Monday, May 23, 2011

Doctor's Appointment and Uterine Rupture Information

My health insurance is with Kaiser Permanente. This means I don't get a lot of say in who provides my medical care. So while I might be able to tell those of you out there with other insurance plans to research your care providers and choose one whose philosophy and practice fits with your desires and goals, I personally have little opportunity to exercise this luxury. I am given the choice to see the same provider for each appointment, and I am asked if I have a preference of provider, but they are all within the one medical office nearest me, and they all operate under Kaiser Permanente's standards and policies, of course.

My prenatal care is provided largely by a Certified Nurse Midwife* (CNM), but because I am a VBAC candidate, I also see an MD once in a while. I really like the CNM I've been seeing. I feel she is very much pro-VBAC and in tune with my desires. I also feel that she understands and respects that I do have a lot of knowledge and doesn't talk down to me. She also appreciates my sense of humor (this is very important to me - that I feel I've connected on a personal level to my care provider). She also seems to be perfectly willing to spend as much time with me as I feel I need, doesn't seem rushed, and answers my questions thoroughly. All-in-all, I'm very happy to see her repeatedly for my care.

*A Certified Nurse Midwife is a registered nurse who has taken advanced training in obstetrical and gynecological care. She is qualified to oversee pre- and postnatal care and provide primary care during labor and delivery, as well as provide general GYN care.

When it came time to see an MD so I could be informed of the risks and benefits of VBAC and sign a consent form, I was asked if I had a preference for which MD to see within the facility. I actually did, but I couldn't remember his name. Oops. I had seen one doctor near the end of my previous pregnancy who was very pro-VBAC and whose personality I liked. I wanted to see him again, but I couldn't remember his name. Curse my lack of memory for detail! Hehe. Anyway, I said to the receptionist that I had seen a doctor before that I'd liked. She looked at my chart and saw a doctor I had seen early in this pregnancy, told me his name, and asked if I'd like to see him. I didn't think he was the one I meant, but I rememberd also liking him well enough, so I agreed to see that doctor. (Now I've jogged my own memory and remember the other doctor's name, so if I need to see an MD later on, I'll request him.)

I don't mean to disparage this doctor, by the way. He is very good at what he does and has been in practice for a long time. But my visit with him was strange. He did the usual prenatal things, listening to the heartbeat with the Doppler, measuring fundal height, asking if I had any questions. He also went over my ultrasound results, which were all reassuringly normal. (I'm having another boy, by the way! I think I forgot to mention that...)

Anyway, then he went into the VBAC portion of the appointment. He asked the reason for my previous cesarean and noted that I had already had one successful VBAC. He said that in about 1 in 200 vaginal birth after cesarean attempts, the uterus may rupture during labor. "This can cause the baby and the mother to die!" He hastened to add, "Of course, you could walk out into the street and be hit by a car, too!" Right. "Oh, but you've had a vaginal birth already. That improves your chances of having another." Ah, thanks. He also added that a c-section has higher risk for the mother, but a vaginal birth has higher risk for the baby. This didn't sound right to me, but I didn't press him. I was in that weird place where I felt like I knew more about it than he did, which is not a feeling you want from your doctor.

The vibe I got from him was "noncommittal," if that makes any sense. It was like, he didn't really care one way or another if I had a c-section or a vaginal birth. On the one hand, that's nice. I get to choose. On the other hand, if I was on the fence, putting the words "baby and mother can die" in the same sentence as "labor" would make me lean heavily toward c-section. Which leads me to believe that he favors the repeat c-section. It's hard to tell. I do know that Kaiser in general does seem to support and encourage VBAC**, so he may be torn between his own medical opinion and the policies of his employer.

**Of course they do. The interesting thing about Kaiser is that they are insurance company and medical care provider in one, so they would like to take the cheapest route whenever possible. A successful vaginal birth, especially one without interventions, costs considerably less than a c-section. So, once VBAC was determined to be both safe and inexpensive, it made sense for Kaiser to jump in with both feet. I'm not unhappy about this. Just realistic.

Anyway, what the doctor said bugged me enough that I went and did some research of my own on uterine rupture. His statistic was essentially correct. In about 0.5 to 0.9% of trials of labor after cesarean (VBAC attempts), the uterus does rupture at the site of the previous scar. I won't lie. This can be very dangerous and often at least results in fetal death, if not maternal death as well due to severe internal bleeding. However, if you are in a facility where the rupture can be detected and you can be taken to an OR immediately, there is a good chance that an emergency c-section will save both you and your baby. According to an excellent article I found, there is approximately a 10 to 37-minute window in which emergency intervention must take place.

The trouble with uterine rupture is that the early signs and symptoms are quite vague, usually first indicated by an abrupt deceleration of the fetal heart rate. A later sign is a feeling the mother has of intense pain and then a feeling of ripping or something "giving way" within her. At that point, she must be immediately rushed to the OR.

The statistics quoted in the study were very interesting. First of all, it is extremely rare, but possible, for a uterine rupture to occur even if there is no prior uterine scarring from previous c-section(s) or other uterine surgery. The primary risk factor for this is five or more previous pregnancies. Again, I stress, this is extremely rare.

There are other factors that can lead to uterine rupture, the primary one being poor health or lack of prenatal care and labor support. Uterine rupture is much more common in underdeveloped countries.

The most interesting bit of information was that the risk of uterine rupture is much lower if you have had a previous vaginal birth, either before or after the cesarean section. A successful vaginal birth prior to the c-section increases your chances of a successful VBAC considerably, and considerably lowers your risk of uterine rupture. A previous successful VBAC also considerably lowers your risk of uterine rupture, from approximately 0.5% (that's 1 in 200) to 0.45%. I know that doesn't look like a big difference, but it's interesting. The authors of the article referenced here surmise that, "a successful prior VBAC attempt assures that (1) the maternal pelvis is tested and that the bony pelvis is adequate to permit passage of the fetus and (2) the integrity of the uterine scar has been tested previously under the stress/strain conditions during labor and delivery that were adequate to result in vaginal delivery without prior uterine rupture."

A successful vaginal birth prior to the c-section reduces risk of uterine rupture during subsequent VBAC attempt to just 0.2%!

However, induction of labor after a previous c-section increases the risk of uterine rupture rather noticeably, to anywhere from 1.4% to 4.0%, depending on the study referenced. If I had known this prior to my Pitocin-induced VBAC, I might not have done it. Since it worked out for me, it apparently was the right choice, though. I suspect there is a difference in this case for women who have previously undergone labor (even if it ended in c-section) than for those who have not. That is just my opinion, based on what I've read. There also might be such a range depending on the length of the labor and the amount of medication needed to start and sustain labor.

The risk of rupture is also increased with each additional prior cesarean section, which is why after more than two previous cesareans, most care providers will recommend a scheduled repeat c-section over a VBAC attempt.

Also note that, in general, the risks to mother and baby associated with a repeat cesarean section during a trial of labor (an emergency c-section) are higher than the risks associated with a scheduled repeat c-section.

You all know by now that I am obviously very pro-VBAC, but it is important to know your risks. I want to point out that for almost anyone who has one previous c-section, whether you have had a prior vaginal birth or not, your risk of uterine rupture during a trial of labor are about 0.5%. For comparison, the risk of developing a post-operative infection after a c-section is approximately 3 to 5%!

So, despite my doctor's frightening statements about uterine rupture and getting hit by a car, I am fully confident that a repeat VBAC is the right choice in my case. I believe that my nearly-complete labor followed by a subsequent successful vaginal delivery have proven my body's ability to start and sustain labor and that my pelvis is plenty wide enough for a baby to come through.

If you have questions, I'll try to field them, but I'm no expert. I just used Google like the rest of you. :)

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