How much is the uterine rupture rate for VBACs downplayed by ICAN? - Mothering Forums
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#1 of 39 Old 02-16-2004, 11:16 AM - Thread Starter
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I thought ICAN was saying the uterine rupture rate among VBACs was 1%.

Does anyone know what the rate actually is and how much ICAN is downplaying the rate? And if anyone knows why they are downplaying it, that would be good to know.

Thanks!
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#2 of 39 Old 02-16-2004, 11:56 AM
 
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How do you know ICAN is downplaying the stats if you don't know what the rate really is? If you are sure they are downplaying it then you must know something about the statistics.

It's been a while since I read the literature on uterine rupture so I did a little search. It seems that a 1% rupture rate is actually quite high. From what I saw it's more like .1-.5%.

Isn't the internet an amazing thing?
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#3 of 39 Old 02-16-2004, 12:01 PM - Thread Starter
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I read here that ICAN downplays the uterine rupture rate. So I inquired further. I am glad you posted on rates.

Yes, I am glad the internet exists, too.
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#4 of 39 Old 02-16-2004, 02:53 PM
 
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The best source for you would be Henci Goers The Thinking Woman's Guide. She has a great chapter on VBACs and rupture rates.

Rupture rates are hard to get solid stats on because many times, ruptures will include small windows in the scar which are found only upon doing another cesarean. These small windows are NOT problems, and usually occur before labor. However, when you include these in a study for the rate of uterine rupture, it skews the results horribly. Then, when you add prostaglandin gel, Cytotec or other induction agents, you've got a creation of ruptures.

The rate of rupture is very low, actually. True, catastrophic rupture. You're at a higher rate (and not because you're a VBAC, but because you're pregnant) for cord prolapse, placental abruption or even getting into a car accident on the way to the hospital.

Still, I highly recommend Henci's book. All in all, she picks apart the research and presents it in a solid way. She is amazing.
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#5 of 39 Old 02-16-2004, 03:51 PM
 
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It is hard to get an actual rate. I used to do billing and coding for an OB/GYN. A lot of uterine ruptures are actually a dehisence (sp) of the incision. It is like that window that a pamamidwife posted. There is no ICD-9 code for uterine dehisence of a uterine incision. The only ICD-9 code that is similar is the one for a uterine rupture. So, your claim gets sent of to the insurance co saying you had a rupture, when you only had a window, and the actual rate is scewed.
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#6 of 39 Old 02-16-2004, 05:10 PM
 
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Have you read Silent Knife? Cohen goes into a lot of detail about rupture, much more than I remember. I believe she said the 1% rate is for classical incisions only.

Her next book, Open Season, tells of a few homebirths that occured after 3 and 4 classical sections. She goes on to say that if a mother does not have labor induced, the rupture rate with a low transverse incision is virtually zero, and that on the rare occasion it does happen, it happens before labor begins. Also, that when Pitocin is used, non-VBAC mothers actually have a higher rate of rupture than VBAC mothers.

I'm sure ICAN's numbers are the most accurate you could find, since they have no financial motive in getting women to agree to VBAC.
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#7 of 39 Old 02-16-2004, 07:05 PM
 
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The risk of VBAC only rises to 1% when you include *induced labors* (and it goes higher than that for ones induced with prostaglandins). When you seperate them out, the uninduced/augemented labors have a rupture rate of around .5% - .7%. All of this ignores the fact that most ruptures are silent and cause no problems. According to the most recent research, the risk of a bad outcome from a rupture is 1 in 2,000 VBAC's!!!!! The following from a midwife on a list I"m on puts the risk of all rupture into perspective:

Relative Risks of Uterine Rupture


Your risk of dying in a car accident, over the course of your lifetime, is between 1 in 42 and 1 in 75. This is roughly 4 to 5 times greater than the risk of uterine rupture.

You're about twice as likely to have your car stolen (that's an annual risk) than to experience a uterine rupture.

Your odds of being murdered are 1 in 140 over the course of your lifetime. That's 2 times more likely than the risk of rupture.

The annual risk of having a heart attack is 1 in 160, 2 times more likely than rupture. Your risk of dying from heart disease is roughly 1 in 6, or 55 times greater than your risk of rupture.

If you're a smoker, your risk of dying from lung cancer is 1 and a half times more likely than a VBAC mom rupturing during her labor.

You're about 17 times more likely to contract an STD this year than you are to have a uterine rupture; more likely to contract gonorrhea than to rupture, as well.

You're 13 times more likely to get food poisoning than to rupture.

You're more likely to have twins than a uterine rupture. Odds of twins: 1 in 90. That's about 3 1/2 times the likelihood of rupture.

If you ride horseback, you're 3 times more likely to die in a riding accident than you are to experience a uterine rupture.

If you ride a bike on the street, you are 4 times more likely to die in an accident (annual risk) than you are to suffer a rupture.

Having a serious fire in your home during the next year is twice as likely as experiencing a rupture.

You're ten times as likely to win at roulette as you are to have a uterine rupture.

If you flip a coin, you'll be more likely to get heads (or tails) 8 times in a row than to rupture.

The risk of cord prolapse is 1 in 37 (2.7%), or nearly ten times more likely than that of rupture.

And a final irony (heads up, those of you who want a doc to give his/her opinion on your likelihood of rupture next pregnancy!)...

You're 6 times more likely to have a doctor who is an impostor than you are to suffer a rupture. Two percent of docs are phonies (1 in 50), according to several sources I found.

So instead of worrying about rupture, why not take a few minutes to check up on your doctor's credentials? It'd be a more profitable use of your time, and a substantially more likely cause for alarm.
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#8 of 39 Old 02-16-2004, 08:56 PM
 
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Mom2six is right... I've been reading a bunch of medical abstracts about VBAC (http://www.worldserver.com/turk/birthing/rrvbac.html), and the UR rate is around 0.7% (7 in 1000, or 1 ~143) when you eliminate the monkey business (as Mom2six says). There was a very large, well-done study recently published (I think by a Dr. Landon at Ohio State? there's an article about it at the ICAN site in their news section) which if I recall correctly has a similar UR rate but they cite the risk of something "serious" happening as 1 in 2000 (serious, IIRC, is maternal or fetal death or catastrophic injury).

The thing is, how you interpret the risk (0.7% or whatever applies to your situation... the actual number which applies to *you* can differ according to your incision type, interventions, etc.) is up to you. I think ICAN thinks 0.7% is really low, and OBs and malpractice insurance companies think 0.7% is really high.

I think it's low. I'm planning on a VBAC. But I don't think it's vanishingly tiny, so I'm also trying to educate myself about what a UR might feel like and what might warn me that something not right is happening.

I also wear a helmet on my bike and a seatbelt in my car, for the same sort of reasons.
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#9 of 39 Old 02-16-2004, 10:40 PM
 
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Quote:
Originally posted by KKmama
But I don't think it's vanishingly tiny, so I'm also trying to educate myself about what a UR might feel like and what might warn me that something not right is happening.
Just a note - many ruptures are painless. I believe that the current info suggests that pain is not a reliable indicator of rupture.

Again, as an L&D nurse the overwhelming number I've seen (and granted, most of these were the "meddling" hospital type of labor), mom either stops progressing/contracting or pushes for hours with no descent - go in for the repeat c/sec and - voila~ open scar. The only one I've seen that had fetal distress was a woman scheduled for a repeat c/sec (by choice) who came in and was having decels when we put on the monitor. Also keep in mind that many women have pain in the area of the scar from stretching and adhessions that has nothing to do with rupture.
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#10 of 39 Old 02-17-2004, 11:43 AM
 
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Yeah, from what I've read, not all women feel pain. But a significant number of women *do* feel pain. The obvious message is that if you *do* feel pain, you'd better not ignore it; you'd better discuss with your dr./mw. (And yeah, it could turn out to be stretching/adhesions.)

Here's something from a study published in 2003: (O'Grady
(Baystate Med. Cntr) Vernixuria: another sign of UR J Perinatol 23 351). "Classical signs are loss of station, cessation of labor, vaginal bleeding, fetal distress and abdominal pain. Case report of UR indicated by vernix and blood in Foley catheter."

Obviously, everyone's got to be on the ball and paying attention to what's going on during labor. (They should be doing that anyway ).
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#11 of 39 Old 02-17-2004, 01:31 PM
 
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A couple of points-
A double layer suture during a previous section will make uterine rupture less likely, no labor inducing drugs should be used (that was my condition when planning a VBAC), and how many previous sections you have had makes a difference- as well as the type (placement) of the incision. I recall telling my midwife (when planning a VBAC) that I might not be one in a million, but I could be one in 2000 (when explaining my stance on no labor inducing drugs- which from what I read raised the rate significantly.

Also- please do remember that uterine rupture can happen during the pregnancy- before labor. I had a horrible bout of pain right on the incision line just before my last c-section- and I ignored it- when I was opened up for the surgery- my right side of my incision was open- not a "window" but actually open, so as a PP suggested- take any signs your body gives seriously- extreme pain (which I might not have noticed had I been in labor- but did absolutely notice not being in labor), bleeding, etc., and trust your own instincts
Oh- and find a care provider whom you trust completely, it is so important to not be questioning their judgement if something seems to be going wrong, if you trust them- it's a huge difference IMO. So trust yourself and trust your Dr. or midwife
HTH!

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#12 of 39 Old 02-17-2004, 03:04 PM
 
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Quote:
Originally posted by suhternbelle
I read here that ICAN downplays the uterine rupture rate.

Can I just add that the thought of anyone saying this really makes me frustrated and sad? Talk about VBAC backlash.
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#13 of 39 Old 02-17-2004, 05:23 PM
 
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I am assuming that the .7% rupture rate is for transverse incisions. DOes anybody know what the rupture rate for classical incisions is, or is there not much info because nobody is willing to assist a VBAC after a classical incision?
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#14 of 39 Old 02-17-2004, 05:28 PM
 
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I would think that some older studies of uterine rupture might be helpful in figuring this out. If I recall, I think it is 1-3% for classical incision, but I have nothing at hand to back this up.

Silent Knife had some classical rupture rates, since that was written back in the time when more women had classical incisions.

Perhaps contacting ICAN or even Nancy Wainer directly?

PM me if you need further help. I can do some sleuthing for you.
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#15 of 39 Old 02-17-2004, 05:35 PM
 
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Quote:
Originally posted by pamamidwife
Can I just add that the thought of anyone saying this really makes me frustrated and sad? Talk about VBAC backlash.
I said it and believe it is true. I think ICAN and other VBAC supporters play down the risks. Also many of the VBAC books that are "must reads" are old and not updated at all. There isnt a whole lot of discussion about rupture rate with interventions but there is a lot of discussion about no intervention. The thing is most women do have interventions in birth if they have hospital births.
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#16 of 39 Old 02-17-2004, 06:17 PM
 
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Gossamer said:
Quote:
I am assuming that the .7% rupture rate is for transverse incisions. DOes anybody know what the rupture rate for classical incisions is, or is there not much info because nobody is willing to assist a VBAC after a classical incision?
At the research abstract site I cited above in the thread, most of the abstracts that list UR rates for classical incisions list a number somewhere around 5-10% (some a bit higher or lower), whereas LT is mostly between 0.2-1.0%.

As far as rupture being understated...

On_the_Fence said:
Quote:
I said it and believe it is true. I think ICAN and other VBAC supporters play down the risks. Also many of the VBAC books that are "must reads" are old and not updated at all. There isnt a whole lot of discussion about rupture rate with interventions but there is a lot of discussion about no intervention. The thing is most women do have interventions in birth if they have hospital births.
Kim, in this case, I'll disagree with you. ICAN and ACOG are citing basically the same numbers (which seem to be drawn from the same sources). Where they disagree is what the numbers mean and how risky VBAC (or even subsequent pg) is. ICAN focuses on the fact that *if interventions like prostaglandins and pitocin are avoided and the mother has a LT incision*, the risk is really quite low. ACOG focuses on the fact that when a UR occurs, it can have catastrophic results (including the dr. getting sued--sorry for the cynicism, but it's true). Same numbers, different interpretations, really.

There's been a ton of research about interventions and VBAC, and it basically all shows that it's bad. I think it's a good thing that research revealed that induction/augmentation of labor and VBAC are incompatible, because a *good dr. or mw* won't go there now (speaking from my own experience here, anyway). Maybe getting the word out has been more difficult?

Maybe you disagree with how ICAN *interprets* the numbers? (You know we're good buddies over on the C support circle... I'm only asking out of friendly curiosity.)
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#17 of 39 Old 02-17-2004, 07:31 PM
 
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I think ICAN and other VBAC supporters play down the risks.
I can't find any possible motive for this. ACOG, on the other hand, has a financial incentive to over-exaggerate the risks of VBAC. They don't want to admit rupture is more likely when intervention is used, even in an unscarred uterus. How does ICAN, or any other VBAC supporter, get anything out of someone having a VBAC?

Open Season is more recent (1991) than Silent Knife. That's close enough for me.

ACOG is a group of surgical specialists and has no business commenting on non-surgical or out-of-hospital birth. (You saw how badly they botched their "homebirth causes 2x the risk of infant death" study.)

Here is what else Open Season says about rupture:

"Doctors who insisted their VBAC mothers follow ACOG guidelines usually found that the women did not have VBACs. But instead of concluding that ACOG's guidelines made it very difficult for a woman's body to birth normally and abandoning the guidelines, they concluded that VBAC just didn't 'work'."

An ACOG publication "Trial of Labor" states, "a practical reason to continue the practice of elective repeat cesarean section relates to the time requirements of allowing a patient a trial of labor. To persue the natural course of labor predestines many patients to arrive at the hospital unexpectedly. This can interrupt the physician's schedule..."

More from Cohen: "Because the incidence of rupture is so low, it is hard to get information on the subject...there has never been a maternal or fetal death associated with a low segment incision rupture. The incidents where there were serious ruptures were on uteri that had never been sectioned - and pitocin was responsible for these situations...there have been no maternal deaths associated with VBAC in all the literature - ever. In contrast, a number of maternal deaths are associated with elective repeat cesarean..."

Dr. Gerald Bullock, in "Apologies of a Reformed Obstetrician" says "The risk of amniocentesis is higher to the baby than the risk of VBAC."
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#18 of 39 Old 02-17-2004, 07:49 PM
 
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OTF, if you believe this is true, could you please site where you get your stats for UR?

I am just really confused - is it a matter of you not trusting anything anyone says that is planning a VBAC? I'm not sure why ICANs rates would be different than what is in the medical literature.

There are varying degrees of "rupture", though, as evidenced by the above conversation. Perhaps ICAN weeds out those studies that do not differentiate between normal windows of scars and full blown ruptures? Is that why you feel their rates are wrong?


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#19 of 39 Old 02-18-2004, 10:56 AM
 
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Looking at this from another perspective, how many in the medical establishment downplay the risks of c-section and repeat c-sections?

Tracy, doula and Army wife and homeschooling mama to A and E
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#20 of 39 Old 02-18-2004, 07:18 PM
 
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Citizenfog,

Good point - it seems that a common viewpoint is that c/s/b guarantees a safe outcome for mom and baby. There is no risk free birth option. It still comes back to doing the footwork of gathering information about your birth options and deciding what your personal best choice is.

It bothers me that the potential risks of c/s/b seem to be frequently overlooked (probably less in these circles). I think I'm fairly informed and I didn't know that the risk of having a stillborn with your second pregnancy increases after you've had a c/s. Is it high? No - 1.1 per 1000 compared to .5 per 1000 that didn't have a c/s. But it's greater than the risk of neonatal death due to intrapartum uterine rupture. Put in simpler terms - if you've had 1 c/s the risk of having a stillborn after 39 weeks in your second pregnancy is greater than the risk of your baby dying from uterine rupture. I don't think many mom's consider stillbirth to be a primary concern in a second pregnancy post c/s, but uterine rupture sure gives everyone the heeby jeebies.

I guess in a way a large factor comes down to what are you best at - an ob/gyn is a highly skilled surgeon and were I to need a c/s that's who I'd choose over a midwife. In my opinion (and certainly there are exceptions to this generalization) midwives have a lot more experience with "normal" birth (and the wide variations normal can have) than an ob/gyn. It makes sense to me that ob/gyns seem to feel safer with c/s/b than with v/b - it's what they're really good at (in general).

Well, food for thought.

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#21 of 39 Old 02-18-2004, 07:53 PM
 
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I seriously doubt there is a big cover-up conspiracy going on at ICAN. "Hey, I know, let's lie about the rupture rate, just to see if people fall for it!":

I agree, the risks of c/b are what is downplayed. Some mainstream books like What to Expect even say the main risk is psychological, and make no mention at all of fetal lacerations or stillbirths.

Open Season mentioned that some other risks are inability to have an orgasm, and secondary infertility.
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#22 of 39 Old 02-19-2004, 10:41 AM
 
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Quote:
Originally posted by KKmama
ACOG focuses on the fact that when a UR occurs, it can have catastrophic results (including the dr. getting sued--sorry for the cynicism, but it's true). Same numbers, different interpretations, really.

There's been a ton of research about interventions and VBAC, and it basically all shows that it's bad. I think it's a good thing that research revealed that induction/augmentation of labor and VBAC are incompatible, because a *good dr. or mw* won't go there now (speaking from my own experience here, anyway). Maybe getting the word out has been more difficult?

Maybe you disagree with how ICAN *interprets* the numbers? (You know we're good buddies over on the C support circle... I'm only asking out of friendly curiosity.)
First there is some belief by some here that I am opposed to VBAC. This is not the case at all. What I am opposed to is propaganda from either side to pressure women to do one thing or another. I disagree on several fronts on how ICAN interprets the numbers and downplays to women the risk, even though small. Unfortunately I dont think the message is to individual women and their personal situations.
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#23 of 39 Old 02-19-2004, 11:29 AM
 
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OnTheFence said:
Quote:
First there is some belief by some here that I am opposed to VBAC. This is not the case at all. What I am opposed to is propaganda from either side to pressure women to do one thing or another. I disagree on several fronts on how ICAN interprets the numbers and downplays to women the risk, even though small. Unfortunately I dont think the message is to individual women and their personal situations.
Oh, I don't think you're opposed to VBAC. I think you just want us to be careful. And I'll allow you the right to your own opinions about ICAN. I have my own, too, not all positive (not all negative, either--kind of mixed).

Your last comment is interesting... there's been a lot of research about VBAC and various scenarios (women before vs. after 40 wks gestation, weight of baby, weight of mama, incision type, types of intervention, GD, age, reason for previous C, twin pg, etc.). It's getting to the point where a care provider can sit down with you and say, "Well, this doesn't necessarily predict how things are going to go for *you*, but these aspects of your situation are reassuring, and these aspects we want to keep an eye on." And in fact, this was done for me.
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#24 of 39 Old 02-19-2004, 02:16 PM
 
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Quote:
Originally posted by KKmama

Oh, I don't think you're opposed to VBAC. I think you just want us to be careful. And I'll allow you the right to your own opinions about ICAN. I have my own, too, not all positive (not all negative, either--kind of mixed).

Your last comment is interesting... there's been a lot of research about VBAC and various scenarios (women before vs. after 40 wks gestation, weight of baby, weight of mama, incision type, types of intervention, GD, age, reason for previous C, twin pg, etc.). It's getting to the point where a care provider can sit down with you and say, "Well, this doesn't necessarily predict how things are going to go for *you*, but these aspects of your situation are reassuring, and these aspects we want to keep an eye on." And in fact, this was done for me.
And I am not against ICAN either. Unfortunately when I determined for myself that I was not going to attempt a VBAC but to have a repeat because I did not want to take the risk with my baby (I have a higher rupture rate and increased risk of having transverse breech due to deformed uteri) I really got no assistance in planning or obtaining informaiton about things I could do to make my planned surgical birth better. In fact I had to dig dig dig to get information to make good choices to reduce risks during my planned surgical birth.

Kim
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#25 of 39 Old 02-22-2004, 07:11 AM
 
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Kim, I'm still really interested in why you think the rates given are incorrect by ICAN.....

Here is an article by the head of an OB/GYN dept that you may find interesting - after all, he's an editor at OBGYN.net - and that website is about as far from vaginal birth activism as you can get:

http://www.obgyn.net/displayarticle....icles/VBAC_dah

He quotes the u/r rate at 0.5%.

Is he wrong? Is he downplaying the risks? Please, tell me. I'm concerned that remarks are being made with out anything to back it up.

Why is this rate considered "downplaying"? I'm really interested and baffled at the stance and statement you made.
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#26 of 39 Old 02-22-2004, 11:50 AM
 
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I, for one, am not comfortable applying statistics to myself. I'm not other people, I'm me. I'm just not able to assume I'd be like someone else, statistically. So I can understand OTF's skepticism.
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#27 of 39 Old 02-22-2004, 03:21 PM
 
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Well, it's fine to personalize what you want for yourself. However, to make blanket statements that insinuate that an organization is purposefully lying to women and thereby endangering them is inappropriate.

True, we all have to make decisions for ourselves. I'm fine with that. When I say that women have a higher rate of cord prolapse than a uterine rupture with a natural birth, I'm not downplaying the statistics. I'm being factual. I'm also pointing out that, in that instance, all women are extremely high-risk and we all should be sectioned before labor starts - according to the current belief system around VBACs.

The true risk of VBACs is a legal system that has pushed a medical system into so much fear that it has long left evidence-based medicine.

And that is hardly downplaying the situation.

I'm merely asking for fact that ICAN downplays the rupture rate.

I'm also asking why older books would be less valid. Is there something that has changed with our bodies to change the rates of rupture over the past 20 years? If anything, the rates have started to decrease since there's been less augmentation and induction with VBACs.
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#28 of 39 Old 02-22-2004, 03:25 PM
 
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Originally posted by pamamidwife
If anything, the rates have started to decrease since there's been less augmentation and induction with VBACs.
That's true, however, around here (and I suspect elsewhere) the risk of induction/augmentation is being used to schedule more repeats as well. The logic goes thus: you *know* how dangerous it is to go past your due date, and we can't induce you, so if you don't go into labor by your due date, we'll have to do a repeat.
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#29 of 39 Old 02-22-2004, 04:11 PM
 
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Ladylee wrote :
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I, for one, am not comfortable applying statistics to myself. I'm not other people, I'm me. I'm just not able to assume I'd be like someone else, statistically. So I can understand OTF's skepticism.
What I find interesting here is that I think we all use statistics to some extent when making our decisions. Well let me qualify that by saying most women here in the birth arena do. We HAVE to apply the statistics to ourselves - but we may not all arrive at the same conclusion - and that's where the personalized/intuitive/gut instinct piece of things comes in I think. Give 2 women the .5-1% UR risk vs. the risk of whatever c/s risk you can pick and they may choose 2 totally different paths.

Ladylee you obviously felt that it was in you and your child's best interest to have a repeat c/s/b and I'm guessing you made that choice based on a variety of factors including the gathering of information/statistics.

There are too many variables to assume that we'll all fall into the positive part of statistics. But I personally find information/research a valuable part of my learning process. When I found out in my particular situation that there had been quite a few women to have a v/b and no ur following my type of surgery, that made a huge difference to me especially given the info I had from my surgeon.

I think that what it comes down to, at least for me, is looking at the info and deciding what's in your best interest, realizing we might each make different choices with the same information. And, we need to look at BOTH sides of the information - risks of VBAC AND risks of c/s/b.

Kim, it sounds to me like your problem with ICAN was lack of support for your decision than thinking they fudge numbers? Not wanting to speak for you, but that was the gist of what I got. As well as feeling that the numbers do not reflect the frequent interventions that occur and that that should be taken into consideration? To me that sounds vastly different than saying that ICAN downplays the uterine rupture rates for VBAC.

LisaG

Lisa , married to Dan, mama to IVF miracle Natalie 5/20/09 :
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#30 of 39 Old 02-22-2004, 05:07 PM
 
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Originally posted by pamamidwife
Kim, I'm still really interested in why you think the rates given are incorrect by ICAN.....

Here is an article by the head of an OB/GYN dept that you may find interesting - after all, he's an editor at OBGYN.net - and that website is about as far from vaginal birth activism as you can get:

http://www.obgyn.net/displayarticle....icles/VBAC_dah

He quotes the u/r rate at 0.5%.

Is he wrong? Is he downplaying the risks? Please, tell me. I'm concerned that remarks are being made with out anything to back it up.

Why is this rate considered "downplaying"? I'm really interested and baffled at the stance and statement you made.
I didnt that they quoted incprrect statistics, I said I believe they downplay the risk of rupture. Big difference. I think they put their own spin on things. Just like Silent Knife, etc. I was involved in ICAN shortly after I had my daughter and they played down uterine rupture. It happens so why not be honest about it, why not post some stories and information about women who had uterine rupture and their personal experiences? Do you belong to ICAN? Rupture is like a taboo thing to discuss except that "it wont happen to you, look at how small the risk is".
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