Single layer closure - Very bad day! - Mothering Forums
VBAC > Single layer closure - Very bad day!
annekevdbroek's Avatar annekevdbroek 12:36 PM 11-03-2006
I had a VERY bad day yesterday during my 29 week midwife appointment. I've already bounced around providers trying to find someone who was VBAC friendly and with who I felt comfortable. Anyhow, she finally received my medical records from my c/s (performed before we moved here) and said I was no longer a canidate for VBAC since the surgeon had used a single layer closure. I was too upset (e.g. cried in her office for 45 minutes) to ask other questions at the time or sort out my thoughts. She did tell me she doesn't know of anyone in the area who will do a VABC after a single layer closure (more than 3 years ago).

I spent the afternoon/evening in tears (now I am dehydrated and have a headache). The research on VBAC after single-layer closure is mixed, some saying it is the same as double layer closure, others saying it is more risky. My husband is going to get a copy of the ACOG VBAC position paper for me today.

Anyhow - Now what? How would I find another provider? Is this a typical policy? If I decide to go to battle over this, who am I fighting: the hospital? The individual OB? Who? How?

I can't even being to process the anger I have towards the doctor who performed the first c/s. I feel a bit like I've been raped; my body has been taken from me. My husband wants to sue if there are grounds (and DH is a doc - generally quite againsts suing) and file a a complaint with the licensing board. Right now I want to put my energy into resolving the hurdles of this birth. Maybe later I can go after that OB to try to insure that he doesn't do this to any other women.

Anyhow - in the meantime advice, support, information would be most appreciated.

logan&jordansmommy's Avatar logan&jordansmommy 12:44 PM 11-03-2006
Oh my gosh I am so sorry you are going through this. Unfortunately I don't have your answers but I know someone will. Have you tried looking at and/or asking on their forums? I am sure someone here will have info too.
Are you open to homebirth? I wonder if any HB mw's would do it.
subha's Avatar subha 12:46 PM 11-03-2006
hi ,

i had a single layer closure for my first emergency ob said i am ok to do VBAC ..but now she is telling me that the gap between deliveries must be atleast 18 months else the risk of rupture is high my case i have a 17 month gap..i was strong in going for VBAC ,but the baby is transverse now(38 week 4 days)..i am going to a chiropractor hoping this baby would turn and try VBAC no matter my OB says..

have hope there is a power more than these doctors...
kathan12904's Avatar kathan12904 01:57 PM 11-03-2006
I'm in the single-layer closure boat as well, but fortunately, my mw is unfazed by it. Have you considered mw care, they are generally more willing to oh, you know, relax. There is a division amongst healthcare providers about the safety of single closure vbac, but it is by far not the most important factor to consider. Time between pregnancies and amount of difficulty during original healing (infection and such) are far more important. If you search the net, you will find that only one study has ever shown an increased risk with single layer closures and that was almost 20 years ago. Since then, there are a plethora of studies that show it is perfectly safe and in some results, women with single were less likely to rupture than women with double. The philosophy about double is that more scar tissue will make a stronger seal than less. However, the philosophy with single is that it takes less time to close up during surgery, so you are exposed to germs for a shorter time, so I wouldn't get too upset at your OB quite yet, and if you knew me, you'd know I am very anti OB, so this must be true I don't know if your bubby's ACOG info is going to support this, they tend to be a little slanted and often way overly cautious due to covering their behinds from a legal perspective. Check out ICAN, Midwifery Today, and put single layer closure vbac into yahoo. This should provide you with a good seleciton of information to go over. As far as seeking a better health care provider, I am all for it. It may seem daunting and frustrating, but finding someone you feel comfortable with is the key to geting the best birth possible. I ended up with my c/s for a number of reasons, but I knew part way through pregnancy that this OB was not the guy for me. I didn't do anything about it because I was young, didn't have ins. and didn't have a clue how to find midwives in a state where their practice is outlawed. This time around, (due 02/07) I've found a woman who is everything I could have ever wanted in a mw and we get along great. I've been nothing but happy and relaxed throughout this whole pregnancy and am confident that she will help me achieve the birth I really want. In this scalpel happy country, we really have to fight for our vbacs. Good luck!
warrior mama's Avatar warrior mama 02:16 PM 11-03-2006
I have a single layer closure and no-one has mentioned (both MD and MW) problems with it. I do believe that single layer is the standard these days. Arm yourself with research and keep fighting. Some providers are just looking for an excuse, IMO.
annekevdbroek's Avatar annekevdbroek 06:01 PM 11-03-2006
I have been seeing a midwife for my care... Thank you everyone for your responses. There are only two hospitals in the area that will even do VBACS, and the one the midwife works at will not do them after single-layer closures. I have to make some calls today. Thanks for the links, referrals, etc. I am also planning to examine options in a city 100 miles away.
ckhagen's Avatar ckhagen 12:02 AM 11-04-2006
I saw a midwife for my VBAC (a homebirth midwife... big difference between that and a hospital midwife in most cases unfortunately).
My OB did not even write a record of my surgery, so I had no idea what closure I had. But, my mw had seen many former patients of my OB and said they were all single layer closure. I asked if that was going to be a problem and she said absolutely not. She doesn't believe that the single layer closure is an increased risk because IIRC... It takes longer to do a double-layer closure, which leaves you exposed for longer and more likely to contract an infection which is more likely to cause a weak scar. So, it wasn't an issue for me thankfully.
PennyS's Avatar PennyS 11:49 AM 11-04-2006
I am really surprised by her comment. I had a single-layer closure with Ds1 and had a hospital VBAC 15.5 months later with Ds2. My OB had no worries about this and said that the scar is well-healed within 6 months. Good luck in your continued search!

(BTW - the one study I looked at comparing single v. double IMHO was flawed b/c it did not take into account that many women with the single-layer had their labor induced or augmented by a variety of methods (pitocin, cervadil, cytotec, etc.)
Ms Ladybug's Avatar Ms Ladybug 02:33 PM 11-04-2006
I had a double layer closure, but my VBAC OB never even asked for my records, and never asked me what kind of closure I had - like it wasn't an issue.
Yes, find someone else. You are 3yrs post c-sec, and I'm believing you can do it!!
Mama2E&O's Avatar Mama2E&O 03:27 PM 11-04-2006
oh my gosh, I am so sorry you are going through this.
I am not even aware what kind of closure I have: they have never said anything about it.
I am so sick of there being so many obstacles getting in the way for us VBAC mamas.
oregonbound's Avatar oregonbound 09:29 PM 11-04-2006
I'm sorry you are having this trouble. My OB asked for my medical records from the C-section, but he said that the only think he cared about was to double check that the incision on my uterus was low and horizontal, didn't even bother to check the double vs. single stitch, so it's not an issue for all providers. Hope it all works out for you!! I know how much I wanted my VBAC and I would have been devastated if my care provider turned around and said that they wouldn't do it.

acordio's Avatar acordio 04:07 PM 11-05-2006
I asked my md before we even started trying for baby #2 and was dissapointed when he told be I am a single. I had read Ina May's Guide to Childbirth she talked about the single vs the double and I had never even heard of that, probably since I had not planned to have a c-section.

My md said it is not a problem and that he has never had a uterine rupture vbac and he does the single closure.

I feel ya on the only being able to go to certain hospitals for a VBAC. There is only one hospital in my area you can go to for a VBAC.
annekevdbroek's Avatar annekevdbroek 06:04 PM 11-05-2006
Thank you for all the support. I am going to speak next week to one of the OBs in the midwife practice who is reportedly the most "liberal". I also found out that ACOG does not make any recommendations regarding single vs. double layer closures at VBACs. So, it is at the discretion of the OB. I have the names of a few local OBs who are reportedly VBAC friendly and will be contacting them. This is just frustrating because there is such inconsistency in the research and then how the OBs may practice.

I've armed myself with a ton of research - the original journal articles. I happen to be a Ph.D. psychologist with 5 years of graduate training in statistics, and training in health psychology, worked in family practice for 3 years. DH is a physician. Overall we are a pretty strong scientific research team - it is just a matter of finding an OB we can BULLY into doing in our way (bully using research, of course!).
ericswifey27's Avatar ericswifey27 06:48 AM 11-06-2006
Oh no!

That is my biggest fear. I need to go get my records too, but I don't want to look. It is also not a question I asked in the interviews (still haven't picked a midwife) but I think I need to go back and ask my midwife too.
kathan12904's Avatar kathan12904 03:22 PM 11-06-2006
[QUOTE=acordio;6454487]I asked my md before we even started trying for baby #2 and was dissapointed when he told be I am a single. I had read Ina May's Guide to Childbirth she talked about the single vs the double and I had never even heard of that, probably since I had not planned to have a c-section.

It is my opinion and the opinion of other knowledgable women that Ina May's views on the single layer closure are either out-of-date or uneducated. She refuses to attend vbacs with a single layer closure, but people I know who have spoken to her about it are convinced that her decision cannot possibly be based on accurate facts. Maybe she just wants to keep her statistics perfect so that the farm can be used as a reference point to support homebirth and midwives. Either way, I disagree with her and so do a lot of women who have successfully completed vbacs with single layer closures. I know one pregnant woman that had a shirt made up that said "Ina May thinks I'm a ticking timebomb." I was very amused and would sign up for one of my own if they were mass marketed. Its disappointing to me that such a well known advocate of natural birth would be unsupportive of this, but it just means she's as flawed a human being as we all are.
nfpmom's Avatar nfpmom 07:50 PM 11-06-2006
Here is ICAN's paper on the Single vs. Double layer suture debate. It is complete with references so it will point you to all the primary articles.
acordio's Avatar acordio 02:31 AM 11-07-2006
Thanks for posting the article.

I need to reread what Ina May has to say about closures. I don't specifally remember what it said, but I know it freaked me out.
MomtoAsh30's Avatar MomtoAsh30 02:34 PM 11-08-2006
I did not know what my closure was at the time I had my c/s, but I have a friend who has to have a c/s with the same doc (mine was for breech, hers is for previa) so she asked him what type of closure he does. He said he does a single closure. She asked what implications that has for VBAC and he said that although it used to be thought that double layer is better, now it doesn't seem to make any difference (that's why he does single closure now).

By the way, OP, I'm in TX too -- DFW area. Are you around that area too, or "deeper in the hot" of TX? If you live anywhere near DFW, I have a list of VBAC-friendly providers if you want it.
kathan12904's Avatar kathan12904 05:41 PM 11-08-2006

This website has a number of different studies that have been conducted on this issue. I personally feel that the ICAN paper is more discouraging than accurate. If you look at the web page above, you will see very early on the that number of studies supporting single layer closure far outnumber those negating it. Don't be afraid, and don't let any care provider use this as a reason to intimidate you out of the vaginal birth that you are so totally capable of performing. Good luck.
annekevdbroek's Avatar annekevdbroek 08:38 PM 11-08-2006
Just checking back in - I found another OB locally - and a second place as possible back-up. I see the new OB next week - I think she has the highest VBAC rate in the city, and everyone else in her practice also supports VBAC. The studies are mixed at best regarding type of closure, advantages and disadvantage of both (not related to VBAC) and later VBACs.....
ericswifey27's Avatar ericswifey27 02:33 AM 11-09-2006
That's great news! So glad you found a supportive place! Keep us posted
hxcmama's Avatar hxcmama 02:17 AM 11-15-2006
I just had to deal with this today, and I am still shaken by it. I interviewd an independant birth center (because no local hospitals will consider vbac, but I don't want a hospital birth anyway) and things were going great, they have a 100% sucess rate with vbac but because it is NH and midwifery is regulated, they have to agree to risk out people with single layer. My face just fell because even though my records say nothing about the suturing, I asked the OB at the time and he told me it was closed single layer. Since there is no record of this I don't know if they would risk me out as quickly, but still, it was extremely discouraging. It also set the seed of fear in my mind - if they take vbac and have so much success but won't even consider just because of the suturing? I don't need to doubt myself! Unfortunately single layer is becoming the standard.
annekevdbroek's Avatar annekevdbroek 11:59 AM 11-15-2006
hxcmamam - Well, the thing is that the vast majority of research on single vs. double layer closure doesn't indicate any increased risk. The ACOG position statement/practice guidelines also make no recommendations regarding VBAC after single vs. double layer closure. So, it is up to the individual practioner to decide what they are going to do. The new OB that I saw yesterday was like "Why wouldn't we do a VBAC after single layer????" Her attitude is significantly different than most OBs I've encountered so far.

All I can say is - keep looking. Try to find out the VBAC rates for hospitals in your area (e.g. state average in TX is about 10%) and call the better one's labor and delivery departments and ask a nurse which docs/midwives are doing VBACs. Then call those people and ask about closure.

Also - be sure to get a copy of your surgical record so you know for sure what type of closure was done.

Best wishes!
cancat's Avatar cancat 10:06 AM 11-16-2006
Originally Posted by warrior mama View Post
I have a single layer closure and no-one has mentioned (both MD and MW) problems with it. I do believe that single layer is the standard these days. Arm yourself with research and keep fighting. Some providers are just looking for an excuse, IMO.
I was given a double-layer closure by the OB last time and was told that this was so it would be easier to VBAC this time...and that this was the standard currently : Either way, my midwives were happy it was double, but wouldn't have refused me if it hadn't been...
Mrs. B's Avatar Mrs. B 11:11 PM 11-18-2006
This happened to me at 36 weeks. It was horrible. My mw was ok with it, but the back-up OB was not, nor was the hopsital. After about 1 1/2 weeks of worry, they finally agreed to do the VBAC, but my mw couldn't accept new patients with single layer sutures. The risk of rupture increased about 4% from a double layer (still less than a 4% chance overall, though) and I was supposed to sign something extra, but never did. Apparently, single layer sutures were the standard of care until about 1-2 years ago around here.

I ended up with another c/s, but the OB told me she did a double layer while we were in the OR, so I hope that means she is ok with VBA2C!
juliema's Avatar juliema 01:05 PM 11-21-2006
The whole suture debate really annoys me. I feel like it's just another excuse for ob's not to have to perform a vbac. I also have a single layer suture and thankfully my midwife was fine with it. There really is no definitive evidence that I've seen yet that double is any better than single. I think they both have their pluses and minuses. From what I've read, In addition to increased infection with double layer suture, it leaves more scar tissue so the risk is increased for future placental issues as well, and healing time is supposedly faster with a single layer as well. I personally am fine with my single layer. anyway, glad you found a supportive provider. That's no easy feat in Texas. I tried and ended up with a midwife at home because I couldn't find anyone supportive enough for me.