Dear Dr. David,
I have had three c-sections due to fetal distress. (On the third section, the doctor discovered that there was a perforation in my uterus from c-section #2, and the umbilical cord was protruding through it. He announced "no more v-bacs". I am having trouble accepting this edict - he was not my doctor, just an on-call the midwives brought in at the last minute.
I would like to try v-bac again in spite of this. What would have happened to that scar site, assuming he patched it in some way? Why would it be safe to be pregnant and not to labor? My babies are always late, and I believe they need the extra gestation time - could I go into labor with a fourth, but not plan on delivering? How great really are the risks of v-bac under these conditions? Do you think I could find someone to let me try? Can I be monitored for signs of rupture? (I am willing to go with no anesthesia.)I feel very mentally scarred by these sections. I cannot write or talk about it without crying. I really feel like I need to do this the "right" way or at least have the opportunity to try.
Thanks for your help.
Melissa
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Dr David
Moderator posted 23 January 2001 06:44 PM
Melissa
There are many issues here.
"perforation from c-section # 2"
This is a "scar dehiscence" or break in the integrity of the uterine wall along the scar line associated with no symptoms or danger to mother or baby. Scar "rupture" is complete separation of the uterine wall with or without expulsion of the fetus, endangering the life of the mother or fetus (ref.1). Incidence of dehiscence is about 2% - whether labour or elective Caesar &endash; and rupture 0.3-0.5%. (ref.2) Most dehiscences are seen at Caesar. Some can be felt at examination after vaginal birth, although this is not routinely practised. "… non-bleeding defects in a haemodynamically stable patient do not need to be repaired." (2)
"What would have happened to that scar site, assuming he patched it in some way?"
The Caesar would have been performed by opening and extending the dehiscence, that is going through the old scar, and the uterine wound would then have been closed in the normal way.
Why would it be safe to be pregnant and not to labor?
Again quoting Phelan, "The question of route of delivery in a subsequent pregnancy after the observation of a dehiscence or lower segment after vaginal delivery remains unanswered. While one patient in the current series with a uterine window did undergo an uncomplicated vaginal delivery, we would recommend elective repeat cesarean delivery in these patients". He is talking about unrepaired dehiscences discovered after vaginal birth. I can't find any data on your situation, that is VBAC after a repaired dehiscence.
Does repaired dehiscence increase the chance of repeat dehiscence? &endash; no data.
Is dehiscence which is benign, that is by definition associated with no danger to mother or baby, predict the development of rupture which IS dangerous, but rarer? &endash; no data.
Is dehiscence just what happens prior to full blown rupture? No-one knows (and probably never will).
"Could I go into labor with a fourth, but not plan on delivering?
See answer to Joline Nov1. 2000. Labour prior to Caesar has some benefits to baby, but may be associated with some (small) risks.
"How great really are the risks of v-bac under these conditions"?
VBAC after 3CS. Again from Phelan, small numbers and I don't know what criteria were used to decide if VBAC could be attempted, but of 62 women with 3 prior CS, 8 attempted VBAC and 7 birthed vaginally. See references supplied to Maria on VBAC discussion forum, Dec 23, 2000 &endash; "Although patients with 2 prior cesars should be counseled differently from patients with 1 prior cesarean scar about the increased risk of uterine rupture and decreased chance of vaginal delivery in a subsequent trial of labor, on the basis of evidence from this study and the existing literature, motivated patients may still wish to undergo a trial of labor". No specific data on x3CS, nor if previous dehiscence.
Can I be monitored for signs of rupture?
Yes, and immediate action, if signs of rupture present, may decrease the risk of neonatal death or brain damage. (ref3)
Finally, Melissa, where to go from here? Keep reading. Try and find a local support network. Weigh the issues and make your own decision.
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.
Refs:
1. Scott JR. Mandatory trial of labor after cesarean deliver; An alternative viewpoint. Obstet Gynecol 97;176:811-4.
2. Phelan et al. AMJOG 87;157:1510-5.
3. Leung et al. AmJOG 1993;169:945-50
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Dr David's 2nd Response -
Moderator posted 26 January 2001 09:40 AM
Melissa
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.