then think about the common practices during labor and delivery in the U.S. and the doctor induced risks that they do every  single day.  What about artificial rupture of membranes, which increase the risk of cord prolapse.  Or high levels of pitocin or the use of cytotec, bith known to cause uterine rupture in unscarred uteri.  Or they cause hyperstimulation of the uterus which can lead to cutting off the oxygen supply to the baby.  Their 'standards' are at least as dangerous as attempting a VBAC, even if you have a 'special' case.

[AlexisT]

Actually, it does matter, because morbidity and mortality are so much higher if you do rupture. The results are not the same, and it's not "you'll wind up with a CS anyway." I'm not trying to play the dead baby card, but the reason you want to avoid rupture is the risk of death. There is a 6% chance of death or oxygen deprivation following a rupture. The problem with the "it's only 10%" logic is that it assumes VBAC is a good to be pursued at all costs. Under ordinary circumstances, VBAC is as safe as RCS. As the risk of rupture rises, the risks of VBAC begin to outweigh the risks of RCS. It's not about whether 4% or 10% is too high an absolute risk; it's about which choice has a lower relative risk in a given situation.

By that logic, you might as well go back to inducing VBACs via prostaglandins instead of performing an RCS when baby needs to come early. We don't do it because the risks of induction outweigh the benefits of VBAC. 

Personally, given that this opinion came from the OB who did the CS and who therefore has a significant bias, I would seek a second opinion. In fact, I would seek a second opinion from an OB in an entirely different practice, one that bears no potential liability for the original mistake. This OB is worrying about legal liability should anything happen, and his partners will be affected by that.

[ablepearl]

My point remains the same.  If you are in the 1% (i.e. the rare risk of rupture) and actually so rupture, or you aer one of the higher number (such as 10% which I pulled out of my rear end as an example- the real risk is probably FAR less than that) you are 'that girl' that ruptured.  At that point, no it doesn't matter.  If you rupture you rupture.  And if you do rupture the doctors follow the same protocol.  Have you talked to women with catastrophic ruptures, especially the women that lose their babies?  Many of them will tell you, that regardless of how small the risk is that the VBAC is not worth it.   Others are more realistic and still believe in VBAC for other women, but the ones that think all VBAC is too dangerous will tell you the same thing.  When it happens to you, the risk you had BEFORE the rupture doesn't matter.

For me, 10% would not be too high.  I know that would not be the same for all women.  Which also means if I needed it and a doctor would agree, I would induce  But, like i said that risk is one I would be willing to accept.

[cinderella08]

OP - you have received some great information.  I personally would first and foremost get a non-biased (VBAC friendly OB!) second opinion before even considering making a choice.  Also look at your risk level and what 'risk' you are ok with.  Discuss with another OB what 'risk' there would be regarding rupture increase due to the cutting of the uterine artery done by your previous OB.  I'd also ask your OB, or your 2nd opinion OB exactly what data they have that shows an increased risk in rupture due to the artery being damaged during your previous surgery.  If they can not produce a suitable answer, I'd allow that to speak for itself.

Good luck!  KUP!

[ablepearl]

http://www.specialscars.org/articles/not_typical.html  While this site doesn't discuss you situation specifically it does discuss scars that are known to increase risk.  The admin here may have information for you if you contact them.

[dlm194]

FWIW, I don't think the OB is making something up.  Diabetics and people with peripheral arterial disease don't heal as well from wounds on their extremities (feet, etc) due to the lack of blood flow to those areas.  With proper care, they can eventually heal.  I'm not sure how long ago your c-section was but that might influence my decision (if I were in your shoes). I guess it depends on how well the OB thinks he fixed it too.   It is also possible to have an u/s measurement of your uterine scar to determine it's thickness (and therefore suitability for a VBAC).  There is tons of controversy on the validity of that measurement (operator bias, etc) but it IS an option to help you make a decision.  I don't buy the oval pelvis thing though.  My midwife had her back up doctor "check" my pelvis during my c-section and that's what he said.  The told me to keep scheduling c-sections but I VBACed just fine.  My VBAC baby's head barely molded during the birth process.