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#1 of 27 Old 11-19-2009, 12:42 AM - Thread Starter
 
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I am facing EXTREME resistance to my second VBAC from the doctors. Long story but a homebirth isn't really an easy option for me, so its with an OB. And I want to know the REAL risks. Thanks!
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#2 of 27 Old 11-19-2009, 01:12 AM
 
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Your second VBAC? Odd they are pressuring you after have already had one.

The real risk is a small % higher risk of Uterine Rupture.
All women have this risk, which is about 0.1% - 0.3% VBAC women have a 0.3% - 0.7% risk.
U/R can occur even before labor, so the theory that having a scheduled c-section before labor will protect a women from u/r is false. No one has a 0% risk.

Would you also like to hear about the risks of another c-section? Or about the risks that occur AFTER a c-section and in future pregnancies?

I borrowed this from a friend of mine's blog.

Quote:
Here are a couple examples of the risk factors with increasing cesarean section surgeries.

2nd Cesarean
Risk of Hysterectomy : 0.42% (1 in 238)
Risk of Blood Transfusion : 1.53% (1 in 65)
Risk of Placenta Accreta : 0.31% (1 in 325)
Risk of Major Complications : 4.3% (1 in 23)
Risk of Dense Adhesion's : 21.6% (1 in 5)

3rd Cesarean
Risk of Hysterectomy : 0.9% (1 in 111)
Risk of Blood Transfusion : 2.26% (1 in 44)
Risk of Placenta Accreta : 0.57% (1 in 165)
Risk of Major Complications : 7.5% (1 in 13)
Risk of Dense Adhesion's : 32.2% (1 in 3)
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#3 of 27 Old 11-19-2009, 11:00 AM - Thread Starter
 
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The OB who is using scare tactics to attempt to persuade me into another surgery was open about the risks of another surgery. However, his point was that those rarely result in death to the mother or baby, while a uterine rupture often does. What are the risks of death of infant and mother when a uterus ruptures?
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#4 of 27 Old 11-19-2009, 11:44 AM
 
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There's a great article on mothering under pregnancy & birth, then VBAC & cesarean, called Fighting VBAC-Lash: Critiquing Current Research. Here's a paragraph I pulled from it, but the entire article is worth reading.

Thus the risk of a baby dying in association with VBAC was 12 times lower than the risk of a baby dying from non-rupture-related causes. No amount of medical intervention can reduce the fetal mortality rate to zero; death will always be a part of birth. Using the very rare risk of fetal death to convince more women to undergo unnecessary surgery still cannot guarantee the parents a live baby."


Good luck with your journey to VBAC; is using a CNM an option for you?? If not, maybe you can hire a doula to not only support you but also fight for you during labor & delivery!

Emily, wife to Todd, mommy to John Isaac (May 2007) and excited for #2 in May!
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#5 of 27 Old 11-19-2009, 12:05 PM - Thread Starter
 
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Originally Posted by John'sMama View Post
There's a great article on mothering under pregnancy & birth, then VBAC & cesarean, called Fighting VBAC-Lash: Critiquing Current Research. Here's a paragraph I pulled from it, but the entire article is worth reading.
Good luck with your journey to VBAC; is using a CNM an option for you?? If not, maybe you can hire a doula to not only support you but also fight for you during labor & delivery!
This is very useful. The OB told dh and I that the risk of maternal death with a ruptured uterus was 50% and the risk of infant death was 80%. How can his numbers be so far from these? I guess I should've asked where he got his numbers. This is so confusing.
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#6 of 27 Old 11-19-2009, 12:13 PM
 
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This is very useful. The OB told dh and I that the risk of maternal death with a ruptured uterus was 50% and the risk of infant death was 80%. How can his numbers be so far from these? I guess I should've asked where he got his numbers. This is so confusing.
I"m also a part of another birth board and we've had a few mom's do HBAC, hospital VBAC as well as a couple of rutpures. No mother died or baby.... actually in both instances I recall the ruptures they were both small partial ruptures. There was one recently who had a fairly large rupture and yes the mother needed some blood transfusions and had a longer recovery however all is fine.

Your OB's numbers maybe higher if he's talking about full ruptures (Your entire CS scar and then some rupturing).

I suggest getting a hold of ICAN and seeing if you can get some information from them to take to your next appointment and ask your doctor for the same thing. You want to see VALID and CURRENT research that is in a medical journal (not via a google search) and see what type of discussion that will open up.

What about finding another more supportive OB?

GOod luck!

Mama to a zoo!
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#7 of 27 Old 11-19-2009, 01:52 PM
 
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Risk of UR is around 0.5% for first VBAC, more like 0.3% if you've already had a successful VBAC. Risk of death to the baby is around 1/10. This makes your ABSOLUTE RISK of death to baby = 0.5%*10% = 1/2000 or 0.05%.

I would ask your OB for the reference for his numbers, since they conflict greatly with the research I've seen. O

Here's a ref that might be helpful to you - brand spankin' new:
Zwart J, Richters J, O¨ ry F, de Vries J, Bloemenkamp K, van Roosmalen J. Uterine rupture in the Netherlands: a nationwide population-
based cohort study. BJOG 2009;116:1069–1080.

[snip from abstract] Results There were 210 cases of uterine rupture (5.9 per 10 000 pregnancies). Of these women, 183 (87.1%) had a uterine scar,
incidences being 5.1 and 0.8 per 10 000 in women with and without uterine scar. No maternal deaths and 18 cases of perinatal death (8.7%) occurred.

Mom to James (ribboncesarean.gif 5/2006), Claire (vbac.gif 6/2008), furry kitties Calvin and Bob, and wife to Dennis. 

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#8 of 27 Old 11-19-2009, 06:50 PM
 
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Emily and Kltroy gave you some most excellent stats! Those numbers are similar to ones I have found.
Why is your OB trying to scare you? Perhaps he himself has had 2 VBAC mom's rupture and one of the babies died? I dont know. It does sound to me like he is not as supportive as he says he is. It also says to me (if he in deed has had mom's rupture) that perhaps he likes to induce VBACs or use Pitocin on his VBAC moms.
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#9 of 27 Old 11-19-2009, 09:09 PM - Thread Starter
 
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Emily and Kltroy gave you some most excellent stats! Those numbers are similar to ones I have found.
Why is your OB trying to scare you? Perhaps he himself has had 2 VBAC mom's rupture and one of the babies died? I dont know. It does sound to me like he is not as supportive as he says he is. It also says to me (if he in deed has had mom's rupture) that perhaps he likes to induce VBACs or use Pitocin on his VBAC moms.
He says he had a very large window just this past weekend, and that he has had babies die as a result of vbac, but I didn't ask for details, nor do I feel he is entirely telling the truth. He does not induce. I asked about that. I was induced with my first vbac, with pitocin. He said that the fact that I had a previous vbac, with induction, is no indication that my scar is strong enough to sustain this birth--that its random when it comes to scars rupturing. He did say he was willing to see me past 41 weeks, which is likely to happen.
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#10 of 27 Old 11-19-2009, 11:24 PM
 
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Well to be perfectly honest, I would feel very comfortable having a doc who had actually *seen* and *dealt with* a UR for my VBAC. Think about it: the first time you see something you (a) don't quite know what you're looking for and (b) aren't quite sure how you would react even though you know how you should react. He's BTDT and to me that's reassuring because the second (or third, or fourth) time around he will feel more confident in his ability to recognize a rupture and deal with it effectively.

I think this may be a case where personal experience and anecdote are more powerful than statistics. If this guy happened to see a few unlucky women then that is going to stick in his mind much more vividly than all the statistics in the world. Anyway, it sounds like you need to continue to have a discussion with him and take it from there. I wish you the best of luck.

Mom to James (ribboncesarean.gif 5/2006), Claire (vbac.gif 6/2008), furry kitties Calvin and Bob, and wife to Dennis. 

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#11 of 27 Old 11-19-2009, 11:33 PM
 
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He says he had a very large window just this past weekend
From what I understand, a "window" is not necessarily a rupture. Apparently it's possible to have those for a large part of a pregnancy, and they don't necessarily pose any threat to the baby or mother. I can't remember if I read that in Silent Knife or in Natural Birth After Cesarean: A Practical Guide, but one of them included information on that.

Lisa  caffix.gif and her wonderful girls: R (9) violin.gif &  J (3-3/4) coolshine.gif 
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#12 of 27 Old 11-20-2009, 01:18 AM
 
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This is very useful. The OB told dh and I that the risk of maternal death with a ruptured uterus was 50% and the risk of infant death was 80%. How can his numbers be so far from these? I guess I should've asked where he got his numbers. This is so confusing.

As the ob how many ur he has had. All ob's have had ur (if they've been in practice for a big)...what I'm saying it is not just vbac moms that ur. Ask him how many vbac's he has done and how many of those had ur. Ask him how many died.

My ob (the one I switched from) told me he did 80-100 vbac's a year and I had a 4% rate of ur (never ever has a study shown that in a low transverse scar) BUT he's only ever seen two ur. Huh,his math was way off. I knew I was switching so didn't show him his mathematical errors, but now I wish I had.
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#13 of 27 Old 11-20-2009, 02:20 AM
 
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You've stated that you don't feel he's telling the truth so from that I will take that you don't trust him. That being the case, why don't you switch to a different OB or a CNM?

- Kim
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#14 of 27 Old 11-20-2009, 02:18 PM
 
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Also think about this. First off, the chance for a catastrophic uterine rupture is much smaller than the UR rate. I can't remember exactly what, but its very very small. There is a very small chance you could have a UR, yes-but its much more likely to be a small rupture, which doesn't pose a huge risk to baby and mom, provided its caught.

In a catastrophic rupture, I believe the risk is higher for the baby. Its still possible for both to come through ok, but not as likely. Oddly of the 10 or so catastrophic ruptures I've read about, 3 occurred before labor even began. And one occurred in a mom who hadn't had a cesarean.

I'd also question his belief that having a previous VBAC, especially one in which pitocin was used, means nothing. From what I've seen, the chances of UR go down even more when mom has already had a successful VBAC. Yes, it doesn't guarantee you're safe, but birth never does.

Finally-in regards to catching UR's-I'm making an assumption here, but if you are not using pain meds, your chances of catching a UR quickly go up by leaps and bounds. Think about it-with an epidural in place, a mom will most likely not be able to feel anything, maybe pressure or something being off, but not pain. Now think about how many moms get epidurals. A LOT. The vast majority. Its entirely possible that the baby/mom would've been ok had they caught the rupture early. With mom not being able to recognize a rupture, all they have left to rely on is fetal heart tones and sometimes bleeding/odd contractions (which aren't guaranteed to happen). By the time the fetal heart tones are getting whacky enough to notice, they're already in some serious trouble. Then with all the time it takes to get to an OR, get surgery started, etc....yeah, it can be something like 5, 10 minutes, fast, but when a baby is in major distress, that may not be fast enough.

I personally wouldn't attempt a VBAC with pain meds in place. I WANT to feel the pain and everything else. I want to be able to say "WHOA, that's not right" and get attention immediately. I can't imagine not having some major pain with any sort of UR...although I admit thats an assumption. I should see if I can find anything on that specifically, from moms that have been there. Knowing what to look for yourself can make all the difference!

And also, as pointed out above, cesarean doesn't come without risks. Babies are more likely to die after a cesarean as are mothers, versus a vaginal birth. Another cesarean increases the risk to any future babies. And cesarean babies are much more likely to have respiratory problems.

Nothing in childbirth comes without risks.

Cari-mama to Eriq, Lile, Paikea, Kaidyn, and Mieke is here!! 2/9/10
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#15 of 27 Old 11-20-2009, 02:38 PM
 
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This is very useful. The OB told dh and I that the risk of maternal death with a ruptured uterus was 50% and the risk of infant death was 80%. How can his numbers be so far from these? I guess I should've asked where he got his numbers. This is so confusing.
If you understood him correctly, then he's just giving you numbers off the top of his head--NOT referencing any actual research. Could it be you misunderstood him...? The only thing I can agree with him on at all, is that babies do die more often than moms in case of UR. But not a lot more often--so many variables play a part, such as how bad the rupture, how far from a hospital that can do csec, other. Otherwise, his numbers are just crazy....either you somehow misunderstood, or he just made that up!

I don't want to call him a liar--but I've known many women who were straight-out lied to by their OBs for various issues (not all vbac related) "for her own and her baby's good".

But in any case of being presented with numbers/stats, I always ask just how those numbers were generated, what factors were taken into account. For instance, in studies of vbac/ur, how many of those women were in a really healthy state during their labors, and how many had really poor diet/lifestyle habits? How many were induced--and with what? How many had to labor with continuous EFM, pretty much in bed, on their backs? How many had doula support, and stayed home til the last minute, vs those who went in the second they thought they were in labor? Other questions come to mind as well.

As far as I can tell from info gathered from homebirth mws I know, for instance, the rate of UR is very low for most of us. Very much lower than any of the studies indicate--and the studies are all about hospital births, because that is where most births happen and it is easy to get a sample of hospital births. Not saying you should have a homebirth (tho I generally do favor it!), only that as a homebirth professional, I tend to think about the differences btwn home and hosp stats--in terms of variations on the norm, especially-- such as breech, vbac, mulitples, group-B strep infections, lengthy rupture of membranes. There is just not enough research done that is homebirth based. Anyway, just something else to question--and I'm just saying that we *should* question all stats, and we should assume that in any group of women/births studied, there are women who may well have all been categorized as 'lowest risk' yet there are still great differences in their relative states of well-being, preparation, the kind of care they receive, etc. We can't 'see' those things in the studies/stats, but I think they do matter very much.
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#16 of 27 Old 11-20-2009, 04:54 PM - Thread Starter
 
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I did not misunderstand him. I was taken aback because the numbers I'd heard previous to that were not nearly as dramatic, but I thought maybe I had misinterpreted the stats I had previously heard. I am not eligible for a homebirth because of my distance from a hospital (80 miles) and that hospital does not have an OB or an anesthesiologist on staff 24 hours, so they won't allow a vbac. I'm already traveling a long distance for this OB, and plan to have a midwife attend the birth as well. He is the OB recommended to me by her, because none of the OBs in any community close to mine are happy about doing vbacs. I had my first vbac before the rules changed, by a midwife and OB who are very supportive (and still are, but not allowed to do them for insurance reasons) of vbac.

Thank you all for your responses!
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#17 of 27 Old 11-20-2009, 06:11 PM
 
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Well....just so you know, some people have 'homebirth'/hbac in someone else's home or even a hotel, close to a surgery-ready hospital. Something to consider while you're considering options.
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#18 of 27 Old 11-30-2009, 03:29 AM
 
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I interviewed 3 professionals when searching my provider for my VBAC. I heard 3 different perspectives, practices and attitudes. A reminder that doctors and midwives are people who are influenced by their experiences.

It doesn't hurt to talk to a few other physicians and see how they view and handle VBACs.
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#19 of 27 Old 11-30-2009, 03:51 AM
 
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According to the research cited in this article http://www.medscape.com/viewarticle/573948_3 the risk of uterine rupture actually decreases after one sucessful VBAC.

Mother of two spectacular girls, born mid-2010 and late 2012  mdcblog5.gif

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#20 of 27 Old 12-01-2009, 03:14 PM
 
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My VBAC happy ob who attended my first VBA2C, has seen three ruptures over the cuorse of nearly 25 years. One of those was in a first time mother. None of them resulted in a dead baby or dead mom, nor a hysterectomy.

Stinkerton 12/10/01 9lbs8oz, induced to c/s; Little Man 5/20/03 7lbs11oz, r c/s, fear of another labor; Jillybean 11/18/07 10lbs8oz 37cm head, induced VBA2C; and the Wee Beastie, 9lbs8oz, 35cm head, rpt VBA2C
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#21 of 27 Old 12-01-2009, 08:45 PM
 
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Wow - your OB is full of it. 80% risk of the baby dying with any uterine rupture? That's clearly BS - let me just put it that way.

Really, most UR's are very mild and actually either go undetected or are detected only after labor is done with. Huge, catastrophic ruptures are rare and when they happen, with a good team in place, the risk still is not 80% infant mortality. These just are not real statistics!

For my VBAC, I am indeed being induced with a mild dose of pit. I am in a bit of an odd situation: lost my last daughter to placental abruption, and not 100% of all the factors that contributed to that, so this time, I'll need to be in hospital. The only hospital in our area that does VBACs is a half hour away, and actually only has the capability to do them in the daytime - no adequate anesthesia team during night hours. So, in order to get my VBAC, in our current situation, pit will have to be used in small doses.

Because there is noooooOOOoo way I am going to have a repeat C. Not without a good shot at a vaginal birth. And I'm not going to stand there and argue in the middle of labor either, should it happen at night. I'm not afraid - even WITH pit, the risks are low.

Actually ironically, having had one placental abruption, the statistical risk of my having another one is 10%. That's an awful lot higher than a uterine rupture, or the risks of an induction with pit in the middle of a freezing cold Minnesota winter...

If I had your OB, I would switch, pronto. My OB loves VBACs. He's against the current hospital policy of no VBACs at night and wants to change it. I'm going with him, because he respects my birth plan, and will be letting me wear my own clothes, use the shower, the birth ball, push the baby out and labor wherever I want, even with the induction. I don't think I'd feel at all comfortable with someone who was so dead set against VBAC... I don't think you'll get a fair shot at what you want with this OB.

Good luck!

Mama to Josie , lost 10/10/08 at 37.4 weeks .
and my rainbow baby, Isobella Mai ...born 1/12/2010 ! in profile...
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#22 of 27 Old 12-01-2009, 10:51 PM
 
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Really, most UR's are very mild and actually either go undetected or are detected only after labor is done with. Huge, catastrophic ruptures are rare and when they happen, with a good team in place, the risk still is not 80% infant mortality. These just are not real statistics!
Help me understand here. I agree the ob is giving bogus stats, and I agree w/ the mild (iow, not catastrophic) but how are most ur undetected? I mean, how do they know that most are undetected? If you've had a vbac, then they don't see the uterus.


And I'm very sorry for the loss of your daughter. All my prayers in your next delivery.
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#23 of 27 Old 12-03-2009, 04:14 PM
 
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Well if your uterine muscle starts to separate, it's called a uterine dehiscence. Usually after the fact, they can tell because of localized pain - or even, if a healthcare provider for any reason needs to manually detach the placenta. Most mild cases of uterine dehiscence are therefor discovered after the fact, and had no bearing on labor. Sometimes, one needs a little repair, but much of the time in a mild case, the uterus naturally heals on it's own

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#24 of 27 Old 12-05-2009, 02:49 PM
 
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Finally-in regards to catching UR's-I'm making an assumption here, but if you are not using pain meds, your chances of catching a UR quickly go up by leaps and bounds. Think about it-with an epidural in place, a mom will most likely not be able to feel anything, maybe pressure or something being off, but not pain. Now think about how many moms get epidurals. A LOT. The vast majority. Its entirely possible that the baby/mom would've been ok had they caught the rupture early. With mom not being able to recognize a rupture, all they have left to rely on is fetal heart tones and sometimes bleeding/odd contractions (which aren't guaranteed to happen). By the time the fetal heart tones are getting whacky enough to notice, they're already in some serious trouble. Then with all the time it takes to get to an OR, get surgery started, etc....yeah, it can be something like 5, 10 minutes, fast, but when a baby is in major distress, that may not be fast enough.

I personally wouldn't attempt a VBAC with pain meds in place. I WANT to feel the pain and everything else. I want to be able to say "WHOA, that's not right" and get attention immediately. I can't imagine not having some major pain with any sort of UR...although I admit thats an assumption. I should see if I can find anything on that specifically, from moms that have been there. Knowing what to look for yourself can make all the difference!

I had a UR with my HBAC attempt last month. I can only speak for myself, but yes, there is a significant pain involved. My MW decided it was time to transfer after I had been complete and pushing for several hours with no progress. Baby was stuck at +3. There was also an increase in the amount of meconium we were seeing. At some point during the trip from home to hospital, my pain went from the regular pain that comes and goes with contractions to a constant pain that was immobilizing and excruciating and did not go away.

Unfortunately, no one at the hospital believed me when I kept yelling "Something is wrong. This hurts so much. Somebody help me!" They tsked tsked me and wrote me off as just not being able to handle the pain of labor because the baby's heartrate looked great. (as it had the entire labor.) They gave me a shot of some sort of pain med that didn't help at all. They finally checked me and discovered the baby was at zero station. Instead of recognizing this as a sign of UR, (baby ascending back up the birth canal) the doctor just wrote off my MW as being "mistaken" about the +3 she had reported.

It was only after I insisted on a c-section (which was the only way they'd agree to give me more pain meds) that they discovered that I had experienced a UR that had also caused my bladder to rupture in the process. Most likely because of some shotty work by the OB who did my primary cesarean that caused my bladder and uterus to adhere to each other.

Baby was fine. I had to go through 5 hours of surgery to repair my uterus and bladder, but managed to avoid needing a transfusion or hysterectomy.

So, yes, there are signs of UR, but because UR are so rare, many doctors do not know what to look for and rely solely on fetal heart rate as an indicator of something going wrong. I would highly recommend avoiding pain meds to anyone attempting a vbac so that you can insist to your care providers something is wrong if your pain becomes constant and different than regular labor contractions.
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#25 of 27 Old 12-08-2009, 02:38 PM
 
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Originally Posted by forestrymom View Post
The OB who is using scare tactics to attempt to persuade me into another surgery was open about the risks of another surgery. However, his point was that those rarely result in death to the mother or baby, while a uterine rupture often does. What are the risks of death of infant and mother when a uterus ruptures?
My apologies if this has already been said - I didn't read the whole thread yet - but uterine rupture actually does not often result in the mother's or baby's death. Most ruptures are partial and happen rather slowly and may not even affect the delivery, not this big, dramatic rip and you bleed out and that's it. I'll try to find the stats on it - I read about it in Open Season and other sources. If you were induced with pitocin for your first vbac, that actually put you at a slightly higher risk of rupture than if you hadn't been induced, and you were fine. So....yeah, I'd be highly suspicious of your ob's scare tactics. The risks of major surgery are still much higher.

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#26 of 27 Old 12-10-2009, 07:21 PM
 
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Originally Posted by Realrellim View Post
From what I understand, a "window" is not necessarily a rupture. Apparently it's possible to have those for a large part of a pregnancy, and they don't necessarily pose any threat to the baby or mother. I can't remember if I read that in Silent Knife or in Natural Birth After Cesarean: A Practical Guide, but one of them included information on that.
This is in Silent Knife for sure. It is an older book, but it says that there is no actual evidence that having a window is even abnormal, much less a problem. There are probably a lot more than people realize, because often no one checks for them.

Myself, there is something fishy about the stats this OB is using, and I doubt it is because he doesn't know any better.

But why not talk to the MW about it if you are having one?

 I like the mind to be a dustbin of scraps of brilliant fabric, odd gems, worthless but fascinating curiosities, tinsel, quaint bits of carving, and a reasonable amount of healthy dirt.
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#27 of 27 Old 02-19-2010, 07:08 AM
 
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Everything I would say has already been said... but I would HIGHLY recommend you (OP, and anyone else who hasn't ) read Silent Knife. EXCELLENT book, anyone wanting a VBAC should read it!!

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