I had an attempted home birth but after pushing for 5 hours agreed to go to the hospital. I had a prominent sacrum and therfore agreed to a section. During the section I received a vertical tear in my uterus down into my cervix and during the cathetar insurtion, my urethra was torn and needed stiching. I have been told I am not a candidate for labour again as it may rupture, I have read all the data in another letter you have answered but is there any differences with my situation and do you think it sounds like there was negligence down during that surgery? The baby was born very healthy and other then just before the epidural, his heartrate was 140 and I was fine but in acute distress, in other words there was no need for sloppiness due to an emergency. What do you think?
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Dr David
Moderator posted 21 February 2001 05:24 PM
Jodi
I will find it difficult to be specific about your situation as I may not have all the relevant information and was not at the Caesar.
Caesars in the late first stage or second stage of labour after hours of pushing are some of the most difficult to perform without complication. The lower segment of the uterus is often very swollen, stretched right out and the tissues can be very friable ('mushy'). It is not unusual to get vertical extensions of the lower segment incision edges going down into the lowest part of the uterus or upper cervix/vagina as the baby's head is lifted out. This may not be due to any "sloppiness" of technique, and I would expect all obstetricians have encountered this situation. (I am presuming here that the tear down to the cervix was at the edge of the uterine incision, not in the midline.)
If the tear is in the lower segment of the uterus, not the upper segment, I wouldn't necessarily feel that this type of uterine scar has a higher risk of rupture. It is not the same as a vertical upper segment incision (classical) or even a vertical lower segment incision. I have not read a study that specifically addresses the question of VBAC in women who had a downwards vertical extension of a transverse lower segment scar, so I suspect that counselling regarding your situation would be based on individual carers experience rather than from results of attempted VBAC in large numbers of women. I am presuming a lot here about your Caesar and the nature of the tear, and advice may be different if I have misunderstood what exactly happened.
A report (see Pubmed reference below) of 103 women who laboured next time after a Caesar where full dilation had been reached but the head didn't descend, described 80% vaginal birth rate. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9800930&dopt=Abstract
Again, it is difficult to know what happened with the catheter insertion. On reading your question it is not clear whether you were told there was a risk of rupture of the urethra with a vaginal birth. This would suggest that there was some sort of injury to the urethra. It can be very difficult to thread a catheter up past a baby's head that is wedged hard down into the pelvis. Some superficial trauma to the urethra would be fairly common in this situation, but I can't picture how suturing would have been needed.
Dr.David
Dr. David,
That was good info to receive from you, thanks, it was more then both ob/gyn's I've seen have explained to me. Anyways, the urethral tear, I am not sure what you meant by being told about possible tearing during birth? I have a copy of my medical file and it says that the resident inserted "foley and balloon was inflated by accident", then it stated foley was removed and another one reinserted. Bleeding continued and sutures were needed internally. I have a known condition called lichen scelorosis, which I specifically mentionned in the surgery so the smallest cathetar would be inserted, my midwife said they ignored my request. I don't know whether that would have made a difference or whether it was a lack of understanding of insertion. The file also states the bladder was high up so perhaps he/she inflated it without noticing whether it was inside the bladder or not. Does this give you any further insight? Thanks for your reply.
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Dr David
Moderator posted 26 February 2001 09:56 AM
Jodi
Your description of events makes the situation seem clear. Yes, during a long second stage the lower segment of the uterus is drawn up and stretched. The bladder is attached to the lower part of the lower segment so may be drawn up also, even above the umbilicus (belly button). Yes, a catheter may need to be threaded up the urethra (tube from bladder to outside) more than twice the length that is usually needed to reach the bladder. Yes, it can be easy to inflate the balloon too early when the balloon is still in the urethra. It is easy to think "gee, I must have threaded it far enough now, maybe she is just very dry after a long labour and there is no urine in the bladder…". Urine may be very blood-stained after a long second stage, even without traumatic catheterisation, as the baby's head can compress the bladder against the back of the pubic bone. In the most extreme situation of obstructed labour where medical help is very delayed (days not hours) a part of the bladder wall necroses (dies) and a vesicovaginal fistula results ( hole between the bladder and vagina so that urine leaks continuously). It is possible that your carers used a larger catheter than you wanted as smaller catheters kink/bend more easily and are generally more difficult to insert in situations where some resistance is encountered.
Dr.David
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This advice is of a general nature to help in decision-making. It
does not constitute recommended treatment for an individual. You must
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