Classical incision vbac?

[wish2B]

I was wondering if anyone has had any experience with a classical incision vbac? I know it's highly discouraged because of the increased ur rate but there does not seem to be too much info out there. I've already had 2 vaginal births that were fast and easy.Thoughts?

[crunchymomof2]

My midwifes grandmother had one and went on to have several vaginal births. But of course that was a long tim ago. I dont know personally of any recent cases.

[TurboClaudia]

a very good friend had her first baby at around 31 weeks via cesarean with a classical incision. then she went on to vbac her second baby (born at 33 weeks, but unfortunately died from post-birth complications at 3 weeks of age), vbac her third baby (born at 35 weeks weighing about 5 lbs) and hbac her fourth baby (born at 40 weeks 1 day footling breech and weighing over 8 lbs). it's possible.

~claudia

[wifeandmom]

Anything is possible I suppose.

However, there is a reason you'd have a very, very, very hard time finding any kind of provider willing to attend a VBAC with a history of a vertical or T incision.

Statistically speaking, the *lowest* risk I've ever seen quoted for non-horizontal incisions is 2%. Typically, the stated risk I've seen thrown around is more like 5-8%, with some studies quoting closer to a 10% risk.

Those numbers are the risk of catastrophic rupture BTW.

There simply is not a 2% risk of life threatening event comparable to catastrophic uterine rupture occurring during a scheduled c-section for mom OR baby, much less a 10% risk of something as devestating.

If the potential life threatening risks of scheduled c-section were higher, there might be more providers willing to attend VBACs with such incisions, but when you look simply at the numbers and compare the risk of either mom or baby or both suffering life long consequences and/or death between the two choices, ERCS will win hands down every time for non-horizontal incisions.

Again, there is a reason you'd be very unlikely to find a reputable provider of any kind to attend such a birth.

[majikfaerie]

I really believe that the risks of doing a VBAC with a classical incision are still less than the risks of repeat C-section, with a HBAC the risks are even less.
I think an important consideration is that the major fear is uterine rupture, which is a term used to describe any opening of the previous scar. the problem with this is that the majority of these "ruptures" are totally benign and do not cause any complications for the pregnancy or birth (in fact, many of them occur LONG BEFORE labour begins!)
And even in the small percentage of labours where the dangerous kind of rupture does occur, it is still very rare for there to be any serious complications. It never happens that mother and/or baby dies on the spot.

I'd say the best plan (assuming the mother and baby are healthy) is to go for a homebirth with a good midwife or doula and have easy access to a hospital if needed (even if labouring IN the hospital, they still take 10 - 15 minutes from "descision to incision" in EMERGENCY cases, and often much more.

[sesta]

I have a classical insicion and am planning a VBA2C! I'm due in 3 weeks!

[wifeandmom]

Originally Posted by majikfaerie

I really believe that the risks of doing a VBAC with a classical incision are still less than the risks of repeat C-section,

What single life threatening event occurs during an ERCS in a *minimum* of 2% of moms or babies? What about a life threatening event (single event, as lumping ALL life threatening events together for ERCS and trying to compare that to a SINGLE life threatening event, in this case catastrophic UR, with attempted VBAC isn't a fair comparison) that occurs in 5-8% of all moms who undergo ERCS? There simply *isn't* an event that occurs that frequently with ERCS.

with a HBAC the risks are even less.

I've honestly never seen any actual research on the risks of UR with classical or T incisions during homebirth. Do you have links to support your claim that it is LESS risky to attempt a VBAC under these conditions? I was under the impression there wasn't even any research to support a plain old VBAC attempt with a *horizontal* incision at home, much less the much riskier overall VBAC attempt with a *NON-horizontal* incision. I'd be interested to read any research you've come across supporting this claim.

I think an important consideration is that the major fear is uterine rupture, which is a term used to describe any opening of the previous scar. the problem with this is that the majority of these "ruptures" are totally benign and do not cause any complications for the pregnancy or birth (in fact, many of them occur LONG BEFORE labour begins!)

The rate of CATASTROPHIC rupture with a lower segment HORIZONTAL incision is known to be approximately 1 in 200, or 0.5%.

Of course, these 'openings' or 'windows', like you said, are totally benign and really shouldn't be a part of this discussion.

However, the rate of CATASTROPHIC RUPTURE, meaning the very real possibility of DISASTER for mom and/or baby, is known to be anywhere from 2-10% with a non-horizontal uterine incision. That simply cannot be sugar-coated or denied. That figure is NOT including the 'windows' you are talking about.

Came back to edit cause I was WAY off on what I thought the rates were from the NEJM study. They found a catastrophic rupture rate of 0.7% overall with TOL, ZERO women in the ERCS group experienced catastrophic UR. They also noted a 0.7% rate *in addition to* the ones who experienced catastrophic rupture of women who had 'windows' noted at some point during delivery. They also made note that of course not all women who had a successful VBAC had their scar inspected in any way, so the obvious conclusion is that perhaps even more women had these 'windows' that were asymptomatic, thus undetected, during delivery.

It never happens that mother and/or baby dies on the spot.

Really? Never? I'll bet those moms who have dead babies at the end of an attempted VBAC where they do indeed experience a catastrophic rupture would certainly disagree. And really, if the baby 'only' dies a few days later of brain damage suffered during a VBAC attempt (as have more than one baby on this very board), is that supposed to make anybody feel better?
:

I'd say the best plan (assuming the mother and baby are healthy) is to go for a homebirth with a good midwife or doula and have easy access to a hospital if needed (even if labouring IN the hospital, they still take 10 - 15 minutes from "descision to incision" in EMERGENCY cases, and often much more.

For a regular VBAC (horizontal incision, 18+ months between c/s and VBAC, one prior section, maybe two), I would say your plan is a reasonable one for some women.

I do have to completely disagree with the '10-15 minutes decision to incision, and often much more' assessment though. Both hospitals I delivered in and every.single.hospital. my DH has ever worked in has the ability to perform a crash c-section with a decision to incision time of 5 minutes tops, and baby is out in under 5 minutes from incision time. That's just under 10 minutes til baby is OUT, assuming of course you are in a hospital with 24/7 OB and anesthetic coverage who know what they are doing.

Of course, even 10 minutes can often be too long if baby is completely cut off from their oxygen supply. Those are the cases where it wouldn't really matter where you were when the catastrophic event occurred in terms of baby's mortality rate.

[wifeandmom]

Can't for the life of me figure out how to transfer the whole chart over here, so here are the comparisons between maternal complications during TOL vs. ERCS:

UR: 0.7 vs. 0

Dehiscence ('windows', but are NOT life threatening): 0.7 vs. 0.5

Hysterectomy: 0.2 vs. 0.3

Thromboembolic disease: 0.04 vs. 0.1

Transfusion: 1.7 vs. 1.0

Endometritis: 2.9 vs. 1.8

Maternal death: 0.02 vs. 0.04

Other maternal adverse events: 0.4 vs. 0.3

One or more of the above: 5.5 vs. 3.6


Statistically speaking, a woman undergoing ERCS has a significantly higher chance of having a blood clot (thromboembolic disease). There's also a *slightly* higher risk of hysterectomy and death with ERCS in comparison to the TOL group, but certainly *no where close* to approaching the 2-10% risk of catastrophic rupture with non-horizontal incisions. There is actually *nothing* on the list of complications for ERCS that is even 2% AT ALL when considering single adverse events.

Otherwise, every other adverse event listed occurred more frequently in the TOL group.

They also broke down ruptures into spontaneous labor (0.4), augmented (0.9%), induced with prostaglandins with or without oxytocin (1.4), and oxytocin alone (1.1).

Baby outcomes went like this: 0.08% experienced hypoxic ischemic encephalopathy with TOL, zero with ERCS. Another 0.08% died with TOL, whereas 0.05% died with ERCS.

Obviously more brain damaged babies with TOL considering there were NONE with ERCS. And more dead babies with TOL, although those numbers are very small either way.

[majikfaerie]

Sorry I dont have time to sit down fo ra long and detailed reply...
anyway, VERY SORRY, it is a rare lapse for me to say *always* or *never* on any point. I definately should have written "ALMOST never", but I'm often typing with a small person climning on me. So let me change it to "almost never happens that mother or baby dies on the spot".

And while these terrible tragedies are rare, of those that occur it isn't necessarily *instantaneous*, CPs usually get some warning time.

incedentaly, I was speaking of figures from the book "Silent Knife", which I will look up directly, (rushing now)

I didn't mean to imply that the classical incision is as safe as the lower horizontal incisoin, sorry if I came across like that. Of course the risk is much higher.

[majikfaerie]

just looked it up quickly,
Quotes "Maternal Mortality in Cesarean Section as Compared to vaginal Delivery", Krone, H.A., Fortschrift Med. 1975

Rate of rupture for a classical incision is between 1 and 3 percent.

[wifeandmom]

Originally Posted by majikfaerie

just looked it up quickly,
Quotes "Maternal Mortality in Cesarean Section as Compared to vaginal Delivery", Krone, H.A., Fortschrift Med. 1975

I prefer to base decisions on medical research a bit newer than 30+ years ago myself.

[kathan12904]

One of the midwives I am working with had 3 c/s all classical incisions and went on to have 2 more babies at home naturally without complication. There is a posting board somewhere on the web that contains a woman posting throughout her 10th (thats right 10th) pregnancy because she had a t/j shaped incision on her 9th and she ended up with a successful, natural homebirth for #10. These stories are out there, they just don't have the coverage and good pr that all the scary statistics have. Of course you should discuss the concerns and risks you have with your prenatal care provider, but in no way does verticle incision risk you out of a successful vbac. Good luck.

[hollyberry1285]

True, recent research seems to be preferred. However, statistical methods of analysis haven't really changed in 25 years, and the physiology of the uterus by far has not had time to evolve enough to warrant excluding research from the 70's. Humans have been giving birth vaginally for hundreds of thousands of years, so that variable definately hasn't changed. I suppose methods of c/s have changed however, if you want to bring up single-suture vs. double suture. However, single suture closure is bad for uterine ruptures in subsequent pregnancies as well as bad for infection/hemorrhaging after the c/s- so can't really be said to benefit either argument. The 1970's were a long time ago but they weren't the dinosaur ages. I recently graduated from the Univ. of SC w/ my bachelor's in bio. It was still perfectly legit for me to use research from even the 60's, as long as statistical/research methods weren't off (it had to be "good science")- and it couldn't have been disproved by multiple other articles- but that standard goes for research presented in any decade, even in the 21st century. If you guys are going to argue about 1.% points, that's a little nit-picky. Obviously, different articles are going to vary rates because different studies use different sets of women, the sampling population is different, perhaps statistical methods used were different or whatever. I think the point is- Yes, it is a higher UR rate. No, it's not impossible, and is a viable option. Although personally, I would be uncomfortable attempting a VBAC w/ classical in my home. I'd rather be in a hospital where I know they can have the baby out ASAP. Feeling comfortable is a major key to dilation. If you would be stressed out and tense at home from the risks, it would be better for you to go to the hospital IMO.
Also, I thought Silent Knife was an incredible book. It did for the VBAC and home birth movement what "The Feminine Mystique" did for the women's rights movement. It has very legitimate points to it, and the research in it still carries weight, even though it is 30 years old.

Holly

[kathan12904]

Originally Posted by wifeandmom

I prefer to base decisions on medical research a bit newer than 30+ years ago myself.

It interesting that you say that, because a large number of the obstetrical procedures performed routinely in hospital births today are based upon theories and statistics that date back to the 1960s, even further in some cases. And I personally don't think its any coincidence that that is the approximate time when women stopped allowing themselves to be routinely "knocked out" during the actual birthing stage, but thats not so much documented fact as hypothesis based on research.

[wifeandmom]

Originally Posted by kathan12904

It interesting that you say that, because a large number of the obstetrical procedures performed routinely in hospital births today are based upon theories and statistics that date back to the 1960s, even further in some cases. And I personally don't think its any coincidence that that is the approximate time when women stopped allowing themselves to be routinely "knocked out" during the actual birthing stage, but thats not so much documented fact as hypothesis based on research.

I can assure you that *my* birthing choices were based upon research findings that were current at the time of my births.

I'm not one to take the word of a doctor, any doctor, no matter how good they are, simply because they are a doctor. Nor am I one to do things 'their way' just to appease the masses, as I truly didn't care if they liked my choices or not. It came down to cold, hard facts, something that is terribly difficult to argue with when they happen to disagree or want you (you being the mom) to do it 'their way' when there is nothing to back up 'their way' in the first place.

[maxmama]

Re: "old" v. "new" research:

In health care (specifically in nursing research, since that's what I'm most familiar with) it is unacceptable to use as a primary source studies more than 5-10 years old, unless they are the ONLY studies available. Clearly, when looking at vertical v. horizontal incision, there are more recent data available. If I tried to use a study from the 1970s in my dissertation, my committee would hand it back to me.

[JanetF]

This is frmo an excellent article on UR by Debby Miller here in Australia. The refs for the whole article are down the bottom and these are just a few excerpts. It's from an ENORMOUS birth after c-sec kit I have which I'm happy to share via email.

Which Women Have Ruptures?
Any woman can have a rupture. This includes women who have never had a csec before. The risk to some women is however higher than for other women. Here is a breakdown (refs 1,2,3,5,6,7,10,16,17,,20,21,22,23,27,28):
•Of all women who go into labour the risk of rupture is 0.017 - 0.07%
•Of all women with a previous CSEC the risk of rupture is 0.068 - 1%
•If the previous CSEC was ;
•- classical 4 - 9 %
- horizontal lower segment 0.2 - 1%
- vertical lower segment 1 - 7%
- T or J incision 4 - 9%
•The risk for women who have had five or more pregnancies (grand multiparity) is also recorded as being higher there were no quoted statistics in any of the articles. In ref 20 they had 13 ruptures and 2 of these were due to grand multiparity.
•There is also a risk of rupture where there is a trauma to the abdomen. A number of the studies cited ruptures resulting from vehicle accidents.
•If you had a first trimester abortion (at some time) your risk of rupture is 1%
•If you have had a hysterotomy or uterine operation (eg fibroid removal) your risk is 6%
Of all uterine ruptures recorded in four studies:
Study one 42 ruptures 71% VBAC 29% in unscarred uterus(ref 5)
Study two 23 ruptures 43% VBAC 57% in unscarred uterus(ref 17)
Study three 480 ruptures 92% VBAC 7% in unscarred uterus 1% in non csec scarred uterus (ref 23)
Study four 81 ruptures 89% VBAC 11% in unscarred uterus(ref 27)
(These studies do not breakdown what types of scars the VBAC had and do not distinguish between ruptures and dehiscences).
It should be noted that in a number of the references there was no indication if the women who were recorded with ruptures had been in labour or not.
I could not find any studies in references that indicated a higher risk of rupture in women with macrosomic (large over 4kg) babies, twin pregnancies or breech deliveries. Ref 33 indicates there were no significant differences in death or injury in VBAC women with babies over 4kg, it also indicated of the recorded twin VBACs there were no ruptures and of the recorded breech there were no significant differences, however it indicated the preference was to do external version on breech babies. (Also a safe practice for VBAC mothers).
Can They Predict If I Will Rupture?
Ref 10 quotes a British study that involves measuring the thickness of the lower uterine segment by ultrasound late in the last trimester of pregnancy (over 35 wks). The study indicates that in women with the thickest lower uterine segments there is a very low chance of rupture. However the study also acknowledges that even for women with the thinnest lower uterine segments the risk of catastrophic rupture is still very small and can be offset with vigilant labour monitoring.
There are no major studies on the identification of a dehiscence however in this same study the sonographers believed they would be able to see dehiscence at the scar site using ultrasound. Given that dehiscence are considered benign I would wonder what the benefit of this would be as there are no studies that correlate the presence of dehiscence with a higher rupture rate, (mind you there are also none that disprove it either).

So how often do these things occur:
Study 1 9 ruptures 2 still born (22%)
(of the nine ruptures there were 2 classical csecs and 6 LSCS and one non scarred, the study does not say which of these mothers lost their babies)
0 hysterectomies and 0 maternal deaths (ref 7)
Study 2 155 ruptures 8 fetal deaths (5% - 5 occurred in mothers who arrived at hospital ruptured) 1 maternal death (doesn't indicate if this was a TOL or unscarred) (ref 10)
Study 3 17 ruptures 0 deaths 8 hysterectomies (ref 13)
Study 4 1 rupture 0 deaths (this rupture was in an elective repeat csec) (ref 14)
Study 5 23 ruptures 0 deaths (ref 18)
Study 6 13 ruptures 0 deaths (ref 20)
Study 7 8 ruptures 1 fetal death (12.5%) 2 severe fetal asphyxia (oxygen deprivation) 3 bladder lacerations 1 hysterectomy (ref 22)
Study 8 10 ruptures 2 fetal deaths (20%) (ref 26)
Study 9 81 ruptures 2 maternal deaths (2%) (these were a mix of scarred and unscarred uterus) 14 bladder injuries 12 hysterectomies 5 fetal deaths (6%) 14 neonatal deaths (17% - after birth deaths - the cause of these deaths is not given) 59 fetal brain damage (72% - the degree of damage is not indicated and it does not indicate if the 14 neonatal deaths are also included in this group) (ref 27)
If we add all of this up we have 317 reported ruptures, 30 (9.5%) fetal death rate, 3 (0.95%) maternal death rate and 61(19%) of babies with some degree of brain damage from oxygen deprivation (this may be minor or major).
To put this into perspective given that the VBAC mothers risk of rupture is around 1% , you have a (0.095%) chance of your baby dying due to rupture in any VBAC delivery, a 0.0095% of you dying due to rupture in any VBAC delivery and a 0.19% chance of your baby suffering brain damage due to a rupture in any VBAC delivery. (Contrast this to the other risk identified below).
The studies all indicated that one of the primary causes of death amongst mothers and infants was mismanagement by hospital staff. A number of the reports sited ignorance among staff of the symptoms of rupture and/or a slowness to act thus compromising both the mother and the child. The generally agreed treatment was that csec needed to be conducted within 30 mins of suspected rupture with some practitioners indicating this figure should be closer to 17 mins.

References
•Peripartum haemorrhage by Dr Sanjay Datta, MD, FFARCS
•Common Peripartum Emergencies by Dr Elizabeth Morrison American Family Physician Journal Nov 1 1998
•Once a CS always a Controversy by Dr B L Flamm ACOG Journal Vol 90 No2 Aug 97
•The Risks of Lowering the Caesarean Delivery Rate by Dr B Sachs MB, BS, DPH, Dr C Kobelin, MD, Dr Mary Ames Castro, MD and Dr Fredric Frigoletto, MD, The New England Journal of Medicine, 7 Jan 1999, Vol 340 No.1
•Induction of Labour and Uterine Rupture by Dr R Foon SHO, CESDI Steering Group 5th annual report 1997: 63-71
•Vaginal delivery after previous csec remain relatively safe by Dr Gregory and Dr L Korst, MD and Dr P Cane PhD Obstetrics and Gynaecology 94(6), Dec 99 pp 985-989
•Coombe Women's Hospital Obstetric Report 1998
•Genital Tract Trauma and Other Direct Deaths: Annual Report of The Maternal and Child Health Research Consortium London Jul 1998.
•Will VBAC become a way of the past OBCNEWS Issue 15.3, 13 Jul 1999
•ICAN /VBAC / Caesarean Webpage
•Recognising Problems in Labour by T. Stevens (Midwifery Research Practitioner)
•VBAC - Vaginal Birth After Caesarean or Very Big Authority Challenge? by B. Beech and P Thomas, AIMS Journal, Vol 8 No. 1 30 Apr 96
•Cases of Uterine Rupture and Subsequent Pregnancy Outcome by Al Sakka, Dauleh and Al Hassani of the Hamad Medical Corporation. International Journal of Fertility & Womens Medicine Nov-Dec 99.
•Delivery after Scarred Uterus at the University Hospital Centre of Dakar by Cisse, Ewagnignon, Terolbe and Diadhiou Journal de Gynecologie, Oct 99
•Vaginal Birth after Caesarean and Uterine Rupture Rates in California by Gregory, Korst, Cane, Platt and Kahn. Obstetrics & Gynochology Dec 99
•Intrapartum uterine rupture and dehiscence in patients with prior lower uterine segment vertical and transverse incisions by Shipp, Zelop, Repke, Cohen, Caughey and Lieberman. Obstetrics & Gynecology Nov 99.
•Rupture of the pregnant uterus a 21 year review - Sakka, Hamsho and Khan. International Journal of Gynaecology & Obstetrics Nov 98
•Vaginal Birth after Caesarean results in 310 pregnancies by Obara, Minakami, Koike, Takamizawa, Matsubara and Sato. Journal of Obstetrics & Gynaecology Research Apr 98.
•Intrapartum rupture of the unscarred uterus by Miller, Goodwin, Gherman and Paul. Obstetrics and Gynecology May 97.
•Risk Factors Associated with Uterine Rupture during TOL after CSEC by Leung, Farmer, Leung, Medearis and Paul. American Journal of Obstetrics and Gyynecology May 93
•Rupture of low transverse csec scars duritng trial of labour. THe Journal of the American Medical Association 18 Sep 91
•Use of Hospital Discharge Data Monitor Uterine Rupture - Massachusetts 1990 - 97. Morbidity and Mortality Weekly Report 31 Mar 2000
•Use of Prostaglandins to induce labour in women with Csec scar by Vause and Macintosh. British Medical Journal Apr 17 1999.
•Csec Scar dehiscence following vaginal delivery by Connoly and Byrne. Journal of Obstetrics and Gynaecology Vol 19 No 6 1999
•Trial of Labour after Csec by McMahon, Luther, Bowes and Olshan. New England Journal of Medicine 1996.
•Catastrophic Uterine Rupture: Maternal and Fetal Characteristics by Kirkendall, Jauregui, Kim and Phelan. Obstetrics and Gynecology 2000
•Uterine Rupture: A placentally Mediated Event? by Jauregui, Kirkendall, Ahn and Phelan. Obstetrics and Gynecology 2000
•Uterine Rupture During a Failed Trial of Labor: Are There Any Identifiable Risk Factors in Labor Management by Burke, Lee, Harish, Sehdev and Ludmir. Obstetrics and Gynecology 2000
•Vaginal Birth After Prior Cesarean by Dr C Brittan. Jul 99.
•Delivery After Previous Csec: A Risk Evaluation by J Rageth. Obstetrics and Gynecology 1999.
•Medical Abortion Complications by D Nemec Obsterics and Gynecology Apr 78
•Cesarean Section: Guidelines for Appropriate Utilization by Dr B Flamm and Dr E Quilligan.

[ckhagen]

More anecdotal stuff...
My mom had a VBA3C and all three of her sections were classical incisions.
After her VBA3C, the birth climate started to change and she went on to have 2 more sections because she couldn't find anyone who would let her VBAC again. Silly huh?

[wifeandmom]

All of this 'I know so-and-so who had a VBAC after however many classic incision c-sections' isn't truly relevant IMO.

I mean, really, didn't one of the Kennedy women have 11 c-sections and come out fine? Does that mean having 11 c-sections is even remotely a good idea? Ever?

Just because something 'can' be done, or 'has' been done by someone, somewhere in the world with no serious consequences doesn't mean it is or was the statistically safest decision to make at the time.

[crunchymomof2]

Originally Posted by wifeandmom

All of this 'I know so-and-so who had a VBAC after however many classic incision c-sections' isn't truly relevant IMO.
Just because something 'can' be done, or 'has' been done by someone, somewhere in the world with no serious consequences doesn't mean it is or was the statistically safest decision to make at the time.

No but sometimes it can be nice to know that other women have btdt and lived to tell about it.