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worst case scenario UR- how long do you have before c-section? - Page 2

post #21 of 44
To address the OP, if the brain is deprived of oxygen for 4 minutes, then generally permanent and catastrophic brain damage will result. *If* you have a rupture, then how catastrophic it is depends on many other factors that cannot be known ahead of time: where the rupture occurs, is the placenta involved, etc.

I had a catastrophic rupture with my second child during a VBAC attempt in the hospital. I had intermittent monitoring and low fetal heart tones were noted at 6:45 PM. Leah was born by emergency c-section under GA at 7:00 PM. She was born with HIE, the fancy medical terminology for severe oxygen deprivation. Obviously she had been oxygen compromised for some time, but we will never know for how long or why. She was floating in my abdominal cavity and my placenta had abrupted, which is why the rupture was so devatating for her.

And FWIW (since there are inevitable questions when I post my story), my rupture was asymptomatic, and I had a natural, spontaneous labor with no epidual. My rupture was noted during the pushing stage.

So technically your midwife is correct. But you could also be killed in a car accident tomorrow. There are no guarantees about anything.
post #22 of 44
Quote:
Originally Posted by egoldber View Post
So technically your midwife is correct. But you could also be killed in a car accident tomorrow. There are no guarantees about anything.
Bottom line. Noted. At least it is to me.
post #23 of 44
Thread Starter 
Quote:
pampered_mom Quote:
Originally Posted by g&a
Quote:
What I mean is that there are all sorts of other awful things that are more likely to go wrong than uterine rupture. Why don't we have all births in the OR??
I'm sure the powers that be would like nothing better than for that to return. Which of course touches on VBAC banning hospitals. Since there are all sorts of bad things that can happen, why is it that it's not safe for some hospitals to "allow" VBACS, but it's perfectly safe for them to "allow" vaginal births?
Yes, I meant it in a sarcastic way.

This has been a very helpful discussion, so far. Exactly the kind of info that I needed. I'm not sure if I feel better about it or not yet. It just hit me suddenly that this stuff is deadly. It's hard to weigh the pros and cons and keep emotions out of it. I keep reminding myself that the chances of a catastrophic rupture are very tiny.

g.
post #24 of 44
Quote:
Originally Posted by g&a View Post
Yes, I meant it in a sarcastic way.
Good...because that was totally the way I took it.
post #25 of 44
Quote:
Originally Posted by pampered_mom View Post
majormajor - The reason why I said what you posted was interesting was because it seems to be the way many "studies" are handled. Most docs read just the summaries...or folks just read the introduction when the remainder of the study may or may not agree entirely with that beginning assertion.

You can say all sorts of things in a "study" and then make the data seem like it supports what you have to say. Or you can start quoting things in terms of relative risk which makes things seem much scarier than they actually are. I tend to take "studies" with a grain of salt. I don't actually think it's possible for them to be 100% unbiased.
what you are saying is true in general, but is not what i did in this case. the OP asked specifically about outcomes of catastrophic uterine rupture, not frequency. it's not my fault that the answer to her question is bad news!

egoldbear, thank you for sharing your story. i'm so sorry for your loss.

g&a, i know what you mean about trying to keep emotions out of it! especially the emotion of fear. a while back i started a thread asking about people sitting on the VBAC fence, so to speak, and a bunch of moms who had been fence-sitters during their pregnancy told about how they finally made a decision. a lot of them said it surprisingly came down to the practicalities. like, they had worked through the fears/emotions by the end of the pregnancy, and were able to make a really objective, practical decision. that gave me a lot of hope that this questioning and emotion is common phase in working towards a VBAC. another thing that has helped was meeting with my OB, who really supports VBAC and told me the risk of rupture is "tiny." very reassuring!
post #26 of 44
Thread Starter 
egoldber-

Thank you for sharing your story. Do you think her brain damage was because of the uterine rupture or something else? Placental abruption, maybe? I'm just curious, I know you said you didn't know for sure.

Also, thanks for the 4 minutes of oxygen deprivation. With that it seems to me that it doesn't matter how soon they do a c-section, unless it's under 4 minutes, it's bad news. I guess it would be hard to research how long you actually have exactly. ie. if it's really 4 minutes in this case.

Am I right in assuming that the danger is that you loose a lot of blood with a uterine rupture and the baby doesn't get enough blood and therefore oxygen to survive??? Is that what happens??

g.
post #27 of 44
In my case, my UR caused a placental abruption. This isn't uncommon in a UR for this to happen. The issue is how much abrupts and is it a critical part of the placenta in terms of the baby's oxygen supply. I didn't have any bleeding, hmm, externally, but there was apparently a lot of blood in my abdomen according to the operative notes.
post #28 of 44
The technical answer to how long a baby can survive obviously depends on exactly how much oxygen he/she is still receiving prior to birth. If we're talking about a rupture where baby is getting ZERO oxygen, you have to ask yourself how long YOU could hold your breath with no oxygen whatsoever and still come out alive without brain damage. More than 3-5 minutes of no oxygen whatsoever and you're almost always looking at some degree of brain injury at a minimum.

The problem is most ruptures don't result in complete absence of oxygen, rather it's decreased oxygen. To what degree and for how long all depend on the severity of the rupture, the location of the rupture, whether or not the placenta is involved, how much blood mom is losing and how quickly, etc.

Mom can literally bleed to death in a matter of 2-4 minutes if she's losing enough blood fast enough. If mom has no ciruculating blood volume, it won't matter if baby is still attached via the placenta or not, because no oxygen will be delivered.

In the worst of the worst, it really doesn't matter WHERE you are (i.e. at home, in a birth center, in the hospital). The only thing that might help in those particular cases might be if you were already on the table ready and prepped for section when the rupture happened.

It's the other cases that are more worrisome IMO. The ones where being in a hospital MIGHT make the difference. Where baby MIGHT be ok if delivered in 10 minutes tops vs. it taking 10 minutes to get to the hospital, another 10 minutes to get baby out, for a total of 20 minutes of severe distress.

The hospitals I've delivered in have all had under 5 minute times for emergency decision to incision and under 5 minutes for incision to birth. Whomever said this is not possible is misinformed. It requires in house OB and anesthesia coverage, an available OR and adequate staff, but it DOES happen in some of the larger hospitals.

It should also be noted that complication rates for mom during this type of 'splash and slash' c-section are *dramatically* higher than with an ERCS. The emergency nature of the surgery leads to many more surgical errors, more blood loss, more post-op infection, etc.

IF this type thing is what scares someone into a hospital VBAC, I'd say you're wasting your time if they don't have 24/7 OB and anesthesia coverage. Otherwise, you're really no better off than just calling ahead from home or a birthing center, assuming both are within a short drive to said hospital.

While none of this may be what someone who desperately wants a VBAC would like to hear, it is what it is. Just as the risks of ERCS are what they are, there are risks to VBAC. Not being able to get baby out fast enough is one of those risks. Being away from a hospital equipped to perform an emergency section in a matter of minutes IS a risk, but this is true for any labor, and relative risk is something only individual mothers can assess for themselves and their babies.
post #29 of 44
Quote:
Originally Posted by g&a View Post
I'm not sure if I feel better about it or not yet. It just hit me suddenly that this stuff is deadly.
Well, let's remember: life is deadly. There's a 100% mortality rate. One reason why we're so nervous (as a society) about pregnancy and birth is that, as soon as life begins, the possibility of death emerges.

So there's your answer: 4 minutes, for the absolute worst-case scenario. No one can go from decision to birth in 4 minutes. So, you hope for *less* than the absolute worst-case scenario, and that you beat the clock. And, ideally, you don't have the scenario at all, and you have a glorious VBAC. But no matter what you do, what condition you're in, there are no guarantees. You do the best you can.
post #30 of 44
Quote:
Originally Posted by wifeandmom View Post
It's the other cases that are more worrisome IMO. The ones where being in a hospital MIGHT make the difference. Where baby MIGHT be ok if delivered in 10 minutes tops vs. it taking 10 minutes to get to the hospital, another 10 minutes to get baby out, for a total of 20 minutes of severe distress.
You're right, there are some instances where being in a hospital MIGHT make the difference, but notice that's just a "might" not a guarantee nor a certainty.

Quote:
Originally Posted by Ironica
Well, let's remember: life is deadly. There's a 100% mortality rate. One reason why we're so nervous (as a society) about pregnancy and birth is that, as soon as life begins, the possibility of death emerges.
Absolutely! I think that's basically in a nutshell the conflict. Especially since our society in the US is so very interested in cheating death, prolonging our lives, and just plain wanting to avoid it at all costs. All of that is fine and dandy, but there are costs associated with these types of choices.

Is what you gain by choosing to birth in the hospital worth what you'll lose, what it will cost you? Is it worth the "mights"? What if you choose the hospital route, make the necessary concessions, and the worst case scenario still happens? What if everyone isn't alright in spite of your location in the best of hospitals that can do it in the timeframe that wifeandmom gives? What then?
post #31 of 44
Quote:
Originally Posted by pampered_mom View Post
Is what you gain by choosing to birth in the hospital worth what you'll lose, what it will cost you? Is it worth the "mights"? What if you choose the hospital route, make the necessary concessions, and the worst case scenario still happens? What if everyone isn't alright in spite of your location in the best of hospitals that can do it in the timeframe that wifeandmom gives? What then?
I think what it comes down to, though, is that there will always be unknowns. You simply *don't know* how your birth will go until it's happened. You may know that if X happens, then you're better off in a hospital, but if Y happens, you're better off at home... yet, without knowing whether X or Y will happen (and having wildly varying statistics on their incidence rates from various studies and agencies), you can't really use that information to decide.

So, what it comes down to is, what are you going to kick yourself for more? For staying home when you "should have" been at the hospital? Or for going to the hospital when you "should have" stayed home? In the absolute worst-case scenario... baby dies, suffers terrible damage, whatever... if you decided to stay home, are you going to be able to live with that decision? Some people can, some people can't. It's just not something anyone else can answer for you.

And chances are, the worst of the worst WON'T happen. There are a whole lot of other things that are more likely. Heck, the other day I got my first-tri screening results, and it was considered "negative," with the chance of Down's Syndrome being downgraded to 1 in 6,719. But... that's DOUBLE the chances of my baby dying of Group B Strep if I'm GBS positive and baby's born full-term without any antibiotic treatment. Wild, isn't it? Pamimidwife's blog has an entry with a great rundown on all the things that are more likely than a uterine rupture during a VBAC. For example, you're three times as likely to get pregnant with twins as have a UR during a VBAC.

So, it's all playing the numbers, gambling on the outcomes that seem most likely (statistically in general, and for YOU), and then deciding what you can live with the most. I have to say, I'll probably go with a hospital birth, because (1) I don't mind hospitals in general; and (2) I just *know* that I'd have trouble forgiving myself if the Ultimate happened and I'd stayed home. No matter what anyone said, I'd wonder if things would have turned out differently if I'd gone to the hospital. And, sure, maybe that's my hangup, but it's MINE. ;-) (And I do have a really good option available for a hospital birth with a nurse-midwife practice, an overall c/s rate of 20%, total rooming-in policy, plus top of the line everything available if needed... if that all wasn't available in one almost-convenient package [drive is half an hour at 3 a.m., and 45-90 minutes during the workday] I might make a different decision.)
post #32 of 44
Quote:
Originally Posted by pampered_mom View Post
You're right, there are some instances where being in a hospital MIGHT make the difference, but notice that's just a "might" not a guarantee nor a certainty.
You are so right. And there are definitely examples where mom and/or baby MIGHT have been ok if they'd been at home vs. a hospital. Not a guarantee, but maybe nonetheless. There are no guarantees, and human nature balks at that.




Quote:
Is what you gain by choosing to birth in the hospital worth what you'll lose, what it will cost you? Is it worth the "mights"? What if you choose the hospital route, make the necessary concessions, and the worst case scenario still happens? What if everyone isn't alright in spite of your location in the best of hospitals that can do it in the timeframe that wifeandmom gives? What then?
I think these are all such important questions for *every* woman to ask herself. And only *she* can answer them for herself and her particular situation.

Whatever a mother ultimately decides is best for her and her baby, I would truly hope that she made that choice based on the best information available at the time. More imporantly, I would hope that deep down in her heart she knew that she was making the best choice she could at the time. That's really all any of us can do.

And in the end, if we find ourselves on the wrong side of the statistics, I'd think that being able to reflect back on that decision making process would offer some degree of comfort. We can only do what we feel is best and right at the time, while realizing that sometimes, somebody, somewhere is going to be on the wrong side of the statistics.

If that someone happens to be *me*, I know that the choices I made for my children's births were the very best I could do at the time, they were decisions I do not regret, and most importantly, they were decisions that FELT RIGHT. I give serious weight to a mother's instinct in these matters too, and that just can't be quantified, kwim?
post #33 of 44
Quote:
And in the end, if we find ourselves on the wrong side of the statistics, I'd think that being able to reflect back on that decision making process would offer some degree of comfort
Well, to be honest, this seldom happens. If the unthinkable happens to you, it is a natural part of the grieving process to regret your decisions. If you HBAC you wish it had been in the hospital. If it was in the hospital (as mine was), I wish more than anything I had never considered VBAC and that I had been the happy patient who just scheduled her repeat for 38 weeks. On the other hand, if you had a child die as result of an ERCS, you'd regret not doing a VBAC.

In the end, as you say, you can only do the best you can with the imformation you have at the time. But don't think thats going to be any real comfort if you do come down on the wrong side of things.
post #34 of 44
Quote:
Originally Posted by egoldber View Post
Well, to be honest, this seldom happens. If the unthinkable happens to you, it is a natural part of the grieving process to regret your decisions. If you HBAC you wish it had been in the hospital. If it was in the hospital (as mine was), I wish more than anything I had never considered VBAC and that I had been the happy patient who just scheduled her repeat for 38 weeks. On the other hand, if you had a child die as result of an ERCS, you'd regret not doing a VBAC.

In the end, as you say, you can only do the best you can with the imformation you have at the time. But don't think thats going to be any real comfort if you do come down on the wrong side of things.

I think for *me*, the fact that all available research indicated at the time that my baby was more likely to die if I attempted a VBAC would have helped me if something had gone wrong during my ERCS. Statistically, I chose what was safest for my baby.

Let's say they'd ended up in the NICU with minor breathing issues (common enough with ERCS babies). Then they got an infection that they never would have been exposed to if they hadn't been in the NICU to begin with. And they died.

Well, at the end of the day, my original choice was still the one that was LESS likely to end up in the death of my baby. I really do think that I would eventually find at least some small amount of comfort in that.

Would I wish desperately that I'd done something different so that my child would have lived? I'm sure. But actually being able to live with my choice and not go absolutely insane blaming myself? It's one of the main reasons I could never wrap my mind around VBAC. I knew that *I* couldn't live with myself if worst case scenerio happened given what I knew about the current research combined with my own personal situation (closely spaced pg, would have required induction, etc).

Maybe I'm wrong, and I am so incredibly thankful that I never had to find out.
post #35 of 44
My point is that second guessing yourself and wishing you had done something different is a natural part of the grieving process. It doesn't matter how logical or rational or sensible the choice is. When something tragic happens, you will always second guess yourself. You do get through it, although some people will spend more time in that grief stage than others.
post #36 of 44
Quote:
Originally Posted by egoldber View Post
My point is that second guessing yourself and wishing you had done something different is a natural part of the grieving process. It doesn't matter how logical or rational or sensible the choice is. When something tragic happens, you will always second guess yourself. You do get through it, although some people will spend more time in that grief stage than others.
yes. or you get information later, that you didn't have at the time, that might have or would have changed your choices if you had found that information. "I made the right decision for the information I had at the time" is very cold comfort.
post #37 of 44
Quote:
Originally Posted by egoldber View Post
My point is that second guessing yourself and wishing you had done something different is a natural part of the grieving process. It doesn't matter how logical or rational or sensible the choice is. When something tragic happens, you will always second guess yourself. You do get through it, although some people will spend more time in that grief stage than others.
Absolutely!

Quote:
Originally Posted by Robinna View Post
yes. or you get information later, that you didn't have at the time, that might have or would have changed your choices if you had found that information. "I made the right decision for the information I had at the time" is very cold comfort.
:

I guess one of my biggest issues is that when it comes to this kind of discussion ERCS vs VBAC unless you are able/willing to go out and do the research yourself (kudos to OP for asking this kind of question to more than just her mw) it is often difficult to get the information you really need because the issue of UR to the medical powers that be is really about a misappropriation of risk.

wifeandmom - You are right, we each need to make the decision we're most comfortable with, but what worries me the most about that sentiment is the fact that it can often be taken and applied to other situations (primary c/s w/out medical indications for example). Where does one draw the line?

And you're right - human nature (and our culture in general) balks at the idea that there aren't any guarantees so we tend to believe those who make the guarantees which I'm sure doesn't make the grieving process any easier to get through when you go contrary to the "guarantee".

As for me....I'll never be comfortable birthing in a hospital nor will I ever be comfortable seeking care from an OB/GYN. For me VBAC far outweighs the risks of UR and I know in my heart that my best chance is at home, not in the hospital. In the hospitals around here my only option is an OB/GYN and all the technological bells and whistles. I've already expereienced that once and know that I cannot go back again.

It probably helps that for my own personal philosophy I am mindful of the fact that there are no guarantees in life. I'm not guaranteed anything more than the moment that I'm in. I have to hold onto my life and the lives of those that I love loosely. For me the medical model runs contrary to that.
post #38 of 44
Thread Starter 
Update:
Well, I think I caught DH reading this thread (I left it open) and now he's freaked about UR. He's adament about choosing hospital over birth center.
I'm pretty sure there's nothing I can say to convince him otherwise.

I've got my heart set on not going to the hospital. In fact, I always picture birthing at home, but I know that's not possible, so this is a compromise.

He said it's like driving a car, you know it is dangerous so you take precautions like wearing a seatbelt. I told him that we ARE taking precautions, we've hired the best midwife around, and we're going to the birth center which is only minutes away from the hospital.

And, in a way, he's right, it would probably be safer in the hospital with the midwife than at the birth center with the midwife, but is it really necessary to go to the hospital??

OK, he just confessed to reading the thread! Silly guy!

I just lost the rest of the thought.

g.
post #39 of 44
Many good thoughts here...good discussion.

Another thing to figure in is that "THE HOSPITAL" is not a catch all, quality and availability of services vary widely. Its important to ask these question in relation to your home and midwife team and your local hospital, and how its staffed.

And how it is "Staphed" is something to consider too. My local hospital has a 30-40% staph infection rate for all admissions up from 26% in 2005, with MRSA raging all over it.....not a place I'd want to have a baby if I could help it.

And an acquaintance had an ERC and her baby was in the NICU three weeks for immature lungs. She spent those first three weeks in the NICU away from her 2 year old, and that made the whole transition to new baby in the family hell for them. Should they be grateful they had a live baby or regret not having had a VBAC that statistically would have gone off just fine?

Choices depend so much on what is available- in my town I can have a homebirth with a midwife, soon I can choose a birth center birth too, or I could have an ERC at the hospital with lower infection rates that does not do VBACs, or ERC or VBAC in the hospital that is very aggressive with intervention and not friendly to mothers who want to move or have intermittent monitoring and some of the docs require an epidural in place in case of rupture (an unmedicated VBAC is my bench mark for health and normal) plus it has mandatory separation of mother & baby in post op during recovery and is the place with high infection rates... or I could leave town and go somewhere with lower infection rates and better VBAC policies, and better post c-section care for mom and baby.

One reason I want to choose VBAC is to protect my future health and the integrity off my uterus. What about the long term risks of adhesions and bowel complications, reduced fertility, or gynecological problems from having my abdomen opened up uterus cut over and over again? Esp. if infection is part of the picture? I just had surgery to fix problems from my first c-section, I know I don't want to go through all that again.

I value spontaneous labor and all the related hormonal reactions that are too complex to be understood, but I suspect they are far more important than we have begun to realize. Like I value my body's natural oxytocin's ability to create love and attachment for me and my baby. I think the hormones of labor are a vital part of creating a healthy baby and mother. What if lack of natural labor hormones is part of the aspergers picture? What if you skip labor and have a child who is life long affected by a neurological disorder, or chronic lung problems from being born early and not getting squeezed out, what then? I believe nature has a purpose in its process of birth, and think its unwise to bypass that if you can help it.

Plus I believe in the energetics of the body, and spinals/epidurals/surgery are far more depleting than vaginal birth. In Chinese medicine c-sections are seen as cutting your meridians and they most often don't reattach right, just like circulation and nerves do not heal/ reattach perfectly, and it creates long-term changes in the flow called stagnation that affects all body processes, especially moods. I think these kinds of energetic problems were my worst post c-section complications. I really have not been the same since, the stagnation issue has been a big one for me, giving me symptoms in my back, low energy, hopelessness and anger. I need acupuncture to clear these things the way someone who had a major injury might need lymph drainage massage. Things just don't flow like they used too! I think submitting to that without good reason seems bad for maternal long term health.

I tend to think that we need to start at the lowest level of intervention that is safe, and react to emergencies when they arise. The question becomes what is the best plan if an emergency does arise, and how much do we let it effect the original course of action? I think VBAC is safest and most sensible option for me, but ideally we need to have surgery ready ASAP in case we are in the minority that poor egold (bless her) was in. But I can not go into the hospital here and have a peaceful, unmedicated VBAC. I know I could not birth in the circumstances available for me in the hospital that VBACs here. And I need to give myself the best shot at a VBAC since I think that is healthiest for me. I am afraid of the myriad of surgery complications from an ERC or "failed" VBAC, totally not worth the risk to me if I can help it, so really it makes best sense for me to try to birth at home.

I am aware of risks of death to my baby, even me, for homebirth rupture and hospital VBAC/elective c-sections. None of the choices are perfect, none can guarantee a good scenario for mom or baby....so what to do? Original poster seems to want answer of what is safest, like minutes from the occurrence of a complication can be calculated and predicted, and the plan can be decided based on that. But no one knows even if you have rupture if it will effect you, or baby negatively at all (the story of the rupture that was undetected until the c-section illustrates this). I wish we could google "what is the right decison, God?". I feel like this is what you are really asking. You are in one of those places in life where safety can not be found or managed on a physical plane, your safety has to be found beyond your numbers, the research, etc in your heart. I think many people let others make this decsion for them- their doctors, their husband, the hospital because its such a huge level of responsabilty to do concisously. I think you are courageous to have even asked. If you find that place of peace in your heart, hold on to it and hope it carries you though if things do not go in the way you hoped, whatever choice you make. Be connected, find your intuition and faith, and do what feels best based on your ways of knowing, and pray to be on the better side of the stats and for mercy and peace if you are not.

Meanwhile, from another thread, this link just puts it all in perspective!!!
And this one tell you why it makes sense to VBAC.
And this is a tear jerker (in a good way) that reminds me why VBAC is worth trying for!
post #40 of 44
Thread Starter 
Wow, that one IS a tear jerker! See, people do VBAC at home!

I should be clear, (my last post was cut off) the choice we're debating now is location - hospital or birth center - both would be with the SAME midwife.
To VBAC or not has never been up for debate in anyone's eyes.

Of course, I am staunchly for birth center for peace of mind reasons, and DH (who thinks his MDC name should be "The Voice of Reason") is now thinking that birth is so inherantly dangerous (not just VBAC) that we ought to be in the hospital at least, if not the OR (ok, I am being sarcastic here, get it, Mr. Reason?).

I think the only thing that would sway his opinion is ANOTHER long chat with the midwife. I wonder if she is tired of us yet!

******

OK, here's another thought: hospital=fear of something bad happening
I am not afraid of uterine rupture! I'm not. I know the possability exists, and now I know how serious it is, but that is not going to stop me from having the best birth possible. That doesn't mean not taking precautions - it just means not going overboard. If we are labouring at the birth center and the midwife says we should go to the hospital, I'm there. Do we make every decision based on fear? Where's the freedom in that?

By going to the hospital we are only protecting ourselves from those ruptures where the baby would be saved with surgery between 10 (5?) and 20 minutes after rupture. That number is so infitessimably small it's hard to believe we're getting all worked up over it.

<sigh> Thanks for reading if you go this far! I'm not expecting anyone to post a magical argument that will solve the whole dilemma, sometimes it's just good to voice it out.

g.
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