why are repeat c-sections so dangerous? - Page 2

[majormajor]

i've seen a lot of studies that show an elective c/s is safer than a VBAC (and i've seen studies that show the opposite. generally, though, the c/s looks safer). the problem is, you can't know until after the birth whether you'll need the emergency c/s or not. so you have to look at outcomes for everyone who goes in planning a vbac. ICAN (international cesarean awareness network, www.ican-online.org) quotes in their vermont/NH VBAC project that women who go into labor hoping for a VBAC have about a 6/1000 chance of fetal death, vs ecs with a 3/1000 chance of fetal death. i've seen this with other studies too. it's not what i want to be true, but i really do think it is.

i know that it's the c/s that increases the risk of placental problems. but laboring with an increased chance of placental problems is riskier than a c/s with a higher risk of placental problems. the studies that list causes of infant death in VBAC labors seem to have about as many incidences of abruption as they have rupture.

have to go again!

[wombatclay]

Random (and fast) search of Pubmed. A more detailed search might give more specific results but dd2 has colic and I'm running on next to no sleep!

Obstet Gynecol. 1999 May;93(5 Pt 1):674-9.

RESULTS: The only significant differences were noted between those patients who delivered vaginally after a prior cesarean and those patients who delivered vaginally without a prior cesarean. Neonates in the successful VBAC group were more likely to have an Apgar score at 5 minutes less than 7 (OR 1.52) or an umbilical arterial pH less than 7.1 (OR 1.69). Those neonates, however, were not at greater risk for an Apgar score less than 4 or a pH less than 7.0.

(but their ultimate conclusion was that vbac was still low risk despite these findings)

J Obstet Gynaecol Res. 1998 Apr;24(2):129-34

CONCLUSIONS: A trial of a VBAC significantly reduced the rate of cesarean sections. Although the rates of uterine rupture and neonatal asphyxia were slightly higher in women who attempted a VBAC than in women who underwent an elective cesarean section, obstetricians should offer the option of a trial of labor, because more than one-half of the women with a previous cesarean delivery might have successful vaginal deliveries, and the VBAC-related maternal mortality rate does not reportedly differ between women undergoing a trial of labor and women undergoing an elective repeat cesarean section.

(but they point out in their findings that the vbac group included babes with complications not seen in the c/s babes, including lower apgars)

N Engl J Med. 1996 Sep 5;335(10):689-95

Apgar scores, admission to the neonatal intensive care unit, and perinatal mortality were similar among the infants whose mothers had a trial of labor and those whose mothers underwent elective cesarean section.

(this study points out a higher maternal risk from vbac, but not a higher infant risk)

J Matern Fetal Neonatal Med. 2004 Jun;15(6):388-93.

CONCLUSIONS: Favorable initial pelvic examination, spontaneous labor and a lack of oxytocin use are associated with successful VBAC in women with a single prior low transverse Cesarean delivery and no prior vaginal deliveries. While attempted VBAC and failed VBAC have more maternal infectious morbidity and lower Apgar scores, infant outcomes are similar to those of elective repeat Cesarean delivery.

(in this study "attempted vbac" seems to mean "successful vbac" since they contrast it with "failed vbac". The findings do indicate a slightly higher level of risk for vbac babes and lower apgars, but it wasn't a "significant" difference.)

Okay...there are more but these are fairly representative. I didn't include any rabid anti-vbac papers since honestly I don't think "rabid-anything" lends itself to rational scientific inquiry. In general the studies show vbac babes have lower apgar scores and a higher risk for certain birth complications. However these risks don't appear to be severe and since a c/s isn't risk free for the babe either (I didn't find any studies comparing wet lung c/s babe rates to low apgar vbac babe rates for example) I don't know that they should influence a mama's decision.

Though it's always good to know what research is out there so you can discuss or explain your birth choice to care providers/family...

ETA- you all probably know the site, but http://www.worldserver.com/turk/birt...bac2005-9.html maintains a collection of national and international vbac research. It's really well organized with summaries of the research findings. The site is maintained by a family with a sort of sad vbac story so don't go past the bibliography page if that will be upsetting to you...I know I read their personal story while pregnant and cried for hours so, um, just so you know ahead of time in case your pregnancy hormones are like mine were!

[holly6737]

One thing to remember when talking about these scientific articles is that these vbacs took place in the hospital, which normally means a good amount of interventions. Were the labors augmented? Were the women given the freedom to move around during labor? Did they have epidurals, etc.? What about fetal monitoring, etc? AROM? Vaginal exams? Inductions? All of these interventions bring with them risks which would not be present in c/s deliveries. Many times, hospitals make vbac labors actually have more interventions which would also affect the vbac vs. low-risk labors. Which is, of course, why I think more vbacs should be done at home.

[majormajor]

here's a study that shows a higher risk of fetal death in VBAC. i have looked at it but haven't searched around for criticisms yet.
http://jama.ama-assn.org/cgi/content/full/287/20/2684

and i like this one because they discuss (briefly) the causes of fetal death:
http://www.greenjournal.org/cgi/content/full/93/3/332

i disagree, though, the VBAC is safer at home. i know a lot of women here feel differently, i just can't see how distancing yourself from an OR could make things safer.

[wombatclay]

holly- Of course! And there are no good randomized studies either (though one is in the works) since most mamas are not going to be okay with being randomly assigned to a repeat c/s or vbac pool at 36 weeks. And birth outcomes are not exactly cut and dried...so many little things can have a huge impact and you simply can't correct or control for all of them!

I think studies and stats are important (I'm a reference librarian ) but I don't think they are necessarily significant/predictive for any specific mama.

majormajor- the question might be easier to see if you look at vbac as simply another birth. Yes, there are risks that aren't present in a birth without a uterine scar but these risks are extremely low. Anyway, if you consider a vbac with a single low transverse incision to be a plain old birth (how my OBs viewed it btw) then being in a hospital does nothing but increase your chances for interventions and increase your chances for the complications/health risks that those interventions can lead to.

I had a hospital vbac. I'm glad I did. But my hospital and care providers both take the stance that birth is normal and natural and a vbac is "just" a birth. There are no routine interventions other than a heplock and intermittent monitoring with a doppler while pushing. That's it. No clocks, expected positions, gowns, denial of food, directed pushing, pressure to accept medication or interventions like arom, etc. The active management of birth in a hospital setting introduces risks you wont find elsewhere in exchange for easy access to an OR on the slim chance that you'll need it. When you compare vbac success rates in different birthing environments you'll find the odds really are against you in most hospital settings.

[majormajor]

i know this is MDC and i might get flamed for this, but i'm not convinced that homebirth is as safe as hospital birth. :
i've actually looked into it pretty extensively, and i don't want to shift the discussion to homebirth, so that's all i'll say about it.

however, you're absolutely right that some hospital interventions decrease VBAC safety. some increase it, though. i'm confident in my ability to say no to the dangerous ones and yes to the good ones, so it's absolutely going to be a hospital for me if i VBAC. the real problem i'm having is whether i'll end up VBACing at all, or whether i'll go for the scheduled CS. i'm heavily leaning towards the VBAC. i'm just really bothered by the increased chance of the baby dying with it. so, i don't know. i'm expecting to change my mind a hundred times before the next baby is born though.

[wombatclay]

No worries majormajor...I'm not trying to convince you one way or the other, just explain the reasoning behind the hospital concern. As I mentioned, I vbac'd in a hospital and so have plenty of other mamas here at mdc and elsewhere. I'm just an information junkie who likes to share.

Are you currently pregnant? Do you have a vbac supportive care provider or a care provider that you're considering? They maybe could help you work through some of these concerns.

[holly6737]

Originally Posted by wombatclay

i
I had a hospital vbac. I'm glad I did. But my hospital and care providers both take the stance that birth is normal and natural and a vbac is "just" a birth. There are no routine interventions other than a heplock and intermittent monitoring with a doppler while pushing. That's it. No clocks, expected positions, gowns, denial of food, directed pushing, pressure to accept medication or interventions like arom, etc.

I really think this would be ideal for most women. It's unfair that many women in our country have to choose between either a forced repeat c/s (or a highly managed vbac, really, if they're lucky) and a home birth, which unfortunately in many states it's illegal for HBACs to be attended. Women should have the right to have VBACs in a hospital without intervention. Unfortunately, cases like that are few and far between with so many hospitals banning vbacs or only allowing vbacs with epidurals, or internal monitoring, or whatever ridiculous rules they have.

If anyone is on the fence about vbac, I would recommend reading "Silent Knife" by Nancy Wainer Cohen. It is a little, um, strong, and it's an older book, but what she says still applies today, really, and it's what finally convinced me to vbac.

[majormajor]

we're just getting ready to start TTC. the OB who delivered my DD retired from delivering babies, so i'm about to start looking for a new one. my old OB was very pro-VBAC, and has told me several times that i'm a great candidate for one and has been SO supportive. she even apologized to me for having to go through labor and a section, but said that "my next labor will go like a second labor" because my body will remember the first, so it wasn't all for nothing.
anyway, you're absolutely right, a good provider that i trust will really help with this decision. i know i need to hear that most of the time, everything goes really well.

that's why i love this forum. so overwhelmingly supportive and positive. i usuallly try to just not post when i'm feeling down about VBAC. today is an exception!

also am totally with you both about freedom to choose where and how we all have our next babies.

[Storm Bride]

Originally Posted by majormajor

i know this is MDC and i might get flamed for this, but i'm not convinced that homebirth is as safe as hospital birth. :
i've actually looked into it pretty extensively, and i don't want to shift the discussion to homebirth, so that's all i'll say about it.

however, you're absolutely right that some hospital interventions decrease VBAC safety. some increase it, though. i'm confident in my ability to say no to the dangerous ones and yes to the good ones, so it's absolutely going to be a hospital for me if i VBAC.

See...I'm not, because I've never had "no" listened to the hospital at all. The reality is that I have at least some control of my environment at home...and none at all at the hospital.

Something I have noticed frequently when women choose ERCS is that they will think and say things like, "at least I know what to expect - after all, I've already had a c-section". I've had three. They were all different. I dodged the "complications" bullet until number three. Now, I don't know when I have to pee, because I can't feel my bladder, and I've lost a lot of sensation in my entire pelvis and lower abdomen. It took about a year and a half before I could even begin to figure out what worked for me sexually again, because nothing feels even remotely the same (formerly sensitive areas that are now just dead, etc.). I've had problems with gas and digestive upsets ever since the surgery. (My doctor said they couldn't possibly be from the surgery, and must be because I'm eating too many carbohydrates. Yeah - no dietary changes at all, but my diet must be causing this whole new problem...not to mention that she had no idea what I was eating...and my diet wasn't carbohydrate intensive.)

The "I know what to expect" comfort zone is an illusion. I'm not saying anyone here is counting on that, but it's something that really makes me a little nuts.

[mommak1]

Originally Posted by Storm Bride

The "I know what to expect" comfort zone is an illusion. I'm not saying anyone here is counting on that, but it's something that really makes me a little nuts.

Thanks for this important reminder. I'm still undecided and actually relate very well to a lot of what majormajor has posted - this will be my last baby and the studies that indicate VBAC poses higher risk to THIS baby, even though lower risk to me and to future babies, worries me. But back to my original point, I really do need this reminder that every c-section is different. I had an emergency c-section because of a prolapsed cord and that was a scary thing to go through. There is a part of me that is tempted to choose an elective RCS to avoid the emotional trauma of an emergency and because I really and truly did breeze right through the surgery and recovery. But to make a good decision, I really do need to remind myself over and over that the next surgery could be completely different.

I'm leaning toward VBAC but just not quite ready to commit to it yet.

[LynnE73]

"My last dr. tried to scare me into an elective c by saying cerebal palsy is a huge risk for vbacs... how is that so? I never heard that before... hence, I switched to the mw practice... what causes cerebal palsy?"

With my daughter I had a *standard* hospital birth, almost all of the usual interventions, pushed for 5 hours and she never decended. I had a c/s and was told by my OB that I could always try for a VBAC on the way into the operating room.

With my son I hired Nancy Wainer Cohen. I pushed for 3 1/2 hours and my son suffered traumatic brain injuries. He had a subdural hematoma on the back right of his brain which caused bleeding and pressure resulting in motor control and vision impairment on the left side of his body. He spent 6 days in intensive care and a few months on anti-seizure medication after he was born. The first year and a half were very hard as his progress was extremely slow and it was downright scary when he would not advance at all for months at a time. Right now he still has very limited control over his left arm/hand, motor control in his left leg needs a lot of work and his field of vision is not complete. He receives therapy and sees specialists for all of this, it is slow going but we continually hope he is on a good road to recovery. Yes, he does have cerebral palsy. He also had a double shoulder dystocia.

So now you have "heard of this."

With all of that said, I DO believe in VBAC and plan on trying again this time around. Hopefully I will have the courage to listen to my own body and not allow ANY interventions (especially getting my membranes ruptured!)

[IslandAndy]

I think what you may want to consider as well, is the psychological aspects. This is only my personal experience talking.

I have had 4cs. Frankly, they weren't so bad and I muscled through them to prove I could. However, I always hated them. I always knew my OB would tell me the baby was "too big", and he always did. I would stress and stew over it for months during every pregnancy.

This time at 20 weeks I demanded that my OB tell me THEN if he would do a VBAC (I also was only going to have 4 ). He finally said no, he would be laughed at and could lose his privileges. I left and found a mw I like and my dh trusts(a miracle since he is a hcp). Oddly enough my weight gain has been normal, NO high heart rates(the others had them), no blood pressure issues, no problems at all! Easy, easy pregnancy. My dh swears my lower stress level regarding a cs and my mellow mw have made this possible.

On a side note, my uterus was always "great", minimal scaring etc, UNTIL I wanted a VBAC. Then it was "thin" and risky.

[wombatclay]

hugs to you and your little one LynnE.

[Robinna]

Just to throw one more thing into the mix - I haven't seen any mention in the thread of the increased risk to babies of both prematurity and breathing problems with a planned c/s. Are these problems not considered significant in the studies?

One major problem I have found in looking at studies comparing c/s and vag birth (of any stripe, not just vbac) is that the compromise of the uterus by the scar is not medically considered to be "major morbidity". So for anybody who believes that the surgical injury to the mother, which can take weeks/months to recover from (never mind permanent injury - I'm talking about the surgical recovery process), constitutes major morbidity, be aware that the numbers in the studies are missing a pretty major priority. For me, losing this big a chunk of time, energy, health, and un-interfered with enjoyment of my baby's infancy to a surgical recovery that (in the vast majority of cases) could have been avoided, is a risk I'm not prepared to lie down for. I think that this risk alone outweighs the increased risks of ercs for a planned but gone awry vbac.

One more thought. The other thing that is often not taken into account is that I believe strongly that I have a responsibility to my family, my whole family not just the new baby coming, to be healthy and strong. I believe it encumbent upon me to do whatever is in my power not to be a lame-duck mama to my older children if there's any chance that it can be avoided. For me, this also weights the risks differently from the actual empirical evidence.

[ericswifey27]

Originally Posted by sarah0404

On a different note: I couldn't sleep last night, and for some reason ended up thinking about Michael Jacksons nose! That seems like the perfect advert not to have surgery done in the same place multiple times!

What an image

It's hard to add anything because of all the good info here, but just remember a csection is MAJOR surgery. That is reason enough to do everything you can to avoid one.

[CEG]

Originally Posted by majormajor

as for the increased risk of VBAC, i'm pretty sure that VBACing increases your risk of placental problems too, which increases the baby's chance of death during labor. but i haven't looked for rates of placental problems (abruption, previa and accretia specifically) and compared them to non VBAC or CS, so i don't really know how that plays out yet.

!

I can't think of any mechanism where a vaginal birth would contribute to a future placental problem. The uterus is unique in that the placental site heals with no scarring. The problem with c-sections is that the incision creastes scarring that causes issues with the placental attachment in later pregnancies.

[Electra375]

TO the OP --
If you do plan on attempting a VBAC again, please read your Operative Reports from all of your c/s and especially the last one -- look for double layer surture in the language. Midwife - Ina May Gasking suggest in her 2nd book that only those with a Double Layer should attempt a VBAC due to the increased risk of uterine rupture.

From personal experience, I've had 2 c/s for the first two children and I've home birthed for the next two children. I was unable to find a doctor locally willing to over see a VBA2C, so I decided I would risk a homebirth. From my reading, some of the reasons I used were off! But I was not going to subject myself to the hospital routine procedures and protocols which landed me my first c/s. SO home I went with a very experienced mw in VBACs.

I personally would not recommend home to a VBA3C from what I've read. I also think you are going to be hard pressed to find a doc willing to let your "try" given you've tried before and the medical community knows labor puts stress on the uterus. It is the stress of labor under pitocin which causes most uterine ruptures, so never accept any labor enhancing drugs as a prior c/s or uterine surgery mom.

The idea one could stay home until crowing is faulty b/c with a uterine rupture it could put the baby in destress before that stage and you would not know it until the uterus did rupture at which point there is 17 min until brain damage will most definitely occurs. A baby will give a trained professional (including midwives) clues in their heart beat that the uterus is in trouble -- so I have read.

I think there comes a point where we accept our fate and do what is medically sound. It is hard to discern the information out there, this I know first hand. As a HBA2C mom, I will tell you if my 3rd had been a c/s I would not have attempted another vbac. And my OB at the time was so against women with c/s having more than 3 children due to complications from the c/s. I cried that Dec w my 3rd child knowing that more children was a huge risk. That told me I had to birth at home #3 and if I "failed" then my fate was only 3 children. I was truly torn up about it until I got my head on straight and made a resolution to myself.

The risk I'm refering to -- every subsequent pregnancy after c/s #3 increases the risk of uterine rupture during pregnancy (I used to know the exact figure), just the stress of carrying the child! Not even talking about labor here. To me, that risk was unacceptable. I know if I made it to 24 weeks my baby would likely survive, but if baby didn't, I knew I would not be able to live knowing I had choosen to carry a baby against medical advice and he or she died in utero from a rupture. I would also loose my uterus and not be able to fill that void with another baby from me. I truly was not willing to take that risk at all.

I am really sorry that vbacing did not work for you in your subsequent pregnancies. It's hard to accept a c/s when it isn't what you wanted for yourself -- I never saw myself having surgery to have a baby, I always saw myself at home, from ds1 but my dh didn't like the idea.

PS - I do know mothers with 5 children all from c/s. And my loving mother reminded me that Rose (I think) Kennedy had 11 children via c/s and that was back in the day they did vertical incisions.

[Robinna]

slightly OT... but a friend of mine has just been told that, due to adhesions from her 3 c/s (the 2nd 2 were "elective"), she now has to either have a hysterectomy or live with the *constant* uterine bleeding and chronic debilitating pain. There is nothing else they can do for her. For this problem that started with a surgery that there's a very good chance was unnecessary in the first place, followed by 2 more surgeries that she had because her caregiver told her vbac wasn't as safe. She's losing her uterus to repeated c/s.

This happens every day. But oh yeah - that's not serious morbidity, either.

[pampered_mom]

Originally Posted by Electra375

TO the OP --
If you do plan on attempting a VBAC again, please read your Operative Reports from all of your c/s and especially the last one -- look for double layer surture in the language. Midwife - Ina May Gasking suggest in her 2nd book that only those with a Double Layer should attempt a VBAC due to the increased risk of uterine rupture.

I don't have access to my info right now, but at the ICAN conference this year Gretchen Humphries did a review of the literature on suturing. The results? That the debate between single layer and double layer suturing is likely not as big of an issue that it's made out to be and that really the kind of sutures has a lot more to do with it.

Totally paraphrasing from memory here....if you can get your hands on someone who was at the conference and can readily access their notes that'd probably be even more helpful! :0)

ETA: Another poster had a much better summary than I did!