Have you ever lied... - Page 2

[wifeandmom]

Originally Posted by bryonyvaughn

Are you claiming a woman w/o a scarred uterus given Cytotec and Pitocin is less likely to have a uterine rupture than VBACing mom w/o the Cytotec and Pitocin?

Yes, that is exactly what I am saying.

What research says that I've seen is women with an UNscarred uterus have a *very* small chance of rupture, regardless of if they are induced or not. The stats come out in the 1 in 15,000-17,000 range.

Those numbers just are not going to drop to the level of rupture risk for a VBAC mom, which are commonly given as 1 in 200 or so. You might lower that risk to 1 in 1000 if you're incredibly lucky (pg spaced far enough apart, no induction, no augmentation, etc etc etc), but you aren't going to get close to in 1 in 15,000.

I can Google some this afternoon, but right now I've got a baby who needs me.

[Lynnette]

What if the HCP orders your records? In my state as a home birth midwife, I need to order the records from the cesarean. I am not sure if this is routinely done by HCPs in the system... (need a better word for the md/hospital route.)

[wifeandmom]

Quick Google of NEJM study that looked at over 17,000 women who attempted VBAC in comparison to over 15,000 who went for ERCS.

Risk of rupture in NON-induced/NON-augmented group (something like 6000 or so fit into this category) was 0.4%. That's roughly 1 in 250 women who ruptured (they only counted full ruptures, nothing else).

Women who were augmented had a rupture rate of 0.9%, nearly 1 in 100, more than twice the risk overall of the women who weren't induced/augmented.

Any use of prostaglandin at all increased the rupture rate to 1.4%, or 3.5 times greater than the nothing-at-all group.

No prostaglandins (defined in the foot notes as manual dilation but no prostaglandins or pit) had a rupture rate of 0.9%.

Oxytocin (aka pit) alone used for induction had a rupture rate of 1.1%.

So, roughly 1 in 250 will rupture with nothing to augment/induce labor, 1 in 100 will rupture once the pit comes out, and 1 in 75 will rupture when prostaglandins are used.

Now....

Find me anything that says a NON-scarred uterus being induced or augmented, with or without prostaglandins, has a rupture rate anywhere near 1 in 250. It's just not true. The previous c-section scar is what jacks the numbers up so much. Inducing and/or augmenting don't help, but neither increase the risk nearly as much as the scar itself.

[bryonyvaughn]

Originally Posted by wifeandmom

Quick Google of NEJM study that looked at over 17,000 women who attempted VBAC in comparison to over 15,000 who went for ERCS....

So, roughly 1 in 250 will rupture with nothing to augment/induce labor, 1 in 100 will rupture once the pit comes out, and 1 in 75 will rupture when prostaglandins are used.

Thanks for the lead. It got me 2001 article plus a lot of helpful related stuff.

Now....

Find me anything that says a NON-scarred uterus being induced or augmented, with or without prostaglandins, has a rupture rate anywhere near 1 in 250. It's just not true. The previous c-section scar is what jacks the numbers up so much. Inducing and/or augmenting don't help, but neither increase the risk nearly as much as the scar itself.

I'll pass, thank you. I'm not looking for a debate but appreciate your setting me straight on the facts. The facts you've shown me has made me think the far more relevant questions are...
* How to decrease the rate of initial c/s?
* How to stitch a uterus to decrease rate of future rupture?
* How to accurately evaluate relative risk in current and future pregnancies of vaginal birth or repeat c/s?

I'm also left curious as to how uterine rupture was defined. I've heard some studies lump dehiscenses (is that the word for the benign windows?) in the statistics with true rupture.

Gotta eat.

Thank you all for your input on truth in the client/HCP relationship.

~BV

[E'smom]

I'd like to say no, I wouldn't lie. Right now, it's not an issue b/c I have very vbac supportive midwives. I don't have a need to lie. However, at my first appointment, the midwife could not find my csection scar. Going au natural helps . :

I totally agree with this:

Originally Posted by JanetF

I'd lie in a heartbeat. The risks of any birth are mine to decide, not a bunch of strangers who'll never see me again and birth is, after all, as safe as life gets

Doctors are out to protect their wallets. If they can LIE to me and claim that repeat csections are safer than vaginal births without presenting all the facts, then I wouldn't feel bad about lying about my birth. If this baby is a successful vaginal birth and we wind up living in a non-vbac friendly area for baby #3 (if we decide to have baby #3), I will have no problem saying I've only had a vaginal birth.

I knew many docs would give moms false encouragement to VBAC, only to insist on repeat c/s at term when no other HCPs would accept them.

Grrrrr..... this happens a lot.



Regarding rupture risk. Yes, vbac has a rupture rate of about 1 in 200. That sounds freaky, scary, right? Not really. I HATE when people throw that around without explaining it. Very few of those result in death. Here is a great summary of vbac studies: http://www.storknet.com/cubbies/vbac/4studies.htm

Many studies DO include dehinscenses in the "rupture" count. We really don't know how many women vbac or just vaginally birth with dehiscenses.

Now, serious rupture is something to be concerned about. I am NOT downplaying it. There are women here and on the ICAN list that have lost babies due to ruptures so that is something to keep in mind.

Also, the statistic for 1 in 15,000 ruptures in unscarred uteruses might be a bit generous. From a summary that I bookmarked a while ago, it appears that 1 in 15,000 is correct for women who have normal vaginal deliveries. The number might be as low as 1 in 802 in women who had a failed trial of labor followed by a primary csection. Obviously, these women were unscarred going into labor. http://www.emedicine.com/med/topic3746.htm This is a summary of a lot of articles and they combine studies so it’s a lot to interpret and go through

Quite frankly ANY hospital should be prepared and looking for a uterine rupture. Banning vbacs is not going to end ruptures. We have hospitals near by that handle 7000 births per year with a 50% csection rate. Statistically speaking, they should expect at least 1 unscarred woman to rupture every other year using the 1 in 15,000 stat. Considering csections put women at greater risk for rupture, they should still have a couple a year. So I don't buy the "they won't expect a rupture if you don't tell them argument."

Bottom line is that doctors are going to do what's best for them at the patients expense so I need to do what's best for me (as all women should do)

ETA: on my nursing board, there was a question about witnessing ruptures. Over 1/3 of ruptures seen were in unscarred uteruses. Anecdotal evidence? Yes! But I wouldn't discount it as something to think about.

[E'smom]

Originally Posted by Lynnette

What if the HCP orders your records? In my state as a home birth midwife, I need to order the records from the cesarean. I am not sure if this is routinely done by HCPs in the system... (need a better word for the md/hospital route.)

I wouldn't lie about my birth experiences to a good midwife who had a proven track record for vbac support and success. I think that's vital to establishing a good and trusting relationship.

Doctors and medwives are another story. I wouldn't be able to trust that they would be truly supportive and not turn on me at the last minute. What they don't know, can't hurt them.

[wifeandmom]

Originally Posted by bryonyvaughn

far more relevant questions are...
* How to decrease the rate of initial c/s?

Bolding mine, but I think this is the number one issue that, if addressed, would help solve much of the VBAC issue.

* How to stitch a uterus to decrease rate of future rupture?

Not sure on this one, as there is already some evidence that double layer suturing decreases risk (to the point of providers not allowing VBAC in single layer closure moms). However, there are so many variables during surgery that the type and extent of suturing might very well need to be decided based upon getting mom out of THAT surgery alive and well, *not* so much based upon potential future pregnancies. Other factors would be the need to free up the OR and/or staff for other urgent cases, making time an issue with more invovled suturing.

* How to accurately evaluate relative risk in current and future pregnancies of vaginal birth or repeat c/s?

That's the mystery question. Also, I think it would be nice if women were presented with the facts, given the choice, and allowed to accept responsibility for making that choice. It would eliminate, or at least greatly reduce, the malpractice exposure, and I personally know several OB's that would still attend VBACs if this were the case. Otherwise, it's considered too risky from a malpractice standpoint.

I'm also left curious as to how uterine rupture was defined. I've heard some studies lump dehiscenses (is that the word for the benign windows?) in the statistics with true rupture.

In the NEJM study, they only counted catastrophic ruptures, not dehiscenses or 'windows' noted at delivery. They actually gave stats on dehiscenses in that study as well, though I can't remember what they were.

[KestrelDream]

I lied, & I would do it again in a heartbeat.

I attempted a homebirth after 3 c-sections with my last. After laboring for approximately 24 hrs, & not getting the support I needed, I trasported to the hospital.

I told them I had only one c-section. I labored for another 12 hrs, & ended up with a fourth c-section.

I may go unassisted next time. I'm reluctant to let midwives into my home...no matter how awesome they seem....the tables can turn mighty quickly.

[doctorjen]

Originally Posted by wifeandmom

In the NEJM study, they only counted catastrophic ruptures, not dehiscenses or 'windows' noted at delivery. They actually gave stats on dehiscenses in that study as well, though I can't remember what they were.

Are you talking about the 2001 study that sort of kicked off the whole anti-VBAC movement?
That study did not apparently only look at catastrophic rupture. It took data from birth certificates and hospital discharge diagnoses. It appears to have counted all ruptures. In the whole study there were 91 uterine ruptures with 5 infant deaths (about a 5.5% death rate - and 11 of the ruptures were in women who had elective repeat cesareans. They actually don't comment in the study on what classifies as uterine rupture, and don't use the word "dehiscense" in the study, but given the death rate, I'm guessing all uterine ruptures are included, since catastrophic rupture generally has a higher death rate.) This study does not comment on other infant outcomes like NICU admission.
I don't know if I can link the full text, but here's an attempt:
http://content.nejm.org/cgi/content/full/345/1/3

[wifeandmom]

Originally Posted by doctorjen

Are you talking about the 2001 study that sort of kicked off the whole anti-VBAC movement?
That study did not apparently only look at catastrophic rupture. It took data from birth certificates and hospital discharge diagnoses. It appears to have counted all ruptures. In the whole study there were 91 uterine ruptures with 5 infant deaths (about a 5.5% death rate - and 11 of the ruptures were in women who had elective repeat cesareans. They actually don't comment in the study on what classifies as uterine rupture, and don't use the word "dehiscense" in the study, but given the death rate, I'm guessing all uterine ruptures are included, since catastrophic rupture generally has a higher death rate.) This study does not comment on other infant outcomes like NICU admission.
I don't know if I can link the full text, but here's an attempt:
http://content.nejm.org/cgi/content/full/345/1/3

No, the one I was talking about was from 2004. From the article itself:

Uterine rupture was defined as a disruption or tear of the uterine muscle and visceral peritoneum or a separation of the uterine muscle with extension to the bladder or broad ligament. Uterine dehiscence was defined as a disruption of the uterine muscle with intact serosa.

So they define the difference between the two very early in the article. And it was *not* a study where they simply looked at birth certificate data.

I don't think you can link to entire articles there, as you have to be signed in to read all of it. I will come back later with more from the article itself.

[Jenlaana]

I feel no obligation to be truthful or honor bound with any OB or any doctor anywhere, to be quite honest. As a PP said, taking risks or not in birth is MY choice, and should be MY final say, not some random person or persons that I will probably never see again.

I tell people what I think will get me the best outcome possible. I don't really care if they like it or believe it. But I'm quite jaded. I am in that "encouraged to have a VBAC until it was too late to find another provider" category. I ended up preparing for an unassisted birth in about my 7th month, because it was only then that my "very nice" provider suddenly decided that I had no choice but to schedule a cesarean due to having a prior cesarean.

Perhaps its just a side effect of being an unassisted birther and knowing the horror stories that come with giving too much information. I don't know. But what I do know is that trusting doctors and midwives without knowing their track record is asking for trouble on so many levels. My last OB/CNM group seemed great... phenominal... reccomended by MANY local women. They were great too, until they realized that I was not going to be a good little sheep and do what I was told. (there was not a single discussion during my entire pregnancy about choosing tests/proceedures - it was all just done to me) Its hard to see the true colors of others until crunch time, and thats not the time that I can handle learning that my "great doctor/midwife" is not so great after all.

All that being said, I actually went out on a limb and told my current CNM that I had an unassisted birth last time, and why (because my OB/CNM practice flat out refused to even discuss a vaginal birth with me). I did it because I was encouraged to by a local direct entry midwife that I hold in very high regard, and because she felt that letting people know my situation might help the cause of allowing midwives to do VBACs again (its currently illegal in SC for homebirth midwives to do VBACs)

I am planning an unassisted birth again, but I am not telling anyone that. So I guess I'm lying again. Its self preservation, which is more important than the truth, in my opinion. I don't trust people who don't share my views to take that truth and hold it to them, and not try to change/ruin my child's birth to their own end. I know that I could have very easily been one of those that was forced by legal intervention to have a cesarean. My OBs felt that strongly about it. That just does not bode well for women, that we can be forced to do something so unnecessary by people who have no vested interest. If it takes lying to avoid that... so be it.

[doctorjen]

Originally Posted by wifeandmom

In the NEJM study, they only counted catastrophic ruptures, not dehiscenses or 'windows' noted at delivery. They actually gave stats on dehiscenses in that study as well, though I can't remember what they were.

The 2004 study looked at "symptomatic rupture" (the study author's words) not catastrophic rupture. The rate of hypoxic-encepholopathy including death in those infants was 0.45 per 1000, or a little less than 1 in 2000. This study used direct hospital record reviews, and called physicians to clarify if they couldn't figure it out from the chart.


I think it's highly unfortunate that we are living in a time where women would feel that they can't get evidence based care or have the ability to make their own decisions and feel they might have to lie to get the kind of care they want.

[dlm194]

The 2004 NEJM article is basically the same information that Landon et al. presented in Obstetrics and Gynecology in July 2006.

It should be noted that the NEJM study includes women attempting vbac after 1, 2 or 3 or more c-sections. All those stats on rupture are not simply for a vba1c attempt. The 2006 study separates that out. The 2004 NEJM study also includes women with vertical incisions, though that didn't seem to affect the overall rate of rupture (but those results were separated out to show the increased risks with non-low transverse scars).

Some of the women induced had misoprostol which should not be used for ANY woman.


I also didn't see the 2004 NEJM study separate out the rupture rates for women less than 2 years from their c-sections. The 2006 study mentioned that about a quarter of the women in the study were less than 2 years from their c-sections which also increases risk slightly (1.1%)

I think the bottom line is that there is so much data and many unique circumstances in a study like this. For instance, how many women were induced and less than 2 years from their c-section delivery? How many women were induced on a vba2c attempt? Which would have more of an effect? It's hard to figure out exactly what the risk is for a particular vbac, especially when there may be multiple risk factors.

Originally Posted by E'smom

Also, the statistic for 1 in 15,000 ruptures in unscarred uteruses might be a bit generous. From a summary that I bookmarked a while ago, it appears that 1 in 15,000 is correct for women who have normal vaginal deliveries. The number might be as low as 1 in 802 in women who had a failed trial of labor followed by a primary csection. Obviously, these women were unscarred going into labor. http://www.emedicine.com/med/topic3746.htm This is a summary of a lot of articles and they combine studies so it’s a lot to interpret and go through

Thanks for that link! I knew rupture in unscarred uteruses wasn't that rare!

[mom3b1?]

Originally Posted by dlm194

The 2004 NEJM article is basically the same information that Landon et al. presented in Obstetrics and Gynecology in July 2006.

It should be noted that the NEJM study includes women attempting vbac after 1, 2 or 3 or more c-sections. All those stats on rupture are not simply for a vba1c attempt. The 2006 study separates that out. The 2004 NEJM study also includes women with vertical incisions, though that didn't seem to affect the overall rate of rupture (but those results were separated out to show the increased risks with non-low transverse scars).

Some of the women induced had misoprostol which should not be used for ANY woman.


I also didn't see the 2004 NEJM study separate out the rupture rates for women less than 2 years from their c-sections. The 2006 study mentioned that about a quarter of the women in the study were less than 2 years from their c-sections which also increases risk slightly (1.1%)

I think the bottom line is that there is so much data and many unique circumstances in a study like this. For instance, how many women were induced and less than 2 years from their c-section delivery? How many women were induced on a vba2c attempt? Which would have more of an effect? It's hard to figure out exactly what the risk is for a particular vbac, especially when there may be multiple risk factors.






Thanks for that link! I knew rupture in unscarred uteruses wasn't that rare!

The other thing that folks don't always seperate out is the degree of rupture. Partial ruptures are not necessarily emergent. Personally it's the catastrophic ruptures that I look at, not the ones that do no harm and require no treatment.

Kiley

[oregonbound]

Originally Posted by mom3b1?

Nope, I"ve never lied to a Doctor, Nurse, or MW about my medical history.

I do plan on lying about my "due date", but not to the MW I might hire. I will tell friends and family that I'm due at least a month later than I am, so they won't be fussing at me to get an induction when the baby takes longer than what they consider "usual" to finish gestating.

I get HUGE. I am tiny, overweight, but short and small boned. I usually measure much larger than my dates would indicate. So, people really freak when they see me anyway. Friends, family and strangers try to comfort me by telling me how cruel my doctor is not to induce me and get it over with, which just upsets me. My first two were induced, and it was extremely traumatic. With my third there was no doctor, and I wanted it that way. The birth began naturally as God and Nature intended, two days shy of 44 weeks.

I"m just going to tell t hem "Marchish" and then they won't be able to say a thing to me about that, though I can't hide the size I'll be.

Kiley

I would think it would be difficult to lie to your care provider and say you've never had a c-section because even after 5 1/2 years I still have a scar (and although it is very low it is a little puckered in the middle and definitely still there). I guess if you had 2 c-sections you could try and lie and say you only had one, for example, my care provider for this pregnancy only asked for my c-section records from my 1st c-section and took my word for it that my second birth was a VBAC (each birth was at a different hospital). I guess if I had had a second c-section I could have lied about it and honestly would consider it if that was the only was I could get prenatal care. I don't believe that UC would ever be for me.

And about the due date thing, what is up with friends/family and due dates? I would tell people I was due at the beginning of February and they all wanted to know the exact date. I guess some people think it's cool if you're due on their birthday, their kids' birthdays, etc., but it's not like the baby is going to come on that day!

[mom3b1?]

[QUOTE=oregonbound;8452923 I guess if you had 2 c-sections you could try and lie and say you only had one, for example, my care provider for this pregnancy only asked for my c-section records from my 1st c-section and took my word for it that my second birth was a VBAC (each birth was at a different hospital). [/QUOTE]

Nope, you get a scar for each c/s. I've got two scars for two c/s. What you could lie about would be if you had vaginal birth and then c/s. If you wanted, for some reason to say that your c/s was first, and that you've already VBAC'd. I'm just not sure what good that would do, but I know I've seen posts from moms planning something like that. I"d think the fact that you've had a vag birth would mean you could do it, period, even if something had happened in subsequent births that led to a c/s.

I've also known moms who lied about LMP to their practitioners, to get a later date, so they wouldn't get risked out of homebirth for going over dates. This makes sense to me, but I've not done it. My plan is to hire a MW who is OK with me going past dates, or not have a MW. Some people don't have that option, and would tell such a lie to protect their baby, which sounds fair to me.

Kiley

[wifeandmom]

Originally Posted by dlm194

The 2004 NEJM study also includes women with vertical incisions, though that didn't seem to affect the overall rate of rupture (but those results were separated out to show the increased risks with non-low transverse scars).

From the 2004 study:

Maternal and perinatal outcomes were compared between women who had a trial of labor and those who underwent elective repeated cesarean delivery without labor or other indications for cesarean delivery, such as a prior classical (up-and-down) or "inverted T" incision, breech or transverse presentation, placenta previa, prior myomectomy, nonreassuring patterns in the antepartum fetal heart rate, genital herpes, or a medical condition precluding a trial of labor.

Looks like they did not count women in the ERCS group that had any of the things listed, including prior classical or inverted T incisions. All of the the things they listed as being criteria to exclude a woman from the ERCS group are things that one would normally expect a CS delivery for regardless, so it makes sense to exclude them and only count the women that had an ERCS presumably ONLY because of the VBAC issue.



And here is where they gave the specifics on rupture rates for each type of incision, though the non-lower transverse incision groups were small and that should be taken into consideration.

The rates of rupture were 105 of 14,483 (0.7 percent) for women with a prior low transverse incision, 2 of 102 (2.0 percent) for those with a prior low vertical incision, and 15 of 3206 (0.5 percent) for those with an unknown type of prior incision. Two uterine ruptures were recorded in 105 women (1.9 percent) with a prior classical, inverted T, or J incision who either presented in advanced labor or refused a repeated cesarean delivery.

[Jenlaana]

Originally Posted by doctorjen

I think it's highly unfortunate that we are living in a time where women would feel that they can't get evidence based care or have the ability to make their own decisions and feel they might have to lie to get the kind of care they want.

Unfortunately there is no *might* about it. The second I truthfully explained to my CNM and OB about not wanting a cesarean birth for my last child, my prenatal care went from warm and fuzzy and comforting to a nightmare that included threats and lies from THEIR side, and many many tears and sleepless nights on my side. If I had lied, my pregnancy would have been MUCH easier.

[Pumpkin_Blythe]

My first daughter was 9 pounds and got stuck coming out of me. They almost had to dislocate her shoulder to get her out.

When my second ended up being 10 pounds I didn't fight the c-section they said I should get becuase it was best for the baby,

Now I am 20 weeks and once again measuring big on top of that, this one is a boy. I could fight for a VBAC but i think it is in my child best interest to be delivered the safest way possible.

[doctorjen]

Originally Posted by wifeandmom

From the 2004 study:



Looks like they did not count women in the ERCS group that had any of the things listed, including prior classical or inverted T incisions. All of the the things they listed as being criteria to exclude a woman from the ERCS group are things that one would normally expect a CS delivery for regardless, so it makes sense to exclude them and only count the women that had an ERCS presumably ONLY because of the VBAC issue.



And here is where they gave the specifics on rupture rates for each type of incision, though the non-lower transverse incision groups were small and that should be taken into consideration.

Yes, interestingly, they excluded any women from the ERCS group who had a medical reason for a repeat cesarean, but INCLUDED any woman in the trial of labor group who perhaps had a reason for a repeat but refused. They mention in the article that they included a number of women with classical incisisons who either showed up in advanced labor or refused surgery.