I'm not sure what to do. All I know is that I don't want another csection. My first child was induced after 10 days late, and ultimately ended up in fetal distress. My second child was elective csection (no election of mine), my insurance company didn't have any doctors that would do VBAC's. The third came last year. I found a doctor that would let me labor. I went into labor 5 days late and it was perfect. I went to the hospital 3 minutes apart and 5 cm dialated. Once I got to the hospital everything slowed. I progressed to an 8 before the doctor on call said there was head compression and I had to have a c seciton. I wanted more of a chance, but I didn't want the baby harmed. He was born 11-25-99 9lb 4 oz. Yes a large baby. My other two were 7 1/2 lbs. I find myself with an unplanned pregnancy due June 24, 2001. I am afraid I won't find someone to do a VBAC. I am concerned becasue of already having three. But, I also know that a fourth one without trying a VBAC will really bother me. Is there any info on VBACs after several c sections?
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Dr David
Moderator posted 02 February 2001 12:42 PM
I cannot find a large amount of data specific to 3 previous caesars.
Phelan reported 62 women with 3 or more previous caesars in the 2 years after they liberalised there policy regarding labour after more than one Caesar. 8 (13%) women laboured and 7 (88%) birthed vaginally. Reasons for excluding from labour are not given. No ruptures nor fetal deaths occurred. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=3425654&dopt=Abstract
Asakura compared outcomes in 1206 women with one previous cesarean with 435 women with more than one cesarean. Don't write how many had 3 previous cesars. Of those with more than one cesar, 302 (69%) attempted VBAC and 194(64%) birthed vaginally.
They found no significant difference in scar separation between women who laboured whether they had one or more than one cesar. Similarly for those with more than one cesar there was no difference in scar separation whether they laboured or not. Important baby outcomes were not affected by number of previous cesars. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7770261&dopt=Abstract
In an earlier post I mentioned uterine scar thickness. These studies do not include women with 3 caesars.
There have been several recent papers about measuring uterine scar thickness by ultrasound near the end of pregnancy. I haven't critiqued the actual papers, nor read such a discussion, but you may wish to discuss the findings with your carer. The main value of ultrasound measurement may be in the women who would not be offered VBAC because of a fear of increased risk of scar rupture. A thick scar may indicate low risk of this complication.
Gotoh showed scar dehiscence in 17/23 women when the lower uterine segment (LUS) was less than 2mm thick. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10725496&dopt=Abstract
Asakura showed that the risk of dehiscence was very small if the LUS was greater than 1.6mm thick. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11031364&dopt=Abstract
Most importantly for your situation, Rozenberg felt that ultrasound measurement of the lower uterine segment can increase the safe use of trial of labor, because it provides an additional element for assessing the risk of uterine rupture. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10579615&dopt=Abstract
Dr.David
DISCLAIMER:
This advice is of a general nature to help in decision-making. It does not constitute recommended treatment for an individual. You must consult your health care provider for individual advice.
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Dr David Responds again -
Moderator posted 15 February 2001 12:22 PM
An ICEA information booklet "VBAC Source book and teaching kit" by N.Jukelevics and R.Ancheta reports on a study that included 241 with three prior cesareans who laboured for VBAC.
"These results were found in a hospital that was often able to deliver a baby by emergency cesarean very quickly after deciding it was necessary. Risks may be higher in a hospital that needs more time to perform a cesarean or for women labor outside the hospital and need to be transported". http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8041542&dopt=Abstract
Dr.David
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And another question from the same person:
I received your information from the last question I sent you. I have done some research and feel as though another try at a VBAC is within my reach. I just had a couple specific questions. I was wondering if it matters how old the scar is. I got pregnant at 10months after the last csec and will birth this one when my scar had 19 months of healing. Is that enough? Also, my exterior scar didn't heal well, the staples were taken out 2 days after birth (as I was ready and willing to go home), and a 2 inch width section of it opened up. It took about 6 weeks to heal from the inside out. I still felt feel itching and sometimes pain in that area, but a sonogram and CAT scan last summer showed that the scar healed internally normal. I'm thinking that I just feel a little pain from the skin in that scar area streching. I wanted your imput. Also, due to my CAT scan last summer, I'm prepared to ask my caregiver to see if we could get a measurement of the scar tissue, as one of the articles suggested.
I know this is long, but one more thing if you have the time. I can't find a Midwife that will work with my doctor at the hospital, but ones that will birth at home. What do you think about birthing at home after 3 c sections? I have, although, found a doula that will work with my doctor. I will be discussing all of this also with my doctor next week. Thank you for any imput you can give.
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Dr David's Response -
Moderator posted 15 February 2001 10:08 AM
Does it matter how old the scar is?
I've seen only one study addressing this, although it doesn't give a specific risk of rupture for each pregnancy interval as it looked only at women with scar failure (dehiscence or rupture) not at all those who didn't have a scar failure.
What they found was that a short pregnancy interval (less than 6 months) was more common (17.4%) in those with scar failure, than in a control group of women who didn't have a scar failure (4.7% had short pregnancy interval). The authors note that the clinical importance of this observation unfortunately cannot be established by such a retrospective case-control designed study. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11084563&dopt=Abstract
Previous wound infection as a risk factor for scar failure?
This is not supported by the evidence according to one review article, and a previous Caesar wound infection is not a reason to exclude VBAC as an option. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9075539&dopt=Abstract
The "measurement of the scar tissue" is done by ultrasound, and is looking at the thickness of the uterus wall in the area of the uterine scar. I believe this investigation would still be seen as experimental, but may be useful in reassuring clinicians in those situations where VBAC would not otherwise be offered.
There are no published studies that I am aware of that look at safety of home VBAC.
Dr.David
DISCLAIMER:
This advice is of a general nature to help in decision-making. It
does not constitute recommended treatment for an individual. You must
consult your health care provider for individual
advice.