worst case scenario UR- how long do you have before c-section? - Mothering Forums
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#1 of 44 Old 10-25-2007, 12:19 PM - Thread Starter
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I was sure I'd read the guidelines were to have a c-section within 30 minutes if you had a big bad uterine rupture. My midwife tells me yesterday that you can die in 5 minutes. I think I may have misinterpreted something - anyone know what the 30 minutes guideline is??

She's pushing for hospital birth, I am pushing for birth center based on the fact that it is very close to the hospital just in case. I thought it was a pretty safe choice but am not wondering. I don't want to cross the stupid line.

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#2 of 44 Old 10-25-2007, 12:38 PM
 
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It is 30 minutes from decision to incision (and that is approximately how long it takes if you are in the hospital, for them to prep you, get the OR ready, etc.). Ask your midwife if she seriously thinks that if you were in the hospital they could get you into the OR and open within five minutes of the time that they think you have ruptured. If she says yes she is either lying to you, or not very educated about this subject.

Another MDCer (Candice, can't remember her screen name right now) said something in another post about this, and the conversation she had with her midwife's backup perinatologist. She asked him if it really mattered if she spent the first 10 minutes of that 30 minutes in the car (while they were prepping the OR) and then getting prepped, and he really couldn't think of a reason why not.
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#3 of 44 Old 10-25-2007, 02:04 PM
 
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i read 10 minutes for a catastrophic rupture, but i'm not sure where i read that. i believe the baby has about 10 minutes before brain damage becomes a possibility. for the mom, i dunno. i think usually the mom has much more time. but i also read that a mom can put her entire blood volume out through her uterus in a matter of minutes if the main artery is somehow severed.

i'll see if i can find references. but, i will personally VBAC in a large, city hospital with a fully staffed OR ready to go at a moment's notice. i wouldn't be comfortable VBACing anywhere else, but that's just me.
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#4 of 44 Old 10-25-2007, 02:11 PM
 
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ok, here's some stuff i found:

http://www.emedicine.com/med/topic3746.htm:
The initial signs and symptoms of uterine rupture are typically nonspecific, a condition which makes diagnosis difficult and which sometimes delays definitive therapy. From the time of diagnosis to delivery, only 10-37 minutes are available before clinically significant fetal morbidity becomes inevitable. Fetal morbidity invariably occurs because of catastrophic hemorrhage, fetal anoxia, or both. The inconsistent premonitory signs and the short time for instituting therapeutic action make uterine rupture a fearful event.

http://www.medscape.com/viewarticle/458963_6:
n a larger study, Leung et al.[14] evaluated 78 cases of uterine rupture in a large tertiary care medical center and reported significant neonatal morbidity when 18 minutes or more elapsed between the onset of prolonged deceleration and birth. When the prolonged deceleration was preceded by severe late or variable decelerations, fetal asphyxia occurred as early as 10 minutes from the onset of prolonged deceleration.

and at the end of this very disturbing article:
Prompt intervention does not always prevent severe, fetal metabolic acidosis or neonatal death. Even in facilities with immediate access to cesarean birth uterine rupture can result in catastrophic outcome. A non-reassuring FHR pattern, occurring prior to the time of uterine rupture, further decreases the amount of time available before fetal insult occurs.


ok i'm stopping. i can't look at these kinds of numbers anymore, or else i'll never VBAC.
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#5 of 44 Old 10-25-2007, 02:30 PM - Thread Starter
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OK, that is REALLY scary!
So basically, she is right, baby can die in minutes, even if you're in the hospital.
UM, not what the VBAC mamas want to hear, whether true or not.
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#6 of 44 Old 10-25-2007, 02:35 PM
 
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but some hospitals are capable of getting a baby out in minutes. i had an emergency c/s with DD, and she was out in less than 15 minutes. your odds are definitely going to be better in a hospital, it's just not a guarantee.

while we're talking about catastrophic outcomes, i don't like being reminded that a baby is severely damaged about 3-4 times more often than a baby dies. i consider severely damaged the kind of outcome i want to avoid... ugh. i really want to choose VBAC, but i don't know if i can.

i'm off to go read some pro-VBAC literature.
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#7 of 44 Old 10-25-2007, 02:47 PM
 
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I had an er c/s and he could have been out in 10 min. They slowed down because his heart rate went back up and stabilized (to which I said then why do we have to do this - which they all ignored).
Anywhoo...it was my understanding at the time that at my particular hospital they had been trained to be able to get the baby out in under 10 minutes! If it had remained an emergency for me I have no doubt they could've done it, honestly.
It is such a hard decision that we have to make and it is not for the faint of heart, but then neither is motherhood :-)

We have a lot of research to do, but in the end we just have to trust ourselves.
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#8 of 44 Old 10-25-2007, 02:58 PM
 
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Here's the post turtlewoymn was referring to. I think it's also good to keep in mind that when the studies are done to come up with the risk for UR they include both dehiscence and catastrophic rupture.

Your chances of catastrophic rupture are significantly smaller than your chances of dehiscence which can often happen w/out any ill effects for the baby. Women who have had no prior uterine surgery also are at risk for uterine rupture and in those cases they are most usually catastrophic.

I only bring this up to put the whole ur discussion into perspective. I find that's helpful to me when considering my options.

I find it interesting that majormajor posted the scariest parts of the articles she found and did not reference other parts that are valuable to this type of discussion.

From the first link:
Quote:
Although a scar from cesarean delivery is a well-known risk factor for uterine rupture, most events that involve disruption of the uterine scar result in uterine-scar dehiscence rather than frank uterine rupture. These 2 entities must be clearly distinguished because their options for clinical management and outcomes analyses differ.
(emphasis mine)

I'd also suggest reading the ENTIRE study as the quote given by the pp is in the introduction whereas there is a more thorough discussion of it further in the study.

A few other sources:

http://www.gentlebirth.org/archives/vbacfrye.html
http://www.mothering.com/articles/pr.../fighting.html
From the second link:
Quote:
The recommendation to be in a hospital cannot be considered valid without a comparison to the risks and benefits of homebirth after cesarean. Given that some of the catastrophic rupture outcomes reported in the medical literature26 and popular press27 have involved caregivers' ignoring impending signs of rupture and dismissal of mothers' feelings of pain or instincts that "something wasn't right," it is not apparent from the existing evidence that laboring in a hospital necessarily decreases the risk of rupture or guarantees positive neonatal outcome in the event of rupture. Indeed, Lydon-Rochelle et al. demonstrate that laboring in a hospital dramatically increases rupture risk when induction agents are used, an occurrence rarely found at homebirths.
(emphasis mine)

I'd be a little bit suspicious of your midwife. imo it seems more like she's trying to scare you into doing what she wants you to do. I'd ask her to prove it and provide you with copies of her evidence the five minutes.
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#9 of 44 Old 10-25-2007, 03:55 PM
 
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Originally Posted by pampered_mom View Post
I find it interesting that majormajor posted the scariest parts of the articles she found and did not reference other parts that are valuable to this type of discussion.
the OP asked one specific question, and I posted the parts that were relevant to her question. why is that so interesting?
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#10 of 44 Old 10-25-2007, 04:28 PM
 
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I had an emergency csection 10 years ago. My baby was out in 20 min. This was without GA and they still had heart tones on her.

Four years ago a friend of mine had an urgent, emergency csection. From the time the decision was made till the baby was out was less than 5 min. She was out before they hit the OR, she was cut open before there was sufficient time to prep. When she woke up she had no idea if she had a live baby or not. She did. She VBACed two weeks ago, btw.

I am not sure where the figure of decision to incision is 30 min came from but that is not the case in life and death situations at most well equipped hospitals.

O, and as for rupture, your baby can die in minutes. When I was pregnant with my last a VBAC patient from my OB group had a castrophic rupture. By the time they opened her up her baby was floating literally in her chest cavity. She ruptured early on in labor, with no interventions.
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#11 of 44 Old 10-25-2007, 04:37 PM
 
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Well, I'm CERTAINLY not pushing for hospital birth, I am UCA4Cing this time after all, but it's not fair to say a hospital needs a half hr. With my first it was decision to incision in LESS than 5 min. - INCLUDING a spinal. They can go VERY fast. The speed is actually what terrified me most of all. And it was all bogus, but that's OT...

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#12 of 44 Old 10-25-2007, 05:14 PM
 
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So they can do it fast. We've established that. And it is pretty scary I can attest to that. Sometimes they need to fast, sometimes they can take their time. Each case is different.

I think that the 30 min may also come from insurance companies unfortunately.

A true uterine rupture needs immediate attention.
A dehiscence they can take some time and decide what to do.

Another point to put this in perspective: in any vaginal delivery there is a chance of cord prolapse which also requires immediate attention. Did any of us fret of that chance before we had a section. I personally never gave it a thought. Never did any research or concerned myself with it at all. (I will credit a woman on the ICAN list with bringing that point up to me).

There is also a chance you could die on the operating table with another section.
...and on and on

Again, I'm early on in my research. So...

OP I would ask your MW to give you the articles or research that shows 5 mins. And ask yourself do you trust her? This is your body and your baby. You need to arm yourself with all the info you can, find support people you trust, and do the best that you can.
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#13 of 44 Old 10-25-2007, 05:19 PM
 
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Let's also not forget rupture can happen at ANY time, not just in labor. And the idea of spending the whole pregnancy in the OR is odd to me.
Just something to think about.

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#14 of 44 Old 10-25-2007, 06:24 PM
 
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Let's also not forget rupture can happen at ANY time, not just in labor. And the idea of spending the whole pregnancy in the OR is odd to me.
Very good point!
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#15 of 44 Old 10-25-2007, 06:41 PM - Thread Starter
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The other thing I keep thinking of is that the chances of other deadly stuff happening is higher than uterine rupture, but homebirths are still safer for the majority of people.

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??

Does anyone know if there is anything at all we can do to decrease our chances of rupture? That's a conversation I'd rather have.

g.

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#16 of 44 Old 10-25-2007, 08:49 PM
 
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I believe the "30 minutes" comes from ACOG guidelines for hospitals that attempt VBACs. Not that it's a particularly useful number; either you have less than 10 minutes, or plenty of time.

But, here's a weird story for y'all: our doula (who has attended over 300 births) has seen exactly one uterine rupture. It was a 3rd-time mom with no prior cesarean. Baby was just fine... but here's the wild part: the rupture happened TWO HOURS before the cesearean was finally done. Mom noticed that "something didn't feel right." She couldn't explain what it was, but when it happened, her contractions just totally slacked off. They tried pitocin; no effect. They finally went for surgery, delivered the baby, and as the OB was about to tuck the uterus back inside, he turned it over to inspect it (routine procedure) and said, "Oh, crap." Not what anyone wants to hear from someone performing major surgery. ;-) There was a hole punched clean through the back wall of her uterus, like baby had just stuck his fist through there or something.

No bleeding, no pain, just "something doesn't feel right." And two hours later, a perfectly healthy baby delivered. Weird!
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#17 of 44 Old 10-25-2007, 08:57 PM
 
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Originally Posted by Ironica View Post
But, here's a weird story for y'all: our doula (who has attended over 300 births) has seen exactly one uterine rupture. It was a 3rd-time mom with no prior cesarean. Baby was just fine... but here's the wild part: the rupture happened TWO HOURS before the cesearean was finally done. Mom noticed that "something didn't feel right." She couldn't explain what it was, but when it happened, her contractions just totally slacked off. They tried pitocin; no effect. They finally went for surgery, delivered the baby, and as the OB was about to tuck the uterus back inside, he turned it over to inspect it (routine procedure) and said, "Oh, crap." Not what anyone wants to hear from someone performing major surgery. ;-) There was a hole punched clean through the back wall of her uterus, like baby had just stuck his fist through there or something.

No bleeding, no pain, just "something doesn't feel right." And two hours later, a perfectly healthy baby delivered. Weird!

Wow! But what a great outcome! And, yeah, "Oh crap"...notsogood! :

~Marie : Mom to DS(11), DS(10), DD(8), DD(4), DD(2), & Happily Married to DH 12 yrs.!
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#18 of 44 Old 10-26-2007, 02:14 PM
 
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My understanding of the rupture timing is 18 minutes, it's a "regular labour" where they tend to allow the 30 minutes - I think it's from TWGtaBB hold on let me check... Ok nope it's not Henci, so I don't remember. But that's what I remember, is that 18 minutes from catastrophic rupture, but depending on when they detect signs of the problem they could need to be considerably faster than that. As we know, they can be. But the point is, they need to be paying attention to the mama, and IMO that means more than just watching her "readout" from the nursing station.

ETA - doesn't seem to be in Silent Knife either. this is going to bug me... it may just be what my MW said to me.
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#19 of 44 Old 10-26-2007, 02:33 PM
 
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Found it, both the 18 and 30 minute references. It's in the Association of Ontario Midwives clinical practice guideline for vbac:

Quote:
For clients choosing birth out of hospital or in a level I hospital, it is important to review clearly the small but significant risk of uterine rupture. Any delay to surgical intervention may have a serious impact on the outcome for both the woman and her baby, either short or long term. One study found that significant neonatal morbidity was experienced when greater than 18 minutes elapsed between the onset of prolonged fetal heart deceleration and delivery.10 Women should understand that level I and II hospitals providing obstetrical care in Ontario require that a physician must be present for labour and delivery within 30 minutes, but that staff are not necessarily on site at all times. At a level III hospital, there is continuous in house presence of obstetric, anaesthetic and paediatric personnel.60
If anybody wants to read the whole document PM me, I have it in MS Word format.
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#20 of 44 Old 10-26-2007, 04:01 PM
 
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Originally Posted by g&a View Post
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?

Quote:
Originally Posted by Robinna
But the point is, they need to be paying attention to the mama, and IMO that means more than just watching her "readout" from the nursing station.
:

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.
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#21 of 44 Old 10-26-2007, 04:27 PM
 
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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.

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#22 of 44 Old 10-26-2007, 04:34 PM
 
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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.

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#23 of 44 Old 10-26-2007, 05:10 PM - Thread Starter
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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.

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#24 of 44 Old 10-26-2007, 05:25 PM
 
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Yes, I meant it in a sarcastic way.
Good...because that was totally the way I took it.
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#25 of 44 Old 10-26-2007, 05:36 PM
 
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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!
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#26 of 44 Old 10-26-2007, 05:58 PM - Thread Starter
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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??

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#27 of 44 Old 10-26-2007, 09:35 PM
 
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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.

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#28 of 44 Old 10-27-2007, 02:42 PM
 
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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.
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#29 of 44 Old 10-27-2007, 07:31 PM
 
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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.
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#30 of 44 Old 10-28-2007, 01:46 AM
 
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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.

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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?
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