tag:blogger.com,1999:blog-23685740.post4462538856493244524..comments2023-11-03T02:07:30.240-07:00Comments on The Birth Book Blog: Repeated VBACs are safe; repeated cesareans are notTina Cassidyhttp://www.blogger.com/profile/14636705157835152712noreply@blogger.comBlogger33125tag:blogger.com,1999:blog-23685740.post-73287917555989113582010-03-04T02:57:04.452-08:002010-03-04T02:57:04.452-08:00Good postGood postbuy Aion Kinahhttp://www.randyrun.nl/Aion/Aion-Kinah:::5653_5654.htmlnoreply@blogger.comtag:blogger.com,1999:blog-23685740.post-4736852039435155302010-02-25T21:41:32.679-08:002010-02-25T21:41:32.679-08:00american dating sites [url=http://loveepicentre.co...american dating sites [url=http://loveepicentre.com/]gay dating online[/url] internet dating leeds http://loveepicentre.com/ singles salsa lessons in chicagoAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-23685740.post-53659113256414538882010-02-18T06:42:06.562-08:002010-02-18T06:42:06.562-08:00Hi Guys
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The main point should be what is safer for all involved, and a vbac is safer for the baby and mother. I had two c-sections. The first because of a placenta previa, but the second was a planned one, and the doctors took my daughter too early. Due dates are only a guess by a doctor. Labor is important! Also, women who have vaginal births are at a lower risk of getting cancer in the reproductive organs.Jenci4https://www.blogger.com/profile/06728220576376519448noreply@blogger.comtag:blogger.com,1999:blog-23685740.post-65385306246742384952008-03-16T20:03:00.000-07:002008-03-16T20:03:00.000-07:00I was also told most of the time, when a doc does ...<I>I was also told most of the time, when a doc does a repeat C/S she trims the excess old scar tissue. SO shouldn't this keep the chance of rupture steady, no matter how many you have?</I><BR/><BR/>A study published in July 2006 in <I>Obstetrics and Gynecology</I> showed that the risk vbac after multiple (2,3, or 4) c-sections is not significantly higher than vbac after 1 c-section. This was the same data used in the 2004 NEJM article on uterine rupture during vabc attempts. It is really difficult to find vbac support when you have had more than 1 c-section though.Unknownhttps://www.blogger.com/profile/08111124373378475582noreply@blogger.comtag:blogger.com,1999:blog-23685740.post-37670614678563114952008-02-07T15:52:00.000-08:002008-02-07T15:52:00.000-08:00Isn't it all so complicated because birth, and lif...Isn't it all so complicated because birth, and life, is unpredictable? Is there actually possible to do enough studies to show, definitively, the absolute safest way for every individual woman in each of her individual pregnancies to give birth? <BR/>So what's wrong with making all the options safe as possible, giving women all the information, and letting them decide for themselves?<BR/><BR/>What is the point in vehemently opposing Home Birth After Cesarean, or any other choices regarding how a baby should be born, for that matter?Unknownhttps://www.blogger.com/profile/05224754672330054232noreply@blogger.comtag:blogger.com,1999:blog-23685740.post-12905390663591341142008-02-07T08:53:00.000-08:002008-02-07T08:53:00.000-08:00?'s for Dr. Amy, or anyone else who knows the answ...?'s for Dr. Amy, or anyone else who knows the answers:<BR/> I was told (by several Drs) that scar tissue was stronger than the original tissue. If this is true, why does risk of rupture increase after a C/S instead of decrease?<BR/> I was also told most of the time, when a doc does a repeat C/S she trims the excess old scar tissue. SO shouldn't this keep the chance of rupture steady, no matter how many you have?<BR/> Please help me understand the process going on here, so I can then better sort out all the conflicting views I am hearing. Thanks<BR/>MarleneMarlene, CPMhttps://www.blogger.com/profile/17483714633192094508noreply@blogger.comtag:blogger.com,1999:blog-23685740.post-7702965589819497342008-02-07T05:39:00.000-08:002008-02-07T05:39:00.000-08:00fact VBACs are safer than repeat C-sections and be...fact VBACs are safer than repeat C-sections and better for mother and baby. Fact risk of uterine rupture and other complications increase with each C-section. I think the better wording for the title would have been safer than repeat C-sections, to avoid conflict from this doctor and the nurses. Still it is sad to see that an OBGYN is afraid of birth.Lisahttps://www.blogger.com/profile/01647438325547198176noreply@blogger.comtag:blogger.com,1999:blog-23685740.post-36109083348307163592008-02-06T07:00:00.000-08:002008-02-06T07:00:00.000-08:00"I have never heard of ANYONE who has had a c-sect..."I have never heard of ANYONE who has had a c-section be counseled on how many children she wanted to have."<BR/><BR/>Funny you should say that. We had a Woman come in for a primary elective C-section for possible macrosomia. The Doctor on Call spent 45 minutes in the room chatting with her. I asked him what he explained about consent.<BR/><BR/>He told me the Green Journal had an article about consent and C-sections. He discussed how many children she was planning to have. Explained Accreta, previa, miscarrige (from implanting on the scar, hysterectomy risk. He also discussed the usual surgery complications. <BR/><BR/>I asked him if he discussed possible respiratory distress with a C-section. He replied "no because she is in labor so that should negate the C-section without labor respiratory distress syndrome.<BR/><BR/>Of course, he also explained shoulder dystocia because that is what she is worried about.<BR/><BR/>So I think OBs are getting better about informed consent.pinkyhttps://www.blogger.com/profile/00198277802918823591noreply@blogger.comtag:blogger.com,1999:blog-23685740.post-54012111637455846652008-02-05T20:50:00.000-08:002008-02-05T20:50:00.000-08:00"how many of the ruptures were associated with the..."how many of the ruptures were associated with the use of Pitocin?"<BR/><BR/>That question was not addressed in the 2008 study. However, this study is a subset of the data from the 2004 NEJM article that showed the increased risk of rupture and neonatal mortality and morbidity in attempted VBAC.<BR/><BR/>In that study, augmentation of labor or induction of labor doubled the risk of uterine rupture. The risk of uterine rupture in spontaneous labor was 0.4%.<BR/><BR/>A much more remarkable factor in uterine rupture was success of the attempted VBAC. Very few of the women who had successful VBACs had a uterine rupture. Failed VBAC led to a 22 fold increase in the risk of uterine rupture. Undoubtedly, this is related in part to the fact that a rupture often leads to fetal distress and an emergency C-section is performed in the middle of labor. However, it also suggests that rupture may be more likely to occur if the uterus is attempting to push through a baby that won't fit.<BR/><BR/>There is some evidence to suggest that women who had the original C-section for reasons other than cephalo-pelvic disproportion, such as breech or fetal distress, have a greater chance of successful vaginal delivery and a smaller risk of rupture during attempted VBAC.<BR/><BR/>It is very important for women to understand that while induction or augmentation increases the risk of uterine rupture, rupture can and does occur during spontaneous labor. During my training, I was taught that it was almost never appropriate to induce or augment labor in a woman with a prior C-section, and that's the rule I followed. I had a very high VBAC rate and fortunately, never experienced a uterine rupture among one of my patients. Of course, I always practiced in places with 24 hour OB and anesthesia coverage, so there were no restrictions at all on VBACs.Amy Tuteur, MDhttps://www.blogger.com/profile/08496583576036722794noreply@blogger.comtag:blogger.com,1999:blog-23685740.post-79503786957880319382008-02-05T19:35:00.000-08:002008-02-05T19:35:00.000-08:00One more question for Dr. Amy. Since you read the ...One more question for Dr. Amy. Since you read the study so carefully, how many of the ruptures were associated with the use of Pitocin?Tina Cassidyhttps://www.blogger.com/profile/14636705157835152712noreply@blogger.comtag:blogger.com,1999:blog-23685740.post-3773635506099549222008-02-05T09:21:00.000-08:002008-02-05T09:21:00.000-08:00Tina,I know there are hospitals with more restrict...Tina,<BR/><BR/>I know there are hospitals with more restrictive policies. But I have been a labor nurse for 20 years in a hospital that has always <BR/> <BR/>-allowed mom just about as many support people in the room as will fit<BR/><BR/>-encouraged intermittant monitoring and walking in labor<BR/><BR/>-Neither pushes nor discourages epidurals..it is the mom's choice....not ours. I strongly believe there is nothing to make a mom feel bad about if she chooses an epidural. Labor does hurt. Our mother's are well informed of the cons/risks of epidurals and most choose them finding the pain relief well worth it.<BR/><BR/>-always done mother/baby recoveries where baby is in mom's arms most of the time. Only out of her arms for the weight, measurement, some of the assessment, and bath..and that is after breastfeeding at about one hour old, and I try to keep that as short as can be, and involve the family...with mom watching from bed, or sometimes, if she is ready to stand up, she walks over and helps and watches. For the past at least 12 years or so at least, baby doesn't go to the nursery AT ALL unless by request of mom. Well, now they go for weight at night, and parents are welcome to come, and PKU, and parents are welcome to come. We really strive to keep them together the whole stay if that is what they want ( and most do want that ). <BR/><BR/>You might be suprised that I once had a home birth. It was a lovely experience with two CNMs. I would never have another though given all I have seen. Mostly what I have seen is that time critical emergencies DO happen to low risk, uninterfered with births and that minutes count. Not only that, but lots of skilled help counts too. If you have seen what it takes to get a mom into the OR with a cord prolapse, how all hands on deck shaves the time it takes because everyone pitches in during an emergency ( never seen one after an AROM...only in one LOW risk mom)...how one team is getting the mom ready while another is preparing for the baby. If you have seen a baby be born completely unresponsive ( also I have seen this in an unmedicated birth ) and seen how many skilled people it takes to do a resuscitation well, and how experience matters at how well it is done. These things matter to the intact outcome of the baby. Something that time and skill affect tremendously. <BR/><BR/>Regarding VBACs- we did them prior to the ACOG change about OB and anesthesia immediately available. I believe it was a GOOD and SAFE change. For a short time we didn't "do" VBACs. To me this is always sort of an odd concept as the patient has a right to refuse anything, so she could just refuse surgery, however, who wants to give birth in an adversarial situation? The community and our doctors ( most are very pro vbac ) worked to change the policy and it was changed. We get women from surrounding communities coming to have VBACs with us. They have to have a saline lock, they have to have continuous monitoring, and OB and anesthesia have to be on campus during active labor. I think those are good rules. <BR/><BR/>Are we rare? Chris works on the other coast of the country and her hospital sounds pretty similar. <BR/><BR/>Regarding are OB's counseling women about VBAC with this newer research about placentation issues with successive C/S and a previous successful VBAC making the risk of uterine rupture less than it was before the successful VBAC. Yes, they are I have seen it. I went to a course in San Francisco where the first study placentation issues with previous C/S and what that might mean to the choices a mother is making who wants a large family was discussed. I would be suprised if the attendants were not using this information as they counsel women. I know they are here. However, there was a time, who knows you may have this in your book, when insurance companies were trying to FORCE Vbac on women. This I believe was mid eighties, it was the same time as women were pushed out of hospital because insurance would only cover 24 hours. Lots of very unhappy, frightened mothers. A VBAC should be forced on no one. Many women are very afraid of going through labor only to have another C/S. And the morbidity of planned C/S is lower than an unscheduled C/S in labor. So that should be the mother's choice. I am glad it is. <BR/><BR/>Thanks for listening. Have you had your HBAC already or is your story retrospective? I wish you well. I am fearful because you are well known, wrote a popular book, and may encourage other women to make similar choices. Some of those women won't be the lucky ones.Susanhttps://www.blogger.com/profile/15464292564190052567noreply@blogger.comtag:blogger.com,1999:blog-23685740.post-20108699098582705252008-02-05T08:23:00.000-08:002008-02-05T08:23:00.000-08:00My hospital does Vbacs. We have telemetry. I encou...My hospital does Vbacs. We have telemetry. I encourage woman to walk around. They leave for 5 minutes to walk then come back and jump in the bed.<BR/><BR/>Maybe since the bed is the most prominent thing in the room, folks think that is where they should be.pinkyhttps://www.blogger.com/profile/00198277802918823591noreply@blogger.comtag:blogger.com,1999:blog-23685740.post-80513687513457410212008-02-05T07:43:00.000-08:002008-02-05T07:43:00.000-08:00Susan, thanks for sending over that info on contin...Susan, thanks for sending over that info on continuous monitoring. That is very helpful to have. How many hospitals would you say encourage women to be upright or walking during labor while hooked up to a monitor? How many hospitals have telemetric monitors? I think your hospital is a rare, but great, exception.Tina Cassidyhttps://www.blogger.com/profile/14636705157835152712noreply@blogger.comtag:blogger.com,1999:blog-23685740.post-20663716431733721312008-02-05T07:38:00.000-08:002008-02-05T07:38:00.000-08:00Yes it is all quite complicated and the headline, ...Yes it is all quite complicated and the headline, as headlines are wont to do, oversimplified the matter. And here's to complicating it further: I have never heard of ANYONE who has had a c-section be counseled on how many children she wanted to have. And yes, repeat c-sections may be safer for the baby in dire situations, but perhaps not the mother.Tina Cassidyhttps://www.blogger.com/profile/14636705157835152712noreply@blogger.comtag:blogger.com,1999:blog-23685740.post-48448068814171955282008-02-04T13:49:00.000-08:002008-02-04T13:49:00.000-08:00In order to be accurate, wouldn't you have to comp...In order to be accurate, wouldn't you have to compare Vbacs with Repeat elective c-sections that are also good vbac candidate? If you have a sick mom to begin with, you have a higher incidence of complications. <BR/><BR/> Also many primips are having their first baby in their 30s and 40s. This coincides with the age of the first cardiac event coming at a younger age. So we now have a population on woman who are destined to have a cardiac event and who are stressing the cardiac system with childbirth for the first time.<BR/><BR/>It all gets so very complicated.pinkyhttps://www.blogger.com/profile/00198277802918823591noreply@blogger.comtag:blogger.com,1999:blog-23685740.post-19326468184171105812008-02-04T10:18:00.000-08:002008-02-04T10:18:00.000-08:00Dear Tina,I am distressed by your headline.""Repea...Dear Tina,<BR/><BR/>I am distressed by your headline.<BR/><BR/>""Repeated VBACs are safe; repeated cesareans are not"<BR/><BR/>It is a huge overstatemet of the implications of these studies, and misleading to women making birth choices.<BR/><BR/>I think it is reasonable to say that the 2008 study did conclude that the risk of uterine rupture decreased after having a successful VBAC. I don't think they said they are "safe". Safety is always relative. Safer than if you had never had a previous VBAC, yes, and that is great information to have when counseling women about choosing a VBAC vs repeat cesarean. If she has already had a successful VBAC her risks of uterine rupture diminish. If I am interpeting it correctly, her risks become even less with each successful VBAC. But not zero. Still, as one person pointed out, useful information for women contemplating large families. <BR/><BR/>The other study, concluded this, also VERY important to women planning large families- "Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery"<BR/><BR/>I am not anti VBAC; I love helping moms have VBACs. I do believe the majority of VBAC research has shown that even though no one indicator of uterine rupture can always be counted on as the sentinel symptom of rupture the most common sign FIRST sign is fetal distress. Thus most hospitals do want continuous fetal monitoring, which, where I practice, and in every nursing textbook I have ever read, is best accomplished with a mother in any position BUT flat on her back because that position decreases uterine blood flow. ( I read that you chose homebirth because you don't want to lie flat on your back and if you had continuous monitoring you would have to lie flat on your back?) Boy, where I work the nurse would ask you to please NOT lie flat on your back. And we have telemetry so you can walk in labor and have the safety of the monitor. I urge you to do more research about how uterine rupture is detected and it's consequences. <BR/><BR/>Here is one reference but the part I think is most important regarding continuous monitoring is way in the middle<BR/><BR/>http://www.emedicine.com/med/TOPIC3746.HTM<BR/><BR/><BR/>Here is the relevant data:<BR/><BR/>The signs and symptoms of uterine rupture largely depend on the timing, site, and extent of the uterine defect. Uterine rupture at the site of a previous uterine scar is typically less violent and less dramatic than a spontaneous or traumatic rupture because the scar is relatively avascular. <BR/><BR/>The classic signs and symptoms of uterine rupture are as follows: fetal distress (as evidenced most often by pattern of abnormalities in fetal heart rate), diminished baseline uterine pressure, loss of uterine contractility, abdominal pain, recession of the presenting fetal part, hemorrhage, and shock. However, modern studies show that some of these signs and symptoms are rare and that many may not be reliably distinguished from their occurrences in other, benign obstetric circumstances (see Table 2).<BR/><BR/><BR/>Table 2. Conditions Associated With Uterine Rupture<BR/><BR/><BR/>Condition Total Cases Cases With Uterine Rupture Incidence in Patients With Uterine Rupture, % Years of Data Collection No. of Studies <BR/>Abnormal pattern in fetal heart rate 344 187 54 1973-2002 8 <BR/>Prolonged deceleration in fetal heart rate or bradycardia 143 114 80 1983-2002 4 <BR/>Uterine tachysystole* or hyperstimulation 30 12 40 1994-1999 2 <BR/>Loss of intrauterine pressure or cessation of contractions 144 6 4 1973-1999 3 <BR/>Abnormal labor or failure to progress 169 49 29 1983-1996 2 <BR/>Abdominal pain 454 118 26 1931-2000 9 <BR/>Vaginal bleeding 381 140 37 1931-2000 8 <BR/>Shock 213 71 33 1931-1993 3 <BR/><BR/>*Defined as > 6 contractions during 2 consecutive 10-minute periods of observation.<BR/><BR/><B>Prolonged, late, or recurrent variable decelerations or fetal bradycardias are often the first and only signs of uterine rupture. Bujold and Gauthier showed that abnormal patterns in fetal heart rate were the first manifestations of uterine rupture in 87% of patients.</B>46 In a study by Leung et al, prolonged decelerations in fetal heart rate occurred in 79% of cases and was the most common finding associated with uterine rupture.54 Rodriguez et al found that fetal distress was the most common finding associated with uterine rupture, occurring in 78%.55 Overall, in 4 studies from 1983-2000, prolonged decelerations of fetal heart rate or bradycardias occurred in 114 (80%) of 143 cases of uterine rupture. In cases that involved the extrusion of the placenta and fetus into the abdominal cavity, prolonged decelerations in fetal heart rate occurred invariably<BR/><BR/><BR/>Just more information and I believe very important information for any pregnant woman contemplating a VBAC and choosing the safest place and type of monitoring for birth.Susanhttps://www.blogger.com/profile/15464292564190052567noreply@blogger.comtag:blogger.com,1999:blog-23685740.post-75784364458870208772008-02-04T09:06:00.000-08:002008-02-04T09:06:00.000-08:00Amen, Mom!Amen, Mom!Mama to Monkeyshttps://www.blogger.com/profile/14696704625536509191noreply@blogger.comtag:blogger.com,1999:blog-23685740.post-10810677656081161472008-02-04T08:54:00.000-08:002008-02-04T08:54:00.000-08:00"They do not show that repeat VBACs are safe and r..."They do not show that repeat VBACs are safe and repeat C-sections are not, and it is misleading to suggest otherwise. For babies, repeat C-sections are safer than VBACs and these studies do not change that fact."<BR/><BR/>One implication that you're skipping over is for families that are planning 3,4, or 5 children. Many of these women, when faced with a primary c-section and then the choice of VBAC or a second c-section for their subsequent baby, are never counseled that their risk of having more and more c-sections raises their risk with each section. Since the stats now show that subsequent VBACs are in fact safer and safer, families planning to have more than two children will need to be informed both when they have their primary c-section, and when they are advised to have more with their additional children.starparticlehttps://www.blogger.com/profile/00302445299886004866noreply@blogger.comtag:blogger.com,1999:blog-23685740.post-80542440217779845622008-02-04T08:38:00.000-08:002008-02-04T08:38:00.000-08:00Could we move on? I'm sick of the stats. Doesn't...Could we move on? I'm sick of the stats. Doesn't mean anyone is doing it right 100% of the time!momhttps://www.blogger.com/profile/13912881102031569038noreply@blogger.comtag:blogger.com,1999:blog-23685740.post-55953302442712888892008-02-04T07:32:00.000-08:002008-02-04T07:32:00.000-08:00"My point is to show that on the one hand, when th..."My point is to show that on the one hand, when the medical community is pushing repeat cesareans, we need to heed the study that says there can be serious complications for repeat cesareans. The other study -- BY CONTRAST - shows that once a woman has had a successful VBAC, future VBACs are quite safe."<BR/><BR/>As it happens, the studies are done by the same group, and the most recent study mentions the first study. Moreover, this is the same group that published the landmark study in the New England Journal of Medicine, <A HREF="https://content.nejm.org/cgi/content/abstract/351/25/2581" REL="nofollow">Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery</A>, which definitely showed that an attempted VBAC has a greater risk than a repeat C-section. They concluded: "A trial of labor after prior cesarean delivery is associated with a greater perinatal risk than is elective repeated cesarean delivery without labor, although absolute risks are low. This information is relevant for counseling women about their choices after a cesarean section."<BR/><BR/>The authors do NOT conclude that their work shows that repeated VBACs are safe in contrast to repeat C-sections. The authors believe that their study shows that once a woman has had a successful VBAC, she is in a different risk category and should be counselled differently than a woman who has never had a successful VBAC.<BR/><BR/>The post is titled "Repeated VBACs are safe; repeated cesareans are not". It does not matter whether you compare the studies or contrast them. They do not show that repeat VBACs are safe and repeat C-sections are not, and it is misleading to suggest otherwise. For babies, repeat C-sections are safer than VBACs and these studies do not change that fact.Amy Tuteur, MDhttps://www.blogger.com/profile/08496583576036722794noreply@blogger.com