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Originally Posted by majikfaerie
I really believe that the risks of doing a VBAC with a classical incision are still less than the risks of repeat C-section,
|with a HBAC the risks are even less.|
|I think an important consideration is that the major fear is uterine rupture, which is a term used to describe any opening of the previous scar. the problem with this is that the majority of these "ruptures" are totally benign and do not cause any complications for the pregnancy or birth (in fact, many of them occur LONG BEFORE labour begins!)|
|It never happens that mother and/or baby dies on the spot.|
|I'd say the best plan (assuming the mother and baby are healthy) is to go for a homebirth with a good midwife or doula and have easy access to a hospital if needed (even if labouring IN the hospital, they still take 10 - 15 minutes from "descision to incision" in EMERGENCY cases, and often much more.|
|Rate of rupture for a classical incision is between 1 and 3 percent.|
Originally Posted by majikfaerie
just looked it up quickly,
Quotes "Maternal Mortality in Cesarean Section as Compared to vaginal Delivery", Krone, H.A., Fortschrift Med. 1975
Originally Posted by wifeandmom
I prefer to base decisions on medical research a bit newer than 30+ years ago myself.
Originally Posted by kathan12904
It interesting that you say that, because a large number of the obstetrical procedures performed routinely in hospital births today are based upon theories and statistics that date back to the 1960s, even further in some cases. And I personally don't think its any coincidence that that is the approximate time when women stopped allowing themselves to be routinely "knocked out" during the actual birthing stage, but thats not so much documented fact as hypothesis based on research.
|Which Women Have Ruptures?
Any woman can have a rupture. This includes women who have never had a csec before. The risk to some women is however higher than for other women. Here is a breakdown (refs 1,2,3,5,6,7,10,16,17,,20,21,22,23,27,28):
•Of all women who go into labour the risk of rupture is 0.017 - 0.07%
•Of all women with a previous CSEC the risk of rupture is 0.068 - 1%
•If the previous CSEC was ;
•- classical 4 - 9 %
- horizontal lower segment 0.2 - 1%
- vertical lower segment 1 - 7%
- T or J incision 4 - 9%
•The risk for women who have had five or more pregnancies (grand multiparity) is also recorded as being higher there were no quoted statistics in any of the articles. In ref 20 they had 13 ruptures and 2 of these were due to grand multiparity.
•There is also a risk of rupture where there is a trauma to the abdomen. A number of the studies cited ruptures resulting from vehicle accidents.
•If you had a first trimester abortion (at some time) your risk of rupture is 1%
•If you have had a hysterotomy or uterine operation (eg fibroid removal) your risk is 6%
Of all uterine ruptures recorded in four studies:
Study one 42 ruptures 71% VBAC 29% in unscarred uterus(ref 5)
Study two 23 ruptures 43% VBAC 57% in unscarred uterus(ref 17)
Study three 480 ruptures 92% VBAC 7% in unscarred uterus 1% in non csec scarred uterus (ref 23)
Study four 81 ruptures 89% VBAC 11% in unscarred uterus(ref 27)
(These studies do not breakdown what types of scars the VBAC had and do not distinguish between ruptures and dehiscences).
It should be noted that in a number of the references there was no indication if the women who were recorded with ruptures had been in labour or not.
I could not find any studies in references that indicated a higher risk of rupture in women with macrosomic (large over 4kg) babies, twin pregnancies or breech deliveries. Ref 33 indicates there were no significant differences in death or injury in VBAC women with babies over 4kg, it also indicated of the recorded twin VBACs there were no ruptures and of the recorded breech there were no significant differences, however it indicated the preference was to do external version on breech babies. (Also a safe practice for VBAC mothers).
Can They Predict If I Will Rupture?
Ref 10 quotes a British study that involves measuring the thickness of the lower uterine segment by ultrasound late in the last trimester of pregnancy (over 35 wks). The study indicates that in women with the thickest lower uterine segments there is a very low chance of rupture. However the study also acknowledges that even for women with the thinnest lower uterine segments the risk of catastrophic rupture is still very small and can be offset with vigilant labour monitoring.
There are no major studies on the identification of a dehiscence however in this same study the sonographers believed they would be able to see dehiscence at the scar site using ultrasound. Given that dehiscence are considered benign I would wonder what the benefit of this would be as there are no studies that correlate the presence of dehiscence with a higher rupture rate, (mind you there are also none that disprove it either).
So how often do these things occur:
Study 1 9 ruptures 2 still born (22%)
(of the nine ruptures there were 2 classical csecs and 6 LSCS and one non scarred, the study does not say which of these mothers lost their babies)
0 hysterectomies and 0 maternal deaths (ref 7)
Study 2 155 ruptures 8 fetal deaths (5% - 5 occurred in mothers who arrived at hospital ruptured) 1 maternal death (doesn't indicate if this was a TOL or unscarred) (ref 10)
Study 3 17 ruptures 0 deaths 8 hysterectomies (ref 13)
Study 4 1 rupture 0 deaths (this rupture was in an elective repeat csec) (ref 14)
Study 5 23 ruptures 0 deaths (ref 18)
Study 6 13 ruptures 0 deaths (ref 20)
Study 7 8 ruptures 1 fetal death (12.5%) 2 severe fetal asphyxia (oxygen deprivation) 3 bladder lacerations 1 hysterectomy (ref 22)
Study 8 10 ruptures 2 fetal deaths (20%) (ref 26)
Study 9 81 ruptures 2 maternal deaths (2%) (these were a mix of scarred and unscarred uterus) 14 bladder injuries 12 hysterectomies 5 fetal deaths (6%) 14 neonatal deaths (17% - after birth deaths - the cause of these deaths is not given) 59 fetal brain damage (72% - the degree of damage is not indicated and it does not indicate if the 14 neonatal deaths are also included in this group) (ref 27)
If we add all of this up we have 317 reported ruptures, 30 (9.5%) fetal death rate, 3 (0.95%) maternal death rate and 61(19%) of babies with some degree of brain damage from oxygen deprivation (this may be minor or major).
To put this into perspective given that the VBAC mothers risk of rupture is around 1% , you have a (0.095%) chance of your baby dying due to rupture in any VBAC delivery, a 0.0095% of you dying due to rupture in any VBAC delivery and a 0.19% chance of your baby suffering brain damage due to a rupture in any VBAC delivery. (Contrast this to the other risk identified below).
The studies all indicated that one of the primary causes of death amongst mothers and infants was mismanagement by hospital staff. A number of the reports sited ignorance among staff of the symptoms of rupture and/or a slowness to act thus compromising both the mother and the child. The generally agreed treatment was that csec needed to be conducted within 30 mins of suspected rupture with some practitioners indicating this figure should be closer to 17 mins.
•Peripartum haemorrhage by Dr Sanjay Datta, MD, FFARCS
•Common Peripartum Emergencies by Dr Elizabeth Morrison American Family Physician Journal Nov 1 1998
•Once a CS always a Controversy by Dr B L Flamm ACOG Journal Vol 90 No2 Aug 97
•The Risks of Lowering the Caesarean Delivery Rate by Dr B Sachs MB, BS, DPH, Dr C Kobelin, MD, Dr Mary Ames Castro, MD and Dr Fredric Frigoletto, MD, The New England Journal of Medicine, 7 Jan 1999, Vol 340 No.1
•Induction of Labour and Uterine Rupture by Dr R Foon SHO, CESDI Steering Group 5th annual report 1997: 63-71
•Vaginal delivery after previous csec remain relatively safe by Dr Gregory and Dr L Korst, MD and Dr P Cane PhD Obstetrics and Gynaecology 94(6), Dec 99 pp 985-989
•Coombe Women's Hospital Obstetric Report 1998
•Genital Tract Trauma and Other Direct Deaths: Annual Report of The Maternal and Child Health Research Consortium London Jul 1998.
•Will VBAC become a way of the past OBCNEWS Issue 15.3, 13 Jul 1999
•ICAN /VBAC / Caesarean Webpage
•Recognising Problems in Labour by T. Stevens (Midwifery Research Practitioner)
•VBAC - Vaginal Birth After Caesarean or Very Big Authority Challenge? by B. Beech and P Thomas, AIMS Journal, Vol 8 No. 1 30 Apr 96
•Cases of Uterine Rupture and Subsequent Pregnancy Outcome by Al Sakka, Dauleh and Al Hassani of the Hamad Medical Corporation. International Journal of Fertility & Womens Medicine Nov-Dec 99.
•Delivery after Scarred Uterus at the University Hospital Centre of Dakar by Cisse, Ewagnignon, Terolbe and Diadhiou Journal de Gynecologie, Oct 99
•Vaginal Birth after Caesarean and Uterine Rupture Rates in California by Gregory, Korst, Cane, Platt and Kahn. Obstetrics & Gynochology Dec 99
•Intrapartum uterine rupture and dehiscence in patients with prior lower uterine segment vertical and transverse incisions by Shipp, Zelop, Repke, Cohen, Caughey and Lieberman. Obstetrics & Gynecology Nov 99.
•Rupture of the pregnant uterus a 21 year review - Sakka, Hamsho and Khan. International Journal of Gynaecology & Obstetrics Nov 98
•Vaginal Birth after Caesarean results in 310 pregnancies by Obara, Minakami, Koike, Takamizawa, Matsubara and Sato. Journal of Obstetrics & Gynaecology Research Apr 98.
•Intrapartum rupture of the unscarred uterus by ******, Goodwin, Gherman and Paul. Obstetrics and Gynecology May 97.
•Risk Factors Associated with Uterine Rupture during TOL after CSEC by Leung, Farmer, Leung, Medearis and Paul. American Journal of Obstetrics and Gyynecology May 93
•Rupture of low transverse csec scars duritng trial of labour. THe Journal of the American Medical Association 18 Sep 91
•Use of Hospital Discharge Data Monitor Uterine Rupture - Massachusetts 1990 - 97. Morbidity and Mortality Weekly Report 31 Mar 2000
•Use of Prostaglandins to induce labour in women with Csec scar by Vause and Macintosh. British Medical Journal Apr 17 1999.
•Csec Scar dehiscence following vaginal delivery by Connoly and Byrne. Journal of Obstetrics and Gynaecology Vol 19 No 6 1999
•Trial of Labour after Csec by McMahon, Luther, Bowes and Olshan. New England Journal of Medicine 1996.
•Catastrophic Uterine Rupture: Maternal and Fetal Characteristics by Kirkendall, Jauregui, Kim and Phelan. Obstetrics and Gynecology 2000
•Uterine Rupture: A placentally Mediated Event? by Jauregui, Kirkendall, Ahn and Phelan. Obstetrics and Gynecology 2000
•Uterine Rupture During a Failed Trial of Labor: Are There Any Identifiable Risk Factors in Labor Management by Burke, Lee, Harish, Sehdev and Ludmir. Obstetrics and Gynecology 2000
•Vaginal Birth After Prior Cesarean by Dr C Brittan. Jul 99.
•Delivery After Previous Csec: A Risk Evaluation by J Rageth. Obstetrics and Gynecology 1999.
•Medical Abortion Complications by D Nemec Obsterics and Gynecology Apr 78
•Cesarean Section: Guidelines for Appropriate Utilization by Dr B Flamm and Dr E Quilligan.
Originally Posted by wifeandmom
All of this 'I know so-and-so who had a VBAC after however many classic incision c-sections' isn't truly relevant IMO.
Just because something 'can' be done, or 'has' been done by someone, somewhere in the world with no serious consequences doesn't mean it is or was the statistically safest decision to make at the time.
Originally Posted by crunchymomof2
No but sometimes it can be nice to know that other women have btdt and lived to tell about it.
Originally Posted by kathan12904
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