1 in 200 is not a small risk - Mothering Forums

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Old 10-01-2005, 12:18 AM - Thread Starter
 
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"One in two hundred is not a small risk!" This is a quote off another board on Mothering about the risk of amnio. The discussion basically is that a 1 in 200 chance of fetal death from amnio is not an acceptable risk. This kind of struck me as odd. I have had 2 c-sections. The largest studies put the risk of rupture for me at 1.7%. So that is almost 2 in 100 risk of rupture which could very easily result in the death of my child. Why is that risk considered acceptable for the people here but not the risk of amnio? I know some will say because amnio is not necessary, but neither is VBAC. I have two gorgeous kids from c-section births. I am playing devil's advocate here because I myself AM planning a VBAC but these things still weigh on my mind. I am so terrified to go to the hospital because I fear I will end up with another c-section. But at the same time how can I go with what I was possibly thinking which was to labour and birth at a hotel near the hospital. If my uterus ruptures there is not much chance baby will be able to be saved. So why is the 1 in 200 risk unacceptable but the 2 in 100 risk completely acceptable?

Shawna, married to Michael, mommy to Elijah 1/18/01, Olivia 11/9/02, and Eliana 1/22/06
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Old 10-01-2005, 12:24 AM
 
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nobody really has solid evidence about what the true risk of a catastrophic rupture is - that is, a rupture that endangers the life of the baby.

what is included in those stats are small windows that have opened in the scar long before labor. those small windows are benign and the only way they are ever seen is through a repeat cesarean. it is suspected that many women preg after a cesarean have these small windows in their scars without any stress or issues with their babies (unless the placenta is implanted over the scar, of course). labor does not make these dehesciences, but just strain of pregnancy in general.

I don't buy the `1.7% rate, for what it's worth. That's because I don't feel like many women get a true natural, uninterfered with birth that will reflect an honest statistic. Besides including the window rates in the "rupture" rate, the incidence of full blown catastrophic rupture is extremely rare....much less than 1.7%.

But, everyone has to evaluate risk on their own. It has to be what you're willing to do and live with. However, there are stats for everything...and some throw them out there to make an arguement for their own bias.
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Old 10-01-2005, 01:11 AM
 
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Well..it depends for me on Why the amnio would be wanted..if it is to help the baby somehow, then maybe the 1 in 200 is worth it...but from what i understand, a lot of the time it is "ordered" for less compelling reasons..if there were true benefits, i guess maybe i would do it....as to the rupture,..I agree with the pp, that the 1.7% is not necessarily a good/true stat..but even if it were..then i guess i would say that i find that a more acceptable risk because the baby getting to be born through vaginal (preferably unmedicated) childbirth has specific benefits which outweigh the risk of the possible rupture.....I'm talking about the benefits of labor on the lungs, for example, or the antibodies and bacteria passed to the babe in the vagina, now being linked to things like cavities, etc..as well as the "benefit" of being born when the babe is supposed to..as opposed to an early date picked for a scheduled C/S.......(although technically i guess you *could* just go into labor and have the C/S after a certain amount of labor...but it is my understanding that repeat C/S are normally scheduled at about 38 weeks (at least in my area), to avoid the mom going into labor on her own, so that baby is both a little premature and doesn't get the benefits of labor)...not having drugs is also a huge benefit to the baby..they are just now being honest about how babies born by C/S or vaginal with meds have risks like being more likely to become drug addicts or other types of addictive personalities later in life..the drugs DO have an effect...plus, at some places(like here), C/S babies are put through more "routine" procedures, seperation, monitoring, testing....all of which can't be good for the baby/more traumatic.....

So, long story short, it is simple math, really, weighing risks, and in the case of VBAC, the benefits of a child being born the way it was designed outweigh the risks that a rupture will happen....in MY opinion...while the risks of an amnio often do NOT outweigh the benefits...depending on why it is being done.....(often for little good reason, IMHO).....although certainly there might be situations in which i might decide the amnio risks are worth the benefit...

rambling....

CPST
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Old 10-01-2005, 11:49 AM
 
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Heavenly, when a previously scarred uterus ruptures, the baby almost always survives. Catastrophic rupture happens on unscarred uteri, like when induced with cytotec, or for some unknown reason. I agree with Pam, the "rupture" rate does include dehiscience, which is only seen during repeat c/s, and nobody knows if it is truly an emergency situation, or if many women's uteri don't get that thin during labor all the time anyway. Dehiscience is never catastrophic. It's one of those things docs say "oh! look here!" and use it to justify the surgery after the fact.
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Old 10-01-2005, 11:58 AM
 
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It's not true that dehiscence is never catastrophic. I have a dear friend who recently lost her newborn baby after a catastrophic rupture. There was no labor augmentation, no medication, no unnatural intervention-- nothing that would have increased her chances of rupture. It's incredibly rare, but it does happen. To tell women that it doesn't makes it impossible for them to make informed choices. I'm a vehement VBAC supporter, but there are no circumstances that make it completely without risk.
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Old 10-01-2005, 12:26 PM
 
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I think that the big difference in the statistics for amnio and the statistics for uterine rupture in VBAC are that an amnio is an optional diagnostic tool. I received some pressure to have an amnio with dd #1 b/c of my AFP test results (never will do that again!), but for me, NO risk was acceptable for a diagnostic test that wouldn't change my pregnancy plans.

Birth, however, is not optional. :LOL It's not like your options are either have a VBAC or keep the baby in there forever. For me, the statistic that really mattered was NOT the rate of rupture in a VBAC, but the fetal death rate for VBACs vs. elective repeat c/s. And those numbers are essentially the same. Plus there are so many more risks for mom with a repeat c/s.

Keep the faith! Planning a VBAC is *at least* as safe for your baby and safer for you.
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Old 10-01-2005, 01:22 PM - Thread Starter
 
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RachelGS - I completely agree. How is it INFORMED choice if pro-VBACer's gloss over the risks. People need to know about all possible outcomes before making a decision. I was talking about this with my DH last night, how it upsets me that on Mothering (love these boards but this bugs me!) people complain so much about people not making informed decision but then turn around and completely gloss over any risks about the choices THEY have made.

Yes I know statistically c-sections bring a higher risk of complications. But this is compared with a normal vaginal birth. So yes 98-99% of the time the c-section has more risks. But 1-2% of the time vaginal birth is definately NOT less risky when the uterus ruptures. I don't think it is fair to say well c-section death risk is 1 in 2000 (just making up these figures for argument sake) and vaginal birth death risk is 1 in 6000 so VBAC is definately safer. It doesn't do anybody any good to not acknowledge that as a VBAC mother you have a chance of rupturing and that does make your vaginal birth risk higher than a non VBAC mom. That seems pretty obvious to me.

As for ruptures not being catastrophic go to google or search.com and type in uterine rupture. You will find many, many women who would not agree with that. Again, it does nothing for the VBAC movement to gloss these risks over. Fine, say they are risks you are willing to take but don't condemn another mom who decides with ALL the available information that it is not a risk she is willing to take. Again I AM planning a VBAC but I still think the risks of it are not acknowledge nearly enough on these boards. I know we have a member on here whom I'v pmed with about this issue who just lost her baby in May. She was in hospital with no drugs whatsoever, no pitocin, nothing. But her uterus ruptured and she lost her baby. Don't dishonor her baby's memory by claiming that ruptures are usually not catastrophic. If you are the one it happens to you will not think a 1 in 100 risk is very small at all.

Shawna, married to Michael, mommy to Elijah 1/18/01, Olivia 11/9/02, and Eliana 1/22/06
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Old 10-01-2005, 03:27 PM
 
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It was not my intent to offend. When I was doing my research (and granted, my vbac was nearly two years ago) I found that catastrophic rupture is very rare, and much more common on an unscarred uterus than on one with a previous incision/scar. You have to do your own research, read all the information available, find the studies themselves, and weigh those risks for yourself, given your unique situation. The % are just averages, and only for those included in the studies. Your risk may be higher, or it may be lower, depending on lots of factors. And there are no absolutes. There are no guarantees with anything that your baby won't die, or yourself for that matter. There's always a chance something might go terribly wrong. We live with those risks all day every day. I didn't mean to minimize the pain others might have. I'm very sorry.
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Old 10-01-2005, 04:11 PM
 
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"It doesn't do anybody any good to not acknowledge that as a VBAC mother you have a chance of rupturing and that does make your vaginal birth risk higher than a non VBAC mom."

Rupture is possible even when there hasn't been a previous cesarean. But yes, you're right that VBACs are at a slightly higher risk statistically, and part of the reason why that is has to do with how labor is commonly managed in our society. So that level of risk may not apply (i.e. be considerably higher or lower) given an individual's unique circumstances -- it's not arbitrary, there is a cause and effect at work, and sometimes we can take precautions against certain causes.
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Old 10-01-2005, 06:39 PM
 
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As was stated, that percent, which sounds very high to me (I thought with 2 c/s it was more like 1% for some reason), includes all dehicences and major ruptures. When you take out the dehicencs you get a catastrophic rupture rate of .05% or 1 in 2000 (this number is taken from the Dec 04 study). With the rate for an unscarred uterus rupturing being 1 in 3000. Birth has risks no matter whether your a first time mom or a mom of many.... whether you've only had vaginal births or only had c/s's. It's just a matter of what risks you're will to take. For me the benefits of vaginal birth and this one very rare risk outweighed the multiple minor and major risks associated with c/s, almost all of which were more common than catastrophic rupture. Just my 2 cents of course.
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Old 10-01-2005, 09:03 PM
 
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I've been looking at VBAC stuff online too, and what I've seen about uterine ruptures indicates that they are almost always brought on by drugs that induce or augment labor. For some reason, docs seem to like to induce VBAC moms, which is horrifying if you consider that their uteri have already been compromised by the previous surgery and are even less suited to handle these unnatural substances than a normal woman's. What I take from all of this is the classic line "JUST SAY NO TO DRUGS!"

Also, as other posters have pointed out, uterine rupture is not the only risk (or inconvenience) of C-S for mother and child. The overall maternal death rate with C-S is 400% higher than with vaginal births and is 200% higher when the C-S is planned (i.e. not an emergency procedure.) Then there are other complications from anaesthesia, etc. etc. But that territory is well covered elsewhere.
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Old 10-01-2005, 09:11 PM
 
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Oh yeah, definitely say no to drugs! And we must remember that all the studies are done on hospy birthing mamas with EFM, drugs, on their back and all the crap that causes c-sec in first time mamas so why would it be surprising when it leads to c-sec again? If the recent hb study in the British Medical Journal showed a 3.7% c-sec rate for all the mamas in it, then obviously staying home is far better and safer. There would have been VBAC mamas in that study since the only place we can achieve evidence based care is at home and away from the surgeons. Birth is as safe as life gets, and like life, there are no guarantees. A percentage of all births will end in a c-sec but the percentage is almost entirely dependant on the model of care you choose. Pick a surgeon, get surgery!
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Old 10-02-2005, 11:06 AM
 
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There are definately vbac moms in that study since I have signed on to help with the next phase of their research.
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Old 10-02-2005, 12:33 PM
 
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Quote:
Originally Posted by Heavenly
As for ruptures not being catastrophic go to google or search.com and type in uterine rupture. You will find many, many women who would not agree with that. Again, it does nothing for the VBAC movement to gloss these risks over.
I believe you misunderstood the meaning of my words. By catastrophic, I meant that someone, either the mother or the baby, dies. Most "ruptures" are not catastrophic in that sense of the word. The medical establishment emphasizes the very worst case scenario to frighten women into compliance. It is manipulation through fear and intimidation, and unfortunately it works. Yes, I'm very passionate about it, and I will continue to speak out very loudly whenever the subject arises.
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Old 10-02-2005, 05:36 PM
 
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Well, I am the aforementioned friend of RachelGS and also the mama mentioned by Heavenly. I had a uterine rupture in April and lost my baby. Since then, I have read and re-read in great detail all the info that I can find available related to uterine rupture in an attempt to process and understand what happened to me.

If you read the NEJM December 2004 study, the risk of rupture with NEITHER augmentation NOR induction is .4% (or about 1 in 200). The rupture rate is actually higher for women who are induced or augmented. Note that rupture rate does NOT include dehiscences in this study, just ruptures. The study puts the risk of perinatal death from rupture at 4 in 10,000 (or 1 in 2000) for those choosing TOL and at 1.4 per 10,000 for those choosing ERCS. Both are low. Rates of maternal death are slightly higher in the ERCS group, but overall maternal complication rates were actually highest in the group that had a failed VBAC.

One thing I have learned since my experience and that is not really talked about is what happens to the babies who do NOT die from UR. Most go on to live normal lives. But many do not. Many have issues ranging from minor developmental delays to severe, severe CP. I belong to a Yahoo Group for women who have had a uterine rupture and many of the women with UR survivor children have a life long battle ahead of them in raising their children. I have learned that sometimes there are things worse than having your baby die, as hard as that is to believe. One woman on my group recently tried to kill herself.

Now the thing to think about is what does all this mean. I lost my child in a UR. But there have been many (too many) mamas on MDC lately who have lost their newborn babies for completely unrelated reasons. Birth accidents happen. Sometimes babies die.

I will say that while I remain convinced of the overall safety of attempting VBAC (under the right circumstances), I personally now have a hard time urging other women to have one. I know that I wish every day and will for the rest of my life that I had endured 100 unnecessary cesareans to have my Leah back in my arms. I DO urge women that I can influence to avoid primary cesareans if at all possible.

One thing that irritates me is when I read things like "if you aren't induced, aren't on your back, you won't rupture". Well, thats simply not true. Even if you do all the "right" things, you can have a UR. While aumentation and induction and other things can increase the risks of UR, you ultimately can't know who will rupture and who will not. Of course ERCS is not without its risks, but a scarred uterus is a scarred uterus and as such is more likely to rupture than an unscarred one.

Here is a link to some criteria recently developed in Britain which tries to predict who might have an emergency C-section during a VBAC attempt. Interestingly, I met 3 of the 6 criteria (older, shorter, no history of prior vaginal birth). http://www.medpagetoday.com/OBGYN/Pregnancy/tb/1734

Honestly, I'm not sure what the point of this post is. I just think its important for women to fully understand their choices. I know that if I had really believed "it could happen to me", I would never have attempted a VBAC. There are just no guarantees in anything and you have to be able to live with the result of your choices.

New WOHM to DD8 and DD3
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Old 10-02-2005, 06:33 PM
 
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Rachel, a dehiscience is NOT a catastrophic rupture. By definition, dehescience means a small button/window opening. This only poses problems when the placenta is adhered over such an opening.

As an aside, the rates for women who have never had surgery and experiencing a catastrophic rupture and women who are VBACs experiencing the same are too similar for my comfort level. Let us not forget that in this current time of frequent induction - especially with things like Cytotec or prostaglandin gel - many women have experienced uteruine rupture.

The rates of serious complications of cesarean to the mother - including hysterectomy, shock, amniotic fluid embolism, disemminated intravascular coagulation, and death - are very similar to those of the catastrophic uterine ruptures.

I think it just depends on what a person feels comfortable with. Hindsight is always 20/20, it's what make litigation around birth so successful.
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Old 10-03-2005, 12:45 AM
 
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With any risk analysis, you look at the benefits on the other side. So when some argue amnio isn't an acceptable risk, they mean in terms of the benefits it provides, ie, mostly knowledge (I'm not judging, just trying to set out what is to me the picture). The benefit vs risk analysis of VBAC is against c-section, which has it's own risks and benefits. So it's more complicated really than the amnio analysis, and risks are traded for risks, whereas if you don't have an amnio, mostly you risk not knowing something sooner that you probably will find out later, although obviously with some amnio detectable problems, you might risk not planning for immediate post birth care that is necessary for some types of problems that you would do if you knew for sure because of the amnio. Whereas with cs v. VBAC, you have to look at the risk of uterine rupture and other problems that could happen with any vaginal birth vs risk of surgery plus risk of severe placental problems in subsequent pregnancies if you think you want more kids. The numbers aren't as solid on placental accreta, etc. but from what I've seen, the risk of having one is something like 0 .8% after 2 c/s, and exponentially higher than that after 3 (not sure of the number though), so that's higher than the risk of just having a uterine rupture. Then there's all the hormonal, breastfeeding, postpartum depression, etc. considerations. Oh yeah, and medical mistakes. I'd really like to see a number on THAT one for VBAC v c/s, but I'm not holding my breath.

There are definitely no guarantees. Uterine rupture happens, so does shoulder dystocia and hypoxia for other reasons when everything is done "right" (although obviously induction increases the risk). There are plenty of problems, including uterine rupture and including other problems that in the aggregate are more common than uterine rupture that require a c/s that sometimes aren't done in time for various reasons, but although some doctors would actually advocate limiting all women to 2 to 3 children and everyone having a c/s for every baby (that to them seems the least risky way to do things), it seems to me that this would create in the end more problems than it would solve.
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Old 10-03-2005, 01:04 AM
 
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Originally Posted by aprilushka
....but although some doctors would actually advocate limiting all women to 2 to 3 children and everyone having a c/s for every baby (that to them seems the least risky way to do things)...
Isn't that just sick? They have no idea what a woman's life is like or why she might want more kids. And, why do they persist in seeing major surgery as the "safe" alternative???

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Loving my amazing dh, James & forever missing ribbonpb.gif Aaron Ambrose ribboncesarean.gif (11/07) ribbonpb.gif

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Old 10-03-2005, 10:04 AM
 
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For me an amnio is about more than just risk... I have more chance of being in a car accident or being mauled by a dog after walking out my own front door. I personally would never have an amnio, mainly because the results would make no difference to me therefore making it an uneccessary invasive procedure.
Life is about risk, it is up to every individual to make the choice about which ones we want to take. Having a VBAC to me is less risk than I would have, driving everyday. Having an amnio for me however is more than just physical risk.
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Old 10-03-2005, 11:34 AM
 
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Rachel, a dehiscience is NOT a catastrophic rupture. By definition, dehescience means a small button/window opening. This only poses problems when the placenta is adhered over such an opening.
Oops. My original post had another sentence in there. I kept debating about whether to post and editing. I know dehiscence and catastrophic rupture aren't the same thing. What I had originally written (and was less clear about when I edited) was twofold: that dehiscence is not entirely without risk and that catastrophic rupture does happen.

I remain a very staunch VBAC supporter. But I do think that the risks are glossed over quite a lot, and I don't think that helps women make choices. And just from my personal experience as someone who loves Beth and Leah, it feels dismissive and dishonoring to Leah's memory (and the memories of other babies like her) for people to talk as though these are just numbers and that nothing awful ever happens. That's what I was responding to in posting.
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Old 10-03-2005, 12:01 PM
 
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Quote:
Originally Posted by pamamidwife
nobody really has solid evidence about what the true risk of a catastrophic rupture is - that is, a rupture that endangers the life of the baby.

what is included in those stats are small windows that have opened in the scar long before labor. those small windows are benign and the only way they are ever seen is through a repeat cesarean. it is suspected that many women preg after a cesarean have these small windows in their scars without any stress or issues with their babies (unless the placenta is implanted over the scar, of course). labor does not make these dehesciences, but just strain of pregnancy in general.

I don't buy the `1.7% rate, for what it's worth. That's because I don't feel like many women get a true natural, uninterfered with birth that will reflect an honest statistic. Besides including the window rates in the "rupture" rate, the incidence of full blown catastrophic rupture is extremely rare....much less than 1.7%.

But, everyone has to evaluate risk on their own. It has to be what you're willing to do and live with. However, there are stats for everything...and some throw them out there to make an arguement for their own bias.
The 1.7% includes those that had cytotec and pitocin. The most accurate stats for unaugmented labor are .5% - or 1/200! And no, those are not all catastrophic ruptures. Many are 'failure to progress - c/sec - WHOA! uterus is found to be ruptured' or a similar scenario.
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Old 10-03-2005, 12:06 PM
 
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Originally Posted by pamamidwife
I don't buy the `1.7% rate, for what it's worth. That's because I don't feel like many women get a true natural, uninterfered with birth that will reflect an honest statistic. Besides including the window rates in the "rupture" rate, the incidence of full blown catastrophic rupture is extremely rare....much less than 1.7%.
This was a point I got stuck on in the op too.

Studies formed to come up with these percentages are often skewed.

I would be more interested in seeing a REAL study done where the births are all drug free and natural, and then see the percentages based on that.
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Old 10-03-2005, 01:05 PM
 
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Beth, (Egoldbr) --I am so sorry for the loss of your precious daughter Leah.
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Old 10-03-2005, 06:08 PM
 
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Beth, I am also sorry to hear of your loss
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Old 10-03-2005, 06:19 PM
 
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I was like the OP, I really struggled the entire time I was pregnant with dd#2, couldn't decide which was better in our situation: a 2nd c/s or a VBAC. Finally I decided that for me personally, I felt safest trying for a VBAC in a hospital. It was the right decision for me. My best advice is to research, talk with your HCP and make the best decision you can for you/your baby.

I'm glad this board is here; the current climate seems to be anti-VBAC (although really more for legal reasons than medical ones IMO) and I think its very important to hear/read everything and make up your own mind
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Old 10-03-2005, 07:11 PM
 
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Sorry for the thread hijack, but I had a look at the link to the British article posted by egoldber and couldn't make sense of their data. (Yes, I almost failed Stats 101 a few years ago).

Could someone out there break it down?

Maternal age (adjusted odds ratio=1.22 per five-year increase, 95% CI: 1.16 to 1.28).
Maternal height (adjusted OR=0.75 per five-centimeter increase, 95% CI: 0.73 to 0.78).
Expecting a male baby (adjusted OR= 1.18, 95% CI: 1.08 to 1.29). The study did not explain the gender difference.
No previous vaginal birth (adjusted OR=5.08. 95% CI: 4.52 to 5.72).
Prostaglandin induction of labor (adjusted OR=1.42, 95% CI 1.26 to 1.60).
And birth at 41 weeks gestation (adjusted OR=1.30, 95% CI 1.18 to 1.42) or 42 weeks gestation (adjusted OR=1.38, 95% CI: 1.17 to 1.62) compared with 40 weeks gestation.

Egoldber claimed to be "older and shorter," but how old and how short must one be to get how much risk? Where do the tables begin and end?

Thanks for any help with this.
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Old 10-04-2005, 10:58 AM
 
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Isn't that just sick? They have no idea what a woman's life is like or why she might want more kids. And, why do they persist in seeing major surgery as the "safe" alternative???
Because they feel more in control with a surgery, where they feel like they are controlling the circumstances. When a woman's body is working on it's own, they are not in control. Hence, it feels safer for them (aside from the legal considerations, which of course, point to c/s from their point of view in a big way).
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Old 10-04-2005, 03:33 PM
 
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I actually have a lot of sympathy with the doctors on the legal front. I wouldn't much care for it if I went ahead and supported a woman who desperately wanted to VBAC, then she turned around and nailed me to the wall in court if something went wrong. Plus, there's not much they can do if their malpractice insurers won't play ball. But, it's so disgusting that it's ever reached this point.

Lisa, lucky mama of Kelly (3/93) ribboncesarean.gif, Emma (5/03) ribboncesarean.gif, Evan (7/05) ribboncesarean.gif, & Jenna (6/09) ribboncesarean.gif
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Old 10-04-2005, 03:47 PM
 
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Does anyone have any stats on your chances of successful VBAC if you have already had one successful VBAC?

I had vaginal birth 1997
C-sec 2000
VBAC at home 2003
Due to try another VBAC at home 2 weeks from now

I dont know if this is OT, I just was getting into all the stats!
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Old 10-04-2005, 07:19 PM
 
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I actually have a lot of sympathy with the doctors on the legal front. I wouldn't much care for it if I went ahead and supported a woman who desperately wanted to VBAC, then she turned around and nailed me to the wall in court if something went wrong. Plus, there's not much they can do if their malpractice insurers won't play ball. But, it's so disgusting that it's ever reached this point.
Sure, I don't expect them to put their careers on the line for me. That's one reason why I'm HBACing. Nonetheless, if for whatever reason I have to deal with a doctor, in a push between them and my baby and I, it's going to be baby and me. I'm not going to change my family planning or have unnecessary surgery just because it's more convenient for them.

On the other hand, the legal thing is exaggerated somewhat-- truly informed women who choose VBAC really understanding the real numbers and risks, how relative those risks are to other risks, the risks of induction and so forth, and who are treated with respect by their care provider, are much less likely to sue. Part of the suing is a result of the god auora doctors and society have created for them, lack of true informed consent (which requires probably a 2 hour conversation rather than a 20 minute one) and their technology as well as callous treatment.
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