Hospital VBAC vs Birthing Center VBAC - Page 4

[Lynann]

Outcome is more important to me too.

Chances I'll die from hospital acquired infection is 0 if I'm NOT in hospital.

Chances of an infection going straight to my brain from the epidural is 0 if I'm NOT in a hospital.

Chances of complications from surgery that was not actually needed, but due to CP impatience is 0 if I'm not in a hospital.

If you think I'm being over dramatic it may be due to reading this article this morning. A perfectly healthy woman DIED IN HOSPITAL after acquiring meningitis in her brain from the carelessness of the anesthesiologist and the lack of proper care after she started showing symptoms. Her son has had to grow up without his mother.

You bet outcome is way more important than anything else. My children deserve to still have their mother around after birth.

None of our choices are without risk, even choosing to birth in a hospital has risks, some of which are not present with an out of hospital birth. Please stop trying to make out that there are no risks with hospital births, as the risks are very real, just never discussed by those who are against out of hospital options.

[Alenushka]

This assertion "Chances I'll die from hospital acquired infection is 0 if I'm NOT in hospital" is just not true.

MRSA and other infections come to the hospital from the community.

One can totally get infection relation to childbirth outside the hospital

http://www.khou.com/news/Kingswood-mother-has-all-four-limbs-amputated-after-home-birth-91858109.html

http://oregonmidwifeinfo.com/midwife-neglects-to-wear-gloves-mother-contracts-flesh-eating-bacteria-in-her-vagina/

[fayebond]

One can get infection related to childbirth anywhere on planet earth.  Its which risks you want to deal with.  Some people, myself previously among them, will happily deal with the hospital risks in order to have a birth there because hospitals have more equipment to deal with the rare, emergency problems of childbirth.  Others prefer to deal with birth center or home birth risks in exchange for the higher odds of positive outcomes and more control over who cares for them.  And yes, VBAC is a positive outcome that isn't necessarily likely at a hospital depending on the circumstances (largely who cares for you at a given moment).  

If your mama gut says to go to the hospital, by all means go, but please don't assume that your choice is the most safe.  I assumed that last time, and would probably never have thought otherwise if I hadn't gone back for baby #2.  If hospitals have everything so safe and pat, why do they get all worried if you want to have another baby?  Why the talk about TOLAC and "if everything goes perfectly"?  If they left me so healthy, why can't they let my body do its baby making thing this time?  Answer, I'm healthy, but VBAC has more risks than a first birth, risks the hospital gave me for no real medical reason (all while assuring me its totally necessary).  The reason many mamas go with out of hospital birth is probably a lack of trust: we were not fully informed of the risks the first time, and now that we are told its so worrisome, we worry about what other effects the hospital is not going to tell us about this round.

[Lynann]

Originally Posted by Alenushka 

This assertion "Chances I'll die from hospital acquired infection is 0 if I'm NOT in hospital" is just not true.

MRSA and other infections come to the hospital from the community.

One can totally get infection relation to childbirth outside the hospital

http://www.khou.com/news/Kingswood-mother-has-all-four-limbs-amputated-after-home-birth-91858109.html

http://oregonmidwifeinfo.com/midwife-neglects-to-wear-gloves-mother-contracts-flesh-eating-bacteria-in-her-vagina/

It is impossible to get hospital acquired infection unless I make some kind of contact with a hospital. I'm not saying I have no risk of any infection, just not hospital acquired ones. Also the risk of infection in my own home is much lower as my immune system is already familiar with my home environment. If my midwife then brings in a foreign infectant that she doesn't then take due care to avoid then my risk is higher. The less she touches me the lower the risk, and I can't see hospital staff being so comfortable with no vaginal exams. With my home birth I had 1 exam when I started spontaneously pushing, just to make sure I was fully dilated. I had a cervical lip so she had me hold on the pushing (not an easy task when its all your body wants to do) for 20 min to give my cervix time to finish dilating and didn't do another exam to confirm as it wasn't needed. In the hospital I was given vaginal exams at least hourly. Each exam increases risks of infection. Getting an epidural increases risk. Having a care provider (no matter who) that continues to touch their cell phone while touching you definitely increases risk of infection.

Can and do things go wrong at home births. Absolutely

Can and do things go wrong at hospital births. Absolutely

Do women and babies die as a result of both. Sadly yes.

Birth has risks no matter where you birth. Interventions can increase that risk as much as medical facilities can help in emergencies.

If I thought my life or the life of my baby might be at greater risk out of hospital then I would transfer my care. That doesn't mean that only hospitals are a safe place to given birth, because for some women it is having a hospital birth that killed them.

[rnra]

Originally Posted by Lynann 

Birth has risks no matter where you birth. Interventions can increase that risk as much as medical facilities can help in emergencies.

I have never seen statistics that show the risk of trained medical intervention during birth is equivalent to undoing the benefits from readily available emergency care.  If such information exists, I would love to see it.

Originally Posted by Lynann 

Do women and babies die as a result of both. Sadly yes.

Yes, babies die in both locations.  However, they do not die at the same rate or for the same reasons in both locations. 

[Alenushka]

So, if I give birth in the hospital then I have 0 possibility of getting home aquired MRSA? right?

[dlm194]

Unfortunately, there is no perfect choice for a woman with a scarred uterus.  There are risks no matter what your choice is.  The question is what risks are you most comfortable with.  Research shows that VBACs without labor inducing/augmenting drugs have the lowest risk of uterine rupture: 0.4% in spontaneous labor vs about 1.0% in induced/augmented labor (http://journals.lww.com/greenjournal/Fulltext/2004/11000/Results_of_the_National_Study_of_Vaginal_Birth.9.aspx and http://www.nejm.org/doi/pdf/10.1056/NEJMoa040405) .  Research also shows that you are more likely to have a successful VBAC in a birth center (87% success in a birth center vs 73.4% in the hospital.   In this study , there were 1,453 women who attempted VBAC at a birth center.  6 of them ruptured.  Of those 6 ruptures, 2 of the babies died. 

This study shows the worst case UR scenarios.  The hospital served a large population of Hispanic women who largely had cesareans in their native countries where vertical incisions were common.  Here is a good breakdown of the data.Quite a few of these women showed up at the hospital IN labor (there is no suggestion that they had trained midwife with them in labor so who knows how long they were in labor before coming to the hospital).

The bottom line is that you need to do what you feel comfortable with.  I don't agree with berating women with guilt trips over their choices and implying it's all about a birth experience.  YOUR health matters too.  Of course you want a healthy baby!  We all do!  But as a mother, you have to think about your other children too and being healthy and alive for them as well.  It is not selfish to try to give your baby the best birth possible.  Yes, there IS a risk of uterine rupture.  You know that.  There is also the risk that hospital interventions will increase your risk of a UR.  There is also the risk that your chance of a RCS are higher in the hospital.  There is the risk of YOUR death following a repeat c-section.

That being said, I don't think the answer is cut and dry.  Ideally, a hospital would give you all the time you need to labor unhindered and ready to respond to an emergency.  But the reality is that they are not all like that.  You need to make the best decision for you and your family.  Good luck!

[MichelleZB]

OP, VBACs are pretty safe. It looks like your birth centre is well-equipped for an emergency and has doctors on call. Honestly? It will probably be fine: go for it! I'm pretty pro-western medicine, but often hospitals do some weird shit to labouring women and I imagine it could be a scary place to VBAC.

That said, I had a vaginal hospital birth. It was basically fine. YMMV in the hospital, depending on the hospital. If your hospital is VBAC-friendly, perhaps that would work too.

[rnra]

Originally Posted by dlm194 

Research also shows that you are more likely to have a successful VBAC in a birth center (87% success in a birth center vs 73.4% in the hospital. 

Did you read the article you are citing?  The authors' conclusion clearly states the following:  "Despite a high rate of vaginal births and few uterine ruptures among women attempting VBACs in birth centers, a cesarean-scarred uterus was associated with increases in complications that require hospital management.  Therefore, birth centers should refer women who have undergone previous cesarean deliveries to hospitals for delivery."  It also says this:  "On the basis of these findings, we advise both birth centers and women with prior cesarean deliveries against attempting VBACs in any nonhospital setting."

Of course women in a birth center are less likely to have a cesarean delivery.  That's like saying women at an Italian restaurant are less likely to have sushi for dinner.  If it's not available at your current location, and the people who work there do not have the necessary training to do it, it's less likely to happen.  But the avoidance of a repeat cesarean doesn't mean that there were good outcomes.  In that same study, the fetal/neonatal death rate in birth center VBACs was 0.5%.  Since birth centers typically only take "low-risk" births, it should be expected to be much lower than births that include women/babies of all risk levels.  For reference, over 2/3 of those deaths did not involve a uterine rupture.  0.5% seems pretty good until you see that the fetal/neonatal death rate for the entire USA during the same year was 0.003% (this includes all pregnancies after 28 weeks gestation, home births, VBACs, etc.) Source

[dlm194]

Originally Posted by rnra 

Did you read the article you are citing?  The authors' conclusion clearly states the following:  "Despite a high rate of vaginal births and few uterine ruptures among women attempting VBACs in birth centers, a cesarean-scarred uterus was associated with increases in complications that require hospital management.  Therefore, birth centers should refer women who have undergone previous cesarean deliveries to hospitals for delivery."  It also says this:  "On the basis of these findings, we advise both birth centers and women with prior cesarean deliveries against attempting VBACs in any nonhospital setting."

Of course women in a birth center are less likely to have a cesarean delivery.  That's like saying women at an Italian restaurant are less likely to have sushi for dinner.  If it's not available at your current location, and the people who work there do not have the necessary training to do it, it's less likely to happen.  But the avoidance of a repeat cesarean doesn't mean that there were good outcomes.  In that same study, the fetal/neonatal death rate in birth center VBACs was 0.5%.  Since birth centers typically only take "low-risk" births, it should be expected to be much lower than births that include women/babies of all risk levels.  For reference, over 2/3 of those deaths did not involve a uterine rupture.  0.5% seems pretty good until you see that the fetal/neonatal death rate for the entire USA during the same year was 0.003% (this includes all pregnancies after 28 weeks gestation, home births, VBACs, etc.) Source

What is with the hostile attitude? It really makes me sad to see what MDC has become.  We used to be so supportive here.  :( Yes, of course I read the study.  I read the WHOLE study, thank you.  I realize what the conclusions are and the OP can use them to make her decision.  Think about it - the study was published in Obstetrics and Gynecology. I'm not surprised they conclude that VBACs (or any woman) should be in the hospital.   I did NOT tell her that she *should* birth in either a birthing center or a hospital.  I opine that it's her choice.  I still believe it's a  good study for the OP to read.  I have to assume that if the OP is being accepted as a birth center birth, she is low risk enough for them.  So she can expect to have a better chance at being successful in her VBAC than if she were in the hospital.  Also, the birth center study includes higher risk VBACs like VBA2C and VBACs after 42 weeks.

Now, if you will please read the NEJM study, it states that women in the hospital who underwent a spontaneous labor had a 0.4% of UR.  Obviously those women were not necessarily as low risk as the ones in the birth center. 

You also really need to do your math.  In your national vital statistic source, you are citing fetal death after 28 weeks gestation.  That rate was about 3 per 1000 which is actually 0.3% (NOT 0.003%).  But you aren't doing an apple to apples comparison.  As stated in your source, fetal death means any intrauterine death of the fetus at any gestational age (you are choosing to look at beyond 28 weeks).  You need to compare it to perinatal deaths which are fetal deaths near delivery and neonatal deaths which are early infant deaths (the birth center study even says "fetal/neonatal death;" NOT just fetal death which you are trying to use to skew the comparisons).  The perinatal mortality rate in 2004 was 6.2 per 1000 births or 0.62%.  Hmmmm.... now the 0.5% at the birth center (which was VBAC attempts ONLY; not all birth center births.  VBACs DO have an additional risk- not just being a VBAC but having a uterine scar in general) doesn't seem so bad.  Of course the study also concludes that "Rates of uterine rupture and fetal/neonatal death were 0.2% each in women with neither of these risks [more than 1 previous c-section and/or beyond 42 weeks gestation]."  So, wow, those rates are actually pretty good. 

Edited by dlm194 - 7/29/12 at 7:43pm

[notaperfectmom]

You will make the right decision for you. I believe you can sense what you need. I have 3 kids. First was c-section (long labor, bad decisions, large, malpositioned baby etc. - similar to so many other stories). My second was a VBAC at home. My third - just a few weeks ago - was a great hospital VBAC. I was not ever able to access our local birth center after my c-section (they don't do VBAC's) and I also may be one of the few people who has had a hospital birth after having a previous home birth. Both my VBAC's were good births - very different in terms of type/length of labor etc. But what I want to say is that in the end SO much of it just depends on the PROVIDER. Not just where you give birth.

Do consider where you want to be and where you will feel comfortable. But more importantly find someone you are comfortable with. My most recent birth could have taken place anywhere. It didn't matter where I was. For the last couple of hours, I'm not really sure I knew where I was (it was kind of intense). What mattered was who was there and how they worked with me as I birthed my daughter.

The people - not just the place -are both key to whether you feel comfortable. Just my 2c.

[rnra]

Thank you for catching my math error.  I was typing way too quickly prior to a family event and miscalculated.  Even with the error in calculations my sentiments remain the same.  Simply the act of having a prior cesarean rules out someone from the "low risk" category in my opinion.

[dlm194]

Originally Posted by rnra 

Thank you for catching my math error.  I was typing way too quickly prior to a family event and miscalculated.  Even with the error in calculations my sentiments remain the same.  Simply the act of having a prior cesarean rules out someone from the "low risk" category in my opinion.

You are certainly entitled to your opinion but if the logic that 0.5% is "too high of a risk" than all births are too high risk for a birth center.  Any planned vaginal birth has about the same risk of a cord prolapse (http://www.patient.co.uk/showdoc/40000243). There is no doubting when a cord prolapse occurs and it means an immediate cesarean delivery is needed.  Yes, I know all about positioning the patient and alleviating the pressure on the cord which would otherwise occlude oxygen delivery to the fetus but you still need a quick cesarean for a safe delivery. A uterus doesn't typically "explode" with a UR.   Some women remain asymptomatic for a while.... or they arrive in labor and it takes time for the staff to evaluate them before the decision for a cesarean is made.  Fetal distress is another potential issue that can come suddenly (in the absence of a uterine scar) and require an immediate cesarean. 

Edited by dlm194 - 7/30/12 at 9:39am