Can you VBAC after having a vertical c-section? What are the overall stats on a ruptured uterus . and the overall effects on baby?
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Dr David
Moderator posted 28 January 2001 12:29 PM
Lesa
The incision in the skin should not be confused with the incision in the uterus. The uterus is divided into the upper segment which is thick-walled, muscular and does the contracting and a lower segment that is thinner, less vascular and stretches out during the later weeks of pregnancy and in labour. The three common uterine incisions are transverse (crossways) lower segment (the commonest), vertical (up and down) lower segment, and vertical upper segment (classical).
Chance of rupture with vertical lower segment incision :
Review of ten studies (Martin) including 382 women. 82% vaginal birth. 4 ruptures (1.05%), but two were away from the site of previous surgery, and one occurred in a woman who had had both vertical and transverse incisions. This is a similar rupture rate to transverse lower segment incision. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_ uids=9240598&dopt=Abstract
A more recent study (Shipp) of 2912 patients comparing vertical with transverse lower segment scar found similar rates of dehiscence and rupture. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list _uids=10546720&dopt=Abstract
Chance of rupture with vertical upper segment scar:
The discussion in the above paper suggests chance of rupture with previous classical scar as 12%. Another review (Chua) of the literature suggests chance of rupture is 2-10 fold and chance of baby death 5-10 fold when comparing vertical upper segment with transverse lower segmant scars. There seem to be no recent series of VBAC with classical scars. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_ uids=9075539&dopt=Abstract
Overall effects on baby.
This is very broad and might include issues of maternal bonding, breast-feeding rates, chance of breathing difficulties etc, which are all very important and are affected by elective caesar.
Limiting the answer to vertical lower segment scars, Martin above shows "No perinatal mortality (death) or permanent perinatal morbidity (sickness and injury) was encountered with these pregnancies."
See above for upper segment scars.
In 62 cases of significant uterine rupture in Australia, 25% of babies died, giving an estimated risk of baby death with a VBAC (transverse scar) attempt of 1 in 2000. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list _uids=10870788&dopt=Abstract
Mozurkewich looked at 39,525 women in a meta-analysis comparing trial of labor with elective Caesar and found chance of death 0.2% (1 in 500) for labor trial and 0.1% (1 in 1000) for elective Caesar. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list _uids=11084565&dopt=Abstract
A review of 108 ruptures in a single institution suggested neonatal morbidity or death were rare when prompt action was taken. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_ uids=8238154&dopt=Abstract
"CAN you VBAC with a vertical scar"?
This is another question entirely that involves you making a decision based on your own circumstances and your thoughts on possible risks and benefits of VBAC.
I have not detailed every relevant study and you should discuss your own situation with your carer.
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.