Originally Posted by Viola P
Is that an exhaustive list?
Why did you say the rate for multiple c-section is "up to" 3-4%? Does that mean it's lower in other studies? To me that percentage is still relatively small. According to the stats you use the rate of catastrophic injury is 0.24% - which to me does mean that such injury is very rare.
All true. There aren't too many studies on VBAMC (and none on UBAMC). Those studies that exist show a rate of rupture between one and 3.7 percent. For the sake of argument, let's cut that risk down 6/1,000 instead of 24/1,000
You're also correct to say that the risk is relatively small. My point is that despite the relatively low absolute risk, you're entering into an entirely different neighborhood of relative risk than in a normal, uncomplicated birth.
Look at it this way: I see a lot of women who are concerned by the risks of maternal mortality from a c-section. But the rate of maternal death for elective c-section is something like 6 in 100,000.
I don't understand how anyone could be concerned by a risk of 6/100,000 and then turn around and say that 6/1,000 is so small that anyone who so much as mentions it is fearmongering.
Originally Posted by Viola P
Regarding proximity to hospital, you yourself imply that this matters. Are you saying it doesn't? I couldn't imagine you taking that position.
There are serious risks and I think that we both agree its up to OP to weigh these and make her own decision. There are risks to another c-section as well, going to the hospital doesn't make birth risk free.
Sorry, I should clarify this point. You're absolutely correct to say that proximity to an OR is essential when it comes to uterine rupture. The only treatment for a rupture is an emergency c-section and we know that the longer it takes to get one, the worse the outcomes are. My objection is that I have a really hard time seeing anyone get from home to the OR within a desirable window unless you literally live across the street. The odds of making it to the hospital before you cross the threshold into the territory where really bad outcomes start to become a real possibility are poor even if you live "only ten minutes away." You're post made it sound-- to me at least-- like its a realistic possibility for most women to realize there is a problem, decide to transfer, struggle out of the house and into a car while in the middle of a complex labor, get to the hospital, and get prepped for surgery in the 10-25 minute window that you're shooting for. I don't think it is.
That's not to say that a 30-40 transfer ALWAYS means a disastrous outcome-- your friend is proof that it doesn't. But she was really, really lucky. That's why even organizations and experts that support both VBAC and homebirth consistently advise against UBAC. That's why all guidelines for trial of labor emphasize the importance of being prepared to perform an emergency c-section within minutes.
I think the more accurate thing to say "The risk of rupture is real but relatively low, but the consequences of a rupture at home are potentially disastrous."
I realize that this wouldn't change your mind-- and I get why that is. It might change someone else's mind, though, so I think it's worth pointing out here. No one is claiming that there is a zero risk option. That doesn't mean that we shouldn't weigh the risks that do exist.
*******This blog post lays out the problem with the whole idea of "ten minutes away:" (http://10centimeters.com/friday-fallacies-the-hospital-is-just-minutes-away/
"There are plenty of problems with the “The hospital is only minutes away!” platitude...
One is the idea that being “ten minutes” from a hospital means that you can go from realizing there’s a problem to having the baby out and alive in ten minutes. This scenario is certainly realistic. IF YOU’RE ALREADY IN THE HOSPITAL. The hospital where I volunteer as a doula can perform a stat c-section in eight minutes... You will have to get to the ER somehow. If you’ve called EMS, it will probably take them a minimum ten minutes to get to your house, five to ten minutes to grab you, load you in and get the hell out, and another ten minutes to get to the ER. Hopefully the paramedics have called in to let them know what to expect and the OBs are racing to the ER to meet you. If you don’t call an ambulance, it might take less time to get to the hospital (or not, seeing that your laboring body probably isn’t moving too quickly), but you don’t have the call ahead or stabilization the paramedics could provide.
Once you’ve arrived, an entire team flocks to you, hooking up monitors and placing IVs, all while trying to get the appropriate details. ...[If you had been laboring in the hospital, the history and physical notes, progress notes, labs (you’re going to need your blood typed and crossed for surgery), and IV sites WOULD ALREADY BE DONE. If you are dehydrated from laboring for an extended period of time or from an attempt to induce your labor using castor oil, they will have a hard time inserting the IV, which could cost precious minutes. They will use a portable ultrasound to check the baby unless the head (or body, as in the Lucian Kolberstein and Henry Bizzell cases) is out, in which case they will attempt to get the baby out or head straight for the OR. Even the very best and most efficient team is going to take an additional ten minutes after you show up in the ER to have you prepped and in the OR for an emergency cesarean, and that’s with rapid intubation and general anesthesia. The BEST CASE scenario is 30-45 minutes, not the eight it would take if you were already there.
Now, this scenario only applies if you happen to live in an area with a large teaching hospital and on-call OBs 24/7. What happens when the closest hospital is a smaller community hospital? More than likely, the only doctor there is going to be an ER doctor, not an obstetrician. The OB will have to be called in, as an ER doctor isn’t going to perform a cesarean unless you are dead and your baby is still alive, and may live up to 30 minutes away from the hospital. If the ER doctor is able to deliver your baby — which he hasn’t done since med school — he or she may be the only doctor at the hospital, so the focus will be split between you and your child. He or she may not have intubated an neonate since med school, either. He or she may not be required to have a neonatal resuscitation certification. By the time the OB and pediatrician arrive, an hour may have passed since your midwife first realized you were in desperate need of a transfer."