A more natural cesarean delivery

As I approach my second cesarean delivery I've been thinking about what tweaks can be made to soften the surgical experience.

Ideas for the Best Cesarean Delivery
Prepared by Penny Simkin, author of The Birth Partner, recommended to me by a doula friend.


Here are some more links about "natural cesarean" deliveries:

The natural caesarean: a woman-centred technique

The new "natural" Caesarean

The main ideas about this type of modification of the delivery experience have come from Great Britain.


So far I've talked to my OB about having my sister doula my surgery again, abstaining from the antibiotic eye gel and about the possibility of them putting the baby on my chest right after delivery.

Dang that hurts like a b*tch! (HSG Report)

I'm just back home from my HSG and what is there to report... I found it really painful again but thankfully I'm not having deep seated cramps right now (they made my knees weak last time three years ago). I had some bleeding/spotting right away afterwards which hopefully will stop before the end of the day.

The test showed that both tubes were open. Imagine the likelihood of that with all the mucking about in my woomba that's gone on in the past couple of years. The uterine shape looked pretty normal otherwise, no funny distortions from adhesions or fibroids this time.

I think they would have let my partner in to watch but since recents reports have said that it is best to limit your lifetime exposure to radiation, including x-rays, it's all for the best. And, as I said to my RE, I have found the HSG to be way more physically painful than a d&c since they sedate you for the d&c. It's over quick but DANG! OUCH! OW! OH! EEEEE! and THAT HURTS! I don't know who the people are who say it is no big deal, I hate it.

Also, a word to the wise, even if you can drive afterwards and go back to work doesn't mean that you should a) go by yourself or b) plan on going back to work. If your scan shows something is wrong, or if you have a strange reaction to the dye (such as weak knees or low blood pressure) then you will most certainly want someone there to take care of you. I'm staying at home the rest of the day and soon I will be taking a nap.

Introducing my new fibroid

I just had my RE appointment this afternoon and it was an interesting experience. My partner basically laid it out there for her, that we were feeling that it was worse to get pregnant than to not get pregnant -- since losing the pregnancies was far worse than not having them. She suggested that we try using Femara to induce ovulation for a few cycles, in the hopes of promoting a stronger ovulation. After a few cycles we could then move on to trying IUI. She said that really, in spite of my partner's poor morphology, that getting pregnant on our own really was the ultimate test of his fertility.

We also discussed and scheduled a HSG for next week, to check for adhesions, any damage to the lining from the two d&cs and make sure the tubes are open. Sounds reasonable, and its what I wanted.

I brought up again that I had read that low ferritin had been linked by some doctors in Britain to lower fertility and increased miscarriage rates and she dismissed me and said that she had never heard that and it wasn't something that she would check for on her own. If I pressed she would do the bloodwork but whatever.

Then she suggested that we do an ultrasound right then and there to see about any new fibroids. Sure I thought, but there weren't any when I had my ultrasounds around the last miscarriage. Low and behold, there was a brand new 2.5 x 3.5 cm intramural fibroid, but away from the uterine lining and towards the outer wall of my uterus. I was in total disbelief. I just went through major abdominal surgery just 14 months before, and there wasn't anything on the scan last June. How could this happen so fast, and in the same are of my uterus?

She said it seemed to be pushing the right ovary out of the way a bit, distorting it on the scan. How nice eh? She said she doesn't think it is causing me any problems right now. She also checked my lining via ultrasound and said that it didn't appear inconsistent which can sometimes be an indicator of adhesions. I'm going to have an HSG on Tuesday next week to check my tubes. If that all looks okay then we'll try for a few cycles using Femara/Letrozole to see if maybe there is an ovulation dysfunction that we can override.

As my doctor was leaving the operatory I said dryly, "well at least I've been growing something in there," and she totally didn't know what to say but then she laughed (my twisted sense of humor overwhelms them you see).

So what should we name this new little interloper?


Some of the lovely things you find in the RE's office.

Report from the ob/gyn visit today

My appointment went well but I was really upset by the end of it, having to explain about all I've been through. The doctor was very nice though and when he saw that I was getting upset he switched over and started saying lots of consoling, positive things which was what I needed. We talked about a c-section delivery and how he would do that and I learned some about their practice. He was a little confused as to why I was seeing an RE without having fertility treatment but finally I think he got it, just circumstantial that we hadn't yet gotten to any fertility treatments. I feel like Annie in the musical, "I think I'm gonna like it here."

I dropped by my RE's office which is now on the next floor down to say hi the office staff who know me pretty well now. Still feeling upset, I decided that I wasn't ready to go in to the office so I went home and took a nap for an hour and a half (I did get up at 5:30 this morning) and then felt tired and icky after I woke up. I cooked lunch and made some passionflower tea to calm my nerves (good stuff) and realized that I was holding my muscles related to my uterus. I've been feeling crampiness like after my HSG. I think it was the PAP that set it off, probably brought back pain memories as well.

I finally got into work after 2pm. C'est la vie right?

Pelvic Adhesions

Adhesions are really common after pelvic surgery but they don't necessarily have to cause you problems or impact your fertility. Some doctors will perform an HSG (hysterosalpingogram) a few months after a myo for women wanting to try to conceive but mine thought we should just see what happened for a few cycle on our own. We were able to conceive and have implantation in my uterus so no problems there for me.

Adhesions & Pelvic Pain
What Women Need To Know About Prevention and Treatment

Pelvic Adhesions

Pelvic Adhesions - Their Role in Infertility and How to Prevent Them
PDF brochure from RESOLVE

Reduction of Adhesions

Asherman's Syndrome

Pelvic Abnormalities: Pelvic Adhesions (photos)

International Adhesions Society
(they are also conducting a survey of patients regarding informed
consent forms with regards to mention of adhesions)

Adhesion Related Disorders

Chronic Pelvic Pain
(includes some info about how to minimize adhesion formation)

Pelvic Adhesions
(fairly clinical and scientific information about adhesion formation and prevention in a Powerpoint presentation)

Pelvic Pain Needing Treatment

Wound Healing and Scarring - Sutures

Prospective clinical trial of SprayGel as a barrier to adhesion formation: an interim analysis.
(there are other media that can be used to prevent adhesion formation as well, if you are interested continue searching on these terms:
"pelvic adhesions barrier agents")

My scan is in 24 hours (3pm PST). I can't wait for it on one hand and in denial on the other. I think to myself that maybe I can just ignore and things will happen or not. Right? I'll either have a miscarriage or a won't. I'll either have a baby in 8 months or I won't. Seeing the scan will just mean that I have to do something, feel something and part of me doesn't want to feel anything.

I feel a bit pregnant but nothing compared to last time when I was exploding with my fibroid. Realistically if there is an embryo inside of me it is the size of a pea or something, with the sac around it. Fairly small over all. My pregnancy symptoms have been pretty easy over the past week, my breasts still hurt but gone is that feeling of knives stabbing into them, my uterus feels a bit full, sometimes at the end of the day it actually feels extra swollen. My abdomen has adjusted to the hormonal bloat. I'm a bit moody -- alternating feelings last night of frustration, anger and wanting to cry. Overall it just feels like a bad case of weird PMS - is that how pregnancy is supposed to feel?

I talked to my partner last night about not wanting to tell anyone about our pregnancy and he said that he felt the same way. We're kinda of feeling like letting people find out if/when it gets noticible. We have no plans either way for telling or not telling -- I guess we'll just have to see how our appointment goes tomorrow.

I'm doing okay but feeling very emotional today. My mother had her surgery and it went well, the cancer hadn't spread at all.

I'm still holding my breath until we have a scan that shows that there is something actually growing in there and not just a blighted ovum like last time. As the day for the scan grows nearer I find myself getting more and more emotional and scared about it. I've been trying not to get my hopes up at all but instead I've been feeling a bit alone about it. I just feel like I've got awful PMS and maybe it will stick and maybe it won't but it's a really hard place to be in. So when you add that on top of the other stuff going on in my life I'm having a hard time not crying while writing right now.

And depending on what treatment my mother has I might not be able to see her, because radiation would make her radioactive and pg women and children (sometimes adults as well) are supposed to stay away.

Even if you get a BFP there is no solace and you don't necessarily feel like you have accomplished anything other than a delayed AF.:(

So I had an A-HA moment this morning. I was seriously showing a lot earlier last time, which makes sense with the normal swelling of the uterus and growth of the sac and placental tissue but I also had a fibroid so my uterus was already enlarged to about 3.5 months pg equivalent in size, and it surely got up to around 5 months pg in size by 8 weeks post O. This is so much easier this time around.

What a relief!!

You can see how I was feeling at this point of my pregnancy in my post from last year.

I'm 16 dpo today and I just got back the results of my second beta. Monday=94 (14dpo) Wed=266 (16dpo). My progesterone was 13.2 but they aren't worrying about it and I'm already supplementing with progesterone cream.

I don't want to say anything until after my 6 week scan, since that was such a rough thing for us last year. After we see a baby then we will let everyone know.

I'm going in for my repeat beta later this morning after my acupuncture appointment. If the numbers look good then I'll post my chart tonight.

I told another friend from the boards yesterday, she hasn't been on in months and is taking a break and just happened to IM me yesterday. She's been trying for ages and it turns out her DH has anti-sperm antibodies. Their relationship has really been affected by the infertility and they are likely going to separate -- a lot has gone wrong in their relationship, this would be for the best.

She told me to let people know so that they could share in the good news. I know what she means but I think about my infertile buddies and how this news would be a mixed thing. I hate how hard it is for ppl, but this really didn't come easy I had to make some pretty radical lifestyle changes and also have surgery.

My breasts are sore, though a touch less sore than yesterday. Its more different sore. I so hope that everything is going to go well. With all the healthy eating I've been doing to help rebuild my system since the surgery, the weekly acupuncture, the select use of medicinal herbs, and the progesterone -- plus not having my blood-sucking fibroid in there anymore -- surely things will go better this time.

My partner, came down last night from his office in the attic and sat next to me and put his head on my shoulder and said "When are we going out to dinner to celebrate my good sperm" He wants to go to that nice restaurant we went to on our anniversary. I reminded him that we opened up a celebratory bottle of champagne last week (yum!) and that it was a good thing we got that out of the way as I wouldn't be drinking for a while. I don't mind a sip here or there, but nothing more.

I think I'll post my updated chart on Thursday if my temps look good and just let people find out that way. Does that seem weird. I'm just so afraid of jinxing it. Ya know?

My breasts are so huge already, much sooner than last time for certain. I tested positive at 19 dpo -- I waited until I was a couple of days late -- and it was the week after that things got interesting. I didn't use progesterone that cycle though so who knows.

I've had lots of belly twinges and also faint waves of nausea but nothing that would stop you in your tracks. I so hope this is a keeper. You have no idea how much my mood lifted when I got the beta result.

You have no idea how surprised I am. I totally wasn't expecting that test to come up positive. I thought to myself that it was just going to be another blank test. Then I noticed a the test dye was activated and it just looked a little bit different. Then I walked away and came back and it looked like nothing but I picked it up and the dye was starting to lightly accumulate some on the test line as well as the control line.

It's been a long time since we started on this TTC adventure. I was just saying on the Ovusoft boards on Saturday about how this would be a bad time to get pg since work is so busy right now with proposals and deals closing. Same as last year though, I was just starting to give up hope and then this. We conceived last May 24th (my ovulation date) so this must be a fertile time for us.

Of course the bathroom is still a mess and the kitchen remodel isn't underway. I still haven't finished renovating the office but now I need to stay away from paints and solvents -- even though we use low toxicity/water-based they still contain compounds which act on the endocrine system.

All it took...

Vasectomy reversal in 1998
Poor morphology 2000
Charting and TTC started 2002
Fibroid dx 2002
Start working with a naturopathic doctor 2002
Consult with a bunch of REs and Ob/gyns 2003
Get partner off of Paxil 2004
Get partner on MFI vitamin mix 2004
Acupuncture for me 2004-2005
Blighted ovum July 2004
Fibroid surgery 2004
Chinese herbs to help rebuild my system after surgery 2005
Fertility monitor Feb 2005
Lots of wonderful online buddies to help keep me sane when things were sure as heck not feeling that way.

Thanks to all who donated babydust to this BFP. I'm spreading a little back out at the rest of you who are needing it.

I forgot to mention that I used vitex as you may recall, for 6 days of this cycle. I think that it actually might have helped to recalibrate me a bit. Then I started using natural progesterone cream (Emerita) starting 8dpo and the combination of the two might have made my wooba more hospitible. I also used cinnamon to help counteract my post O fatigue which did help. I haven't posted my updated chart yet, I'll do that for Thursday morning, after I have the result from my second beta draw. Oh, and I also did what another TTC buddy did -- I went out shopping for new clothes last week.

Ovulation, eventually.

I took vitex for about 5-6 days and it really did help stop my breasts from hurting. But then when it gave me a headache I stopped taking it. It took me an additional 5-6 days until my body ovulated this cycle which was on May 1 or 2, so no ovulation in April.

After I ovulated I was exhausted for a few days. Really, really exhausted. Like after a full nights sleep wanting to lay down in my office at work and nap. I wasn't on herbs or meds or anything. The second day of that I did go home in the afternoon and fell right asleep. I woke and went to a community meeting and then went back to bed for another 10 hours.

When I saw my acu for my weekly visit I asked him what was up. He said that my kidney yang was depleted, that is the warming energy that heats things up during the luteal phase. He did some moxa and other heated needle work on me and told me to have more cinnamon. That seemed funny to me too but it worked. I had a lot more energy on Thursday. Friday, well that was another story.

Friday I was dealing with a deadline and some really nasty horrible moody feelings. Kind of miserable really -- I can't be the only one who feels this way during their luteal phase. Saturday I was still a bit on a downer note but then in the afternoon I decided to kick my own a$$ and make myself do things that would make me feel better. I decided to cook dinner for our extended family and give some gifts. You know, it worked. Then I spent a good amount of time on Sunday exercising, washing the car, working on home improvement projects, and baking. I've been much better this whole week thank goodness.

My basel temps were awful though, not only that but they were tanking when they should have been at their peak for a non-pregnant cycle. I started using my natural progesterone cream Sunday night (it was part of my original plan for this cycle but I somehow didn't get around to it), and my temps have been up all week into a reasonable range. I think that this cycle is a total nogo but what the heck do I know. I'm on 10 dpo so technically I'm still in the reasonable range for implantation.

I'm tired of all the energy that I've put into TTC right now though. And with all the grief and healing that I had to do (physical and emotional) my work really bore the brunt and now we are all feeling it. I had to change my priorities, so for now I'm feeling a lot quieter.

Jumpin' Jiminy! Supplements work!

So don't think I'm an idiot for not knowing sooner, I got the last test results over the phone in May 2004 and we got pg that same cycle so it wasn't like we were having to pay too much attention.

I met with the nurse practitioner this morning and she was of the same opinion as my partner -- that my fibroid was a big impediment to our fertility so having it out really changes the lay of the land. She agreed that unless we were feeling really impatient that the best course of action is to just keep trying on our own and give things a chance to work on their own. She pulled up my partners last s/a results and I was surprised to see the results -- his last test did include a morphology check and it had jumped up to 5%!

Date	10/13/2003	5/18/2004
Viscosity	Normal	Normal
Volume	4	4.1
Concentration	49 mill/ml	36 mill/ml
Motililty	57%	57%
Morphology	2% Kruger	5% Kruger
Prog	Grade 2	Grade 2
Agglutination	Slight	None

So, I really need to look at this like we're just starting over. Being 34 means that our fertility is a bit less than prime but the nurse thought waiting until August before re-evaluating was totally reasonable. She advised me to go get a pelvic exam and a pap and then to just keep timing things properly and something should happen. I sure as heck hope so.

Going Back in for Testing

I just called my RE's office to set up at "What Next" appointment after talking to the nurse there for a while. We haven't used any birth control since February 2000, and then it took us two years of fairly diligent trying (2002-2004) to finally get our BFP only to have it be a blighted ovum. In spite of the delay in our return to TTC until February (so the second half of 2004 was out) I still can't help but feel like there is something else at play. I haven't had my panels done since Feb 2003 and a lot has happened since then and I'm older now too.

I'm also going to get CD3 bloodwork done since that's tomorrow and I can just make sure that hormonally everything is swimming right (at the end of AF in my last cycle I had this odd temp rise that seemed unusual to me). The nurse said it might be time to have another HSG as well, not fun but I want answers.

My partner wasn't upset by the tests but he has this idea that my fibroid was the root of all evil and I'm not convinced that it was. When you can read stories about women having pregnancies with 5 tumors the size that I had (how they do it I don't know), it just boggles my mind. He keeps telling me that we just have to have a lot of sex. We have been having a lot of sex. I have three years worth of records of the majority of times we had sex -- somedays we even did it twice and you can't mark that down as a double in the charting program I use. Maybe I should do the math for him and tell him how many sperm he has deposited over the past three years and maybe then he will understand my frustration.

He wants me to just start over like it was the beginning again and we were just coming to this place where we are TTC in our lives. I don't know about you but I can't just erase three years of stress and heartache without a lobotomy. He got all pissed with me and said "I hate when you get like this" and I just said goodbye and hung up.

If we end up pg I can tell you it will be a result of all my hard work, research, hours of commiseration with my online buds, some surgery, some tests and not just because we had a lot of sex!

Here's a shot of my myo scar 5 months after my surgery. Not bad at all.



Well, I don't know that I'll be doing any nude modeling but surely a little body makeup could make that just about disapppear.

How long to take off for recovery post myomectomy

I was out of work for 3 weeks and then returned part-time at first and then worked up to full time. I did that in part to try to allow my body to focus on healing, all that thinking we do takes up valuable energy that the body could use to help heal itself. Also, it isn't comfortable as you are swollen and have lots of aches and pains in the first 6 weeks or so. It isn't too bad though, manageable really. It depends on many things --

* if you lose a lot of blood or go in anemic then healing will go slower, and you may be fatigued longer
* if you are in good shape your body should be able to heal you more quickly,
* if you eat really well you should heal better,
* if you really do take it easy for the time you are off you will heal better
* if you have any complications such as the incision opening then it will take longer
* some people say that the more quickly you are able to start walking again regularly that it can help promote healing -- but you can't do anything like yoga or running for at least 6 weeks.

I've been running/walking a mile each day with my dog for the past couple of weeks. I've been really good about keeping it up. I did fall off the wagon and I had hot cocoa and cheese over the weekend which made me feel awful. I'm not lactose intolerant, its just that my body doesn't like taking milk -- it causes more stagnation in my system. I'm trying to be good again and not slide off into my bad dietary habits. Want to know what they are? Well either way, I'm going to tell you -- they fall among the following:



not drinking enough fluids throughout the day

not eating breakfast

not eating breakfast and not eating lunch until after 2:30pm

eating chocolate when I have skipped breakfast and eaten lunch late

eating simple carbs and not enough protein or veggies

not going to the bathroom right away and holding it in (i have an aversion for public bathrooms, it is a problem)



My weekend... My partner's other brother is in town, visiting from France with his girlfriend. We spent a lot of time with them, they leave tomorrow afternoon. We were over at my SIL's house on Sunday and I boldly chose to stay behind with her when everyone else went to lunch, I figured that since she is staying home with the two little ones all the time this might help give her a break and make it so she wasn't feeling left behind. We chatted and eventually the conversation turned to my miscarriage. It was a very difficult and emotional conversation for us both and we both cried. She didn't understand why I couldn't talk to her for 6 months since my partner said I was fine (which wasn't true) -- she was a week behind me in getting her BFP so it was very difficult for me to see her. It was hard for me to have to open it up and explain it to her, but it had to be done as it was unresolved between us. I didn't tell her the nasty things, the really awful feelings I had along the way -- such as hating her, wishing her baby would die too, thinking she was selfish for only trying to reach out to me once. It is normal, I'm not the only one who has felt that way but I can't tell her that stuff. I told her instead that you worry enough when you are pregnant and that I didn't want her to see the dark side of pregnancy -- which is partially true as well.

She told me she was glad that I was accepting of my niece and that ultimately the pregnancy meant nothing -- we both agreed that, but I told her I just didn't need the constant reminders of the baby I wasn't having, the pregnancy that had failed.

Vaginal Birth After Myomectomy -- Uterine Rupture Risks

My latest thing is trying to evaluate the risks of a vaginal birth now that I've had an incision all the way through my uterine wall. I have been advised to have a scheduled c-section by my surgeon. I've researched this topic before, and I even avoided the surgery for a long time because I knew that they would say I would have to have a c-section.

It looks like the risks are:

* up to 9% (4-9%) chance of a uterine rupture total (including
ruptures that occur prior to active labor, i.e. rupture at 28-34
weeks)

If the uterus was to rupture there is a:

* 1 in 3,300 births chance of the baby dying, and a
* 1 in 5,000 risk of hysterectomy
Is vaginal birth after cesarean risky?


Additionally:

"The risk of uterine rupture is 1 in 500 even with planned repeat
cesarean versus 1 in 10,000 with an unscarred uterus."
CIMS Alarmed by Highest US Cesarean Rate Ever

"women having planned cesareans for a subsequent birth were three
times as likely to have hysterectomies as women planning VBACs: 1 in
220 versus 1 in 625."
Is vaginal birth after cesarean risky?

"For women being induced without use of prostaglandin, the odds went
up only slightly, but when labor induction included prostaglandin,
they soared to 1 in 900 for hysterectomy and 1 in 770 for infant
death."


This in contrast to the rupture rates among VBACs with a transverse
incision:

”1 in 625 with a planned repeat cesarean,
1 in 192 with starting labor on their own,
1 in 130 with an induction of labor but without using prostaglandin
to soften the cervix first,
1 in 41 with labor inductions that included prostaglandin.”
Is vaginal birth after cesarean risky?

and

"cord prolapse, or antepartum hemorrhage) in any women giving birth,
is approximately 2.7%, or up to 30 times as high as the risk of
uterine rupture with planned vaginal birth after cesarean"
[Note that they are referring to VBAC after low transverse section
data)

So, if 9 women will have uterine rupture does that mean that the
other 91 women shouldn't be allowed to do a trial of labor?

I was looking in A guide to effective care in pregnancy and childbirth 3rd Edition (Enkin, Keirse, Neilson, Crowther, Duley, Hodnett and Hofmeyr, Oxford University Press) and found these interesting quotes:

"Maternal mortality and serious morbidity are fortunately very rare, and for this reason estimates of their frequency are imprecise. A large meta-analysis showed maternal mortality of 2.8 per 10,000 for women undergoing trials of labor, and 2.4 per 10,000 for women having an elective cesarean. Uterine dehiscence (asymptomatic separations of the uterine scar) or ruptures occur in less than 2% of trials of labor, the same proportion as is seen among women who have routine repeat cesareans. Most of these are asymptomatic and of no clinical importance."

"The rate of maternal death associated with cesarean section (approximately 4 per 10,000 births) is four times that associated with all types of vaginal birth (1 per 10,000 births). The maternal death rate associated with elective repeat cesarean section (around 2 per 10,000 births), although lower than that associated with cesarean sections overall, is still twice the rate associated with all vaginal deliveries, and nearly four times the mortality rate associated with normal vaginal birth (0.5 per 10,000 births)."

"...the probability of requiring an emergency cesarean section for acute other conditions (fetal distress, cord prolapse, or antepartum hemorrhage) in any women giving birth, is approximately 2.7%, or up to 30 times as high as the risk of uterine rupture with planned vaginal birth after cesarean"[Note that they are referring to VBAC after low transverse section data)

"Hospitals whose capabilities are so limited that they cannot deal promptly with problems associated with a planned vaginal birth after cesarean are also incapable of dealing appropriately with other obstetrical emergencies."

It is strange how the ob/gyn field reacts towards childbirth and its complications, even though it is a natural process. When you contrast what I've learned through my experience with fibroids, that many women who have finished having children are advised to have hysterectomy for these benign tumors though they can be safely excised via abdominal or laparoscopic surgery. In contrast, a doctor specializing in the colon, when presented with a patient with a polyp in the colon, does not proceed to remove the colon, s/he would remove the polyp alone. And then I was looking for stats on complication rates after other surgeries and saw this, perhaps not the best comparison but still:


"The Duke analysis found that the mortality rates for heart failure patients was 11.7 percent, compared to 6.6 percent for coronary artery disease patients and 6.2 percent for patients without heart disease. In terms of readmission rates after surgery, heart failure patients had a 20 percent rate, compared to 14.2 percent for coronary artery disease patients and 11 percent for patients with out heart disease."
from: Heart failure patients at increased risk during non-cardiac surgery


So the death rate from having non-heart related surgeries on patients with heart disease is really high. Much higher than the risks associated with childbirth, and much higher than the risks of uterine rupture. It just boggles the mind how different these specialties are when they approach patient care.

"Early findings suggest that a the greatest influence on a woman's decision to attempt a VBAC trial of labor is her personal philosophy of birth (normal life event vs potential disaster) and the attitude of her healthcare provider surrounding VBAC trial of labor. The final findings will be presented at the 2004 ACNM Annual Meeting in New Orleans, Louisiana."Vaginal Birth After Cesarean (ACNM 48th Meeting)

While uterine rupture is slightly more likely with planned vaginal birth (5 per 1,000 versus 2 per 1,000 for a repeat cesarean), newborn outcomes do not differ. With appropriate care, 7 out of 10 women or more laboring after a cesarean will birth vaginally.
CIMS Alarmed by Highest US Cesarean Rate Ever

"Leaving aside that cesareans impose other risks that balance out the risk of uterine rupture during a VBAC, commentators on the Washington State data deemed the 1 in 3,300 chance of losing the baby during a spontaneous VBAC labor was sufficient to mandate planned repeat cesarean. The odds of amniocentesis precipitating a miscarriage fall somewhere between 1 in 200 and 1 in 400, more than ten times the risk of the baby dying from a VBAC-related uterine rupture. Yet obstetricians aren’t lobbying for an end to amniocentesis on the grounds that it is too hazardous."Is vaginal birth after cesarean risky?


"Even the way in which the Washington study data was presented was biased against VBAC. The article stated that spontaneous VBAC labor increased the risk of rupture 3.3-fold compared with repeat cesarean, a statistic quoted in media articles. This sounds alarming, but the absolute difference was four women per thousand, a miniscule number when you consider that two-thirds of women experiencing uterine rupture will suffer nothing worse than the cesarean they would have had in any case had they not decided on a VBAC."
Is vaginal birth after cesarean risky?


Increased risks are associated with:

• Gestational age of at least 42 weeks also raised the risk for a negative outcome.
  Results of the National Study of Vaginal Birth After Cesarean in Birth Centers (scroll down a bit)
  
  
• “Awaiting spontaneous labor beyond 40 weeks of gestation decreases the likelihood of successful VBAC but does not increase the risk of uterine rupture”
  Practice Guidelines: ACOG Releases Guidelines for Vaginal Birth After Cesarean Delivery
  
  
• “Approximately 50% of uterine ruptures that occur may be catastrophic, with significant rates of morbidity and mortality to both the fetus and mother.”
  Uterine Rupture and Vaginal Birth After Cesarean Section: An Historical Enigma
  
  
• “One study showed that women who had a previous vaginal delivery prior to attempting a trial of labor had a rupture
  rate that was one fifth the rate of women who did not have a previous vaginal delivery.”
  Uterine Rupture and Vaginal Birth After Cesarean Section: An Historical Enigma
  
  
• “Prior classical uterine incision is associated with a rate of uterine rupture of up to 12%.”
  Minimizing Obstetrical Risk: Vaginal Birth After Cesarean Section
  
  
• “Interdelivery interval: If the prior delivery was less than 18 months, there was a 3-fold increased incidence of uterine rupture compared with women having a longer interdelivery interval” and
  “Maternal age: Women over 30 years of age were 3 times more likely to experience a uterine rupture than those under 30 years”
  “Number of prior cesarean births: Women with 2 or more prior cesareans had a 3-fold increase in the incidence of uterine rupture (1.7%) compared with women with only 1 prior cesarean (0.6%).[9]”
  “Single-layer vs double-layer uterine closure: The 1-layer closure technique is associated with a 4-fold increase in the incidence of uterine rupture (3.1%) compared with prior 2-layer uterine closure (0.5%).”

Vaginal Birth After Cesarean (ACNM 48th Meeting)


"Pain at the scar does not reliably indicate uterine rupture. Caesareans for this reason often find intact scars.
Changes in contraction strength do not reliably indicate rupture, so routine intrauterine pressure catheters have little value.
Manual exploration of the scar results in both false positives and false negatives. False positives lead to unnecessary surgery. Wound openings without other symptoms probably need no repair anyway. The exploration (which is painful) may introduce infection and could potentially convert a wound opening into a rupture."http://www.bambi-bangkok.org/magazine/2000/b2_aug00.htm

"The majority of dehiscences after lower segment transverse incisions are 'silent', 'incomplete', or incidentally discovered at the time of repeat cesarean section. The potential dangers of uterine rupture are related to the rapid 'explosive' rupture, which is most likely, to be seen in women who have a classical midline scar. Rupture of the scar after a classical cesarean section is not only more serious than rupture of a lower segment scar, it is also more likely to occur. Rupture may occur suddenly during the course of pregnancy, prior to labor, and before a repeat cesarean section can be scheduled. A review of the literature at a time when classical cesarean section was still common, showed a 2.2% rate of uterine rupture with previous classical cesarean sections and a rate of 0.5% with previous lower segment cesarean sections. That is, the scar of the classical operation was more than four times more likely to rupture in a subsequent pregnancy than that of the lower segment incision.

Unfortunately, even in the older literature, there are very few data on the risk of uterine rupture of a vertical scar in the lower segment. One 1966 study reported an incidence of rupture of 2.2% in classical incision scars, 1.3% in vertical incision lower segment scars, and 0.7% in transverse incision lower segment scars. The distinction between the risk of rupture of vertical and transverse lower segment scars may be related to extension of the vertical incision from the lower segment into the upper segment of the uterus.

The uncertain denominators in the reported series make it difficult to quantify the risk of rupture with a previous classical or vertical incision lower segment scar. It is clear, however, that the risk that rupture may occur, that it may occur prior to the onset of labor, and that it may have serious sequelae, are considerably greater with such scars than with transverse incision lower segment scars. It would seem reasonable that women who have had a hysterotomy, a vertical uterine incision, or an 'inverted T incision, be treated in subsequent pregnancies in the same manner as women who have had a classical cesarean section, and that trial of labor, if permitted at all, should be carried out with great caution, and with acute awareness of the increased risks that are likely to exist."
Labor and birth after previous cesarean, 4.4 Type of previous incision in the uterus

The length of time from your c-section to your current due date is another issue. If less than 12 to 24 months will have passed since your c-section, your health-care provider will question whether there has been sufficient time for healing. Is the scar site strong enough to go through labor without separating? The highest risk for uterine rupture during labor is during the first year after a cesarean delivery. The risk of uterine rupture decreases over the following years. Other factors, such as surgical technique, suture material used, or infection may be involved as well. This issue is controversial and is being studied.
Midwife Elizabeth Stein on Vaginal Birth After Cesarean

“A woman's risk of uterine rupture increases with:

• Each additional uterine surgical scar. While a uterine rupture occurs in up to 8 per 1,000 women with one scar, up to 37 per 1,000 women with two scars develop a rupture.
  
• The use of medication to start (induce) labor. Use of misoprostol (Cytotec) or oxytocin (Pitocin) to induce labor has been linked to increased risk of uterine rupture during VBAC. In a recent study, uterine rupture occurred in:
  * 24.5 per 1,000 women who were induced with misoprostol.
  * 7.7 per 1,000 women who were induced with oxytocin.
  * 5.2 per 1,000 women who had a spontaneous labor.
  * 1.6 per 1,000 women who had a repeat cesarean without labor.
  However, careful use of oxytocin to aid (augment) a slow labor has rarely been linked to uterine rupture.4, 3
  
• Any uterine scar tissue that reaches above the lower, thinner part of the uterus. About 40 to 90 per 1,000 women with a vertical incision develop a rupture.

”
Rupture of the uterine scar and VBAC


“The type and location of the previous uterine incision helps to determine the risk of uterine rupture. The incidence of uterine rupture is 0.2% to 1.5% in a woman who attempts labour after a transverse lower-uterine-segment incision 14,16,18,27,45 and 1% to 1.6% after a vertical incision in the lower uterine segment. 46-49 The risk is 4% to 9% with a classical or “T” incision; and for this reason, a TOL after Caesarean is contraindicated in these situations.16,19,30 Shimonovitz et al. found the risk of uterine rupture after 0, 1, 2, and 3 VBAC deliveries to be 1.6%, 0.3%, 0.2%, and 0.35%, respectively, indicating that the risk of uterine rupture decreases after the first successful VBAC.”
SOGC Guidelines for Vaginal Birth After Previous Caesarian Birth

“Four studies have examined the relationship between the interdelivery interval and the rate of successful VBAC and uterine rupture.102-105 Esposito et al. examined 23 cases of uterine rupture and compared them to 127 controls.102 There was an increased risk of uterine rupture with a short interpregnancy interval (<6 months between pregnancies; <15 months between deliveries) compared to controls (17.4% vs. 4.7%, P=0.05).102 Shipp et al. reviewed 311 women who underwent a TOL after Caesarean less than 18 months after their Caesarean section and compared them to 2098 women who underwent a TOL after Caesarean after more than 18 months.103 The shorter interval was associated with a 3-fold increase in the risk of uterine rupture (2.25% vs. 1.05%: OR, 3.0; 95% CI, 1.2–7.2).103 Huang et al. reviewed 1185 women undergoing a TOL after Caesarean and noted no difference in the success of vaginal delivery in those with a shorter interval of <19 months (79% vs. 85.5%, P=0.12), but they did note a significant difference in successful
VBAC in women who underwent medical induction compared to spontaneous labour (14.3% vs. 86.1%, P<0.01).104 Their study noted no difference in the rate of uterine rupture.104 In 2002, Bujold et al. reported an observational study of 1527 women undergoing a planned TOL after Caesarean at different intervals from the index Caesarean delivery.105 The rates of uterine rupture were as follows: <12 months, 4.8%; 13 to 24 months, 2.7%; 25 to 36 months, 0.9%; and >36 months, 0.9%.105 After adjustment for such confounders as number of layers in the uterine closure, induction, oxytocin, and epidural use, the odds ratio for uterine rupture in a woman <24 months from her last delivery was 2.65 (95% CI, 1.08–6.46).105”
SOGC Guidelines for Vaginal Birth After Previous Caesarian Birth

Here's one more article about VBAC:
Predicting Cesarean Section and Uterine Rupture among Women Attempting Vaginal Birth after Prior Cesarean Section

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1201366/

AF arrived last night so I got to use my fertility monitor this morning. I know the first cycle it is just gathering data to compare to in future cycles but I have to say that the first day you use it is it a bit of a downer. I guess I don't have to POAS again until next week. I wonder how it will interpret my fertility, especially in contrast to my charting.

Do you know that I'm so much better since I felt all emotional and sick on Tuesday and then had to deal with my SIL's delivery. I feel like my ghost pregnancy, the one that you can't help but think about after that 9 months is defined when you get pregnant, the one that has been hanging over me -- it's over. I completed it and now I can go on. I metaphorically delivered my ghost baby up the other day. Does that make sense?