VBA2C's including invert T ???

[lorrainez]

Hi ladies

Just wondering if anyone in Australia has VBAC'd after 2 sections, the first being an inverted T or other 'odd' type? I had an 'elective' sections 2nd time because was told be everyone I couldn'y have another vag birth. When 2nd section was completed doc told me my 1st scar had healed that well they could barely find it. My first bubs was vag birth, although induced. I'm TTC and want to get as much info as possible before getting pregnant. I am 2 hrs from Adelaide so any good Obs, don't have private so need to be public, to talk to about this? Even Obs from another state that you know are really pro VBAC that I could contact for info? I know there would be IM's who would consider it but don't have the $'s to go down that path and also I'm not real comfortable with that at this stage, living 45 mins from the closest hosp that would be able to section if emerg arose is another negative factor!
Thanks

[RainbowBrite]

I had a classical c-section (inverted T) for my 6th bub after 5 natural drug free vaginal births and was told I would never be able to have another vaginal birth again as the risk of uterine rupture is too high.
When fell with my 7th I asked a lot of medical professionals about it and no one was even going to entertain the idea.
I ended up having an emergency c-section.
I wish you the best of luck TTC
(Sorry if I come across negative...but that is just my experience and a few others I know)

[MusicLover83]

If you google "Special Scars" there are a few sites with birth stories of women who have VBACed after having vertical incisions and I think one of the sites also have links to recent studies.
I think they are all from the US though.
Good luck

[RoyaUK]

Hi there,

I tried very hard with my third child to VBA2C after my 2nd c-section ended up with inverted T scar. I was extremely committed to trying, did months of research and had an independent midwife who supported me. I had all 3 girls at a public hospital so they 'had' to let me 'try' but i did have a hard struggle convincing the doctors that i understood the risks involved and i had a lot of research that i had to show to each doctor who saw me.

The difficulty is that there are so few women worldwide who have given birth naturally in this situation (after having an inverted T) that it comes down to a statistics game. I'd be happy to dig out my research for you (might take me a few days as we've moved house since DD3 was born & it'll be in a box somewhere.....)

Unfortunately i did end up with a c-section third time round but i had been through 7 days of 10 minutely contractions (prelabour) and i think have come to accept that perhaps my spinal issues prevent me from giving birth naturally (i have scoliosis).

[blessedatlast]

I have asked the same question. I had a classical cut for my twins and have also been told no vaginal births. I did some research and the risk of rupture increases quite a bit, so at this stage I am happy for another c section. I will however google 'special scars' I have never heard of that before.

[Arimeh]

In my 3 years of research, the only thing remaining constant throughout all material is that vbacs are safe after 1,2,3 sections - with the exception of a classical incision.

It's hard to find support for a vba2c (believe me!) but it can be done.

[Oliando]

Oh my goodness! Your situation was my situation exactly! I had an inverted T scar with my first, an "elective" csection with my second, a home birth with my 3rd and in 8-10 weeks I'm having another home birth with my 4th . I am just one of a group from Australia who have VBAC'd after an inverted T, classic or J scar we exist!

so far as the assertion that the risk of rupture is "too high" I am yet to meet any Drzps familiar with statistics, the few studies that do exist say very much the opposite so it's more a prevailing presumption than a known and investigated, peer reviewed FACT Dr's are aware of. Join the Facebook group Jessica runs, check out the studies that exist, look at the peer reviewed information she has and take it to your care providers. They might reject it, but it took me till 30ish weeks to find a care provider for my home birth, but she was incredible and so was the birth . Also whilst many of the women on Jessica's site might be American, a vagina and a scarred uterus work the same way over there as here so take strength from the birth stories and know this IS an option for you too. The actually small risk of rupture as compared to the 100% certainly ruptured c-section belly with all the other associated risks of death for you and bub, roughly 1 in 90 risk of losing your uterus entirely to surgical complications....the more you read about VBAC the more you might find comfort in the science that supports it, even though evidence based care is not always adopted as quickly in hospitals, the studies ARE there.

Please just remember to ask for Dr's to provide peer reviewed evidence for any studies they might refer to, that proves a higher rate of rupture. Also remember it's your choice to decide acceptable risk, not the Dr. I am going to post this and come back to edit with links...


Pooh I hate using the iPad! It's so clumsy!

Here are Jessica's studies http://www.specialscars.org/articles/index.html.

Here is my birth story - http://slow-bullet.livejournal.com/30326.html

Also as StarrSky mentions below, a classic cut was VERY common in the 1950's and women were rarely informed about their scar type and just went on to birth.

I will keep adding links as I find them.


TRUST that you can do this!!!!

[STARRYSKY]

I don't have any scientific stats to add but just wanted to say how much I admire the fact you are researching your options.

anecdotally- my grandmother had a classical c section 50 or so years ago with her second child, then went on to have 4 more children vaginally. It can be done.

[blessedatlast]

That's really interesting Oliando. I also had a look at the Special scars website and saw that indeed there were successful VBAC's. Just when I thought I had made up my mind! I think also an issue for me is getting someone to support me through a VBAC. Going through an IM or home/free birthing aren't options for me. I simply wouldn't feel confident enough not being under medical care with my underlying heart condition.. I'm confused. I want a VBAC, but in all honesty it seems the easiest option just to go with elective c section. *sigh. I'll talk to my doctor about it, but I know what she'll say... Maybe I should print off some literature to take with me.

[Oliando]

Blessed -hug- everywoman is going to have factors which influence her choices, I couldn't begin to comment on heart issues of course! But what I would say is that you want to trust your care providers are actually working for you, not simply from within their own desires, you know? If you want to have a conversation with your Dr, keep having that discussion until you feel she has given it the consideration and investigation it deserves. I found one OB who did not just snap out a 'no' but he wanted me to have induced labour (hello?! THERE is a HUGE rupture risk!) if I went over 41 weeks. Genetically its normal for women in my family to gestate longer, so there was no point having my pregnancy on another woman's genetic timetable
He was a good Dr but ultimately unable to provide care specific to ME and not just based on averages.

If your Dr says no, then ask her to explain why and provide evidence for it. This is someone you have employed to look after your health and wellbeing, you are entirely in a position to feel equal in the process of decision making. Imagine if you hired a wedding planner who picked your dress! This is YOUR baby, YOUR body and only YOU live with the outcome forever. For your DR, you are her job. Make sure you feel respect and heard.



I still have other links I am hunting down

[Tuesday's Child]

I was involved in a study on BAC done through the WCH in Adelaide. The study only included women with 1 previous c-section, but I do recall that women with inverted-T scars were eligible (though there were very few involved). The study was over quite some time ago but I haven't seen it published yet (politics ).

Jodie Dodd and Caroline Crowther were the two main investigators and both practice at the WCH. They have done a lot of research in this area. You should be able to contact them through the University of Adelaide Dept of O&G.

[Oliando]

Tuesday, do you remember any if the goals or parameters of the study? I would love to read it

edit for links

These are the links and studies I've found which were useful to me in researching a homebirth after an inverted T cut.


A book! Natural Childbirth After Cesarean Karis Crawford & Johanne Walters. One of the Authors had two homebirths after a T-scar. I don’t have it yet, but I’m trying to get a copy.





http://www.emedicine.com/MED/topic3746.htm

http://www.ngc.gov/summary/summary.a...7&nbr=5914#s30


http://f1.grp.yahoofs.com/v1/oFb8SKW...Associated.pdf
CONCLUSION: Classic cesarean section has a higher maternal
and perinatal morbidity than inverted T cesarean and
much higher than low transverse cesarean. There is no
increased maternal or perinatal morbidity if an attempted
low transverse incision has to be converted to an inverted
“T” incision compared to performing a classic cesarean
section. (Obstet Gynecol 2002;100:633–7. © 2002 by
The American College of Obstetricians and Gynecologists.)
* * *


http://www.gentlebirth.org/archives/vbacfrye.html
While the risk of disruption of uterine integrity certainly exists, it remains small, even for those who have had multiple Cesareans or Classical incisions. Neither multiple gestation nor breech birth appears to increase the risk of scar separation. (Davies and Spencer, 1988) In fact, rupture of the unscarred uterus occurs more often and does more harm than rupture of the scarred uterus. (Martin, et al.., 1988) In addition, the scar which has remained intact up to the threshold of labor is very likely to remain intact through the birth. (Macafee, 1958)

Those with classical or T-shaped incisions are at more risk for rupture, which tends to be more traumatic than the usually benign scar disruptions which occur in women with low transverse incisions. While some types of incisions pose more risk, the highest risk is still probably around 5% (some scars are more rare and limited data is available. From looking at the existing data, 5% seems to me a generous estimate of risk for all types of Cesarean scars, with the order of risk as follows: low transverse [0.5% Haq, 1988; to 2% Clark, 1988], low vertical [1.3% Enkin, 1989], classical and inverted T [probably about the same for both: 2.2% to 4%, depending on the study], upright T and J-incision [probably somewhat higher, but no specific data is available].). Women with an upright T, J-shaped, or classical incision or those who have experienced previous uterine rupture may want to birth in the hospital, although finding a practitioner that will assist them to have a VBAC will be more difficult. However, in these cases scar disruption is **most likely** [emphasis the author's] to occur during pregnancy with accompanying fetal distress and possible death, or not at all. The mother must weigh the risk of rupture with a VBAC, with the risks of major surgery and multiple Cesareans. As a midwife, you must assess whether you are up to dealing with the increased risk at home, especially since rupture of these incisions tends to be more traumatic than scar disruption in a low transverse incision. Studies indicate that a history of multiple surgical births does not increase the risk of rupture. (Farmakides, 1987; Porreco & Meier, 1983; Roberts, 1991)"
Classical and T- or J-shaped incisions pose significantly more risk of rupture than does a low transverse incision... These incisions are more likely to give way during pregnancy. However, when you consider that the overall maternal mortality for Cesarean section has been reported to be at least four times higher (Petitti, 1982) to as much as 26 times higher (Evrard and Gold, 1977) than for vaginal birth, the relatively small risk of uterine scar separation is put into perspective."

This is a conversation on a forum between a mother and Henci Goer - she was asking about a VBAC at a hospital with her inverted T scar - she replies later to say she did it, a natural drug free birth.
There is also an excellent point made by Henci about the reason stats are so high for older classic cuts...

http://www.lamaze.org/NormalBirthFor...c/Default.aspx

The rate that I have seen bandied about in the literature for scar rupture of a classical incision is even higher than 7%. After reading the Landon 2004's statistic, I looked up the sources for the higher number. Turns out it came from two older studies from back in the days when a fair number of classical uterine incisions were still being done, but these studies did not distinguish between scar dehiscence (a harmless window) and scar rupture (the scar opens completely and causes symptoms). Landon 2004 did, as do all of the more recent studies and reviews.

other key quote -

You didn't ask me this, but you may be interested in knowing what the odds are of the scar opening and causing problems with a c/sec uterine incision that is not the standard type (low, transverse). A large recent study of 17,900 women planning VBACs reported a rate of scar rupture of 2% (2 out of 105) in women with classical (vertical), inverted T, or J incisions. This is compared with a rate of 0.4% in women with the usual type of uterine incision who labored spontaneously (no induction, no augmentation). Keep in mind, though, that while a scar rupture is serious and will almost certainly require an urgent cesarean, the baby is almost always fine. Here is the citation for the study in case anyone is interested:

Landon MB, Hauth JC, Leveno KJ et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean ********. N Engl J Med 2004;351(25):2581-2589.

[Tuesday's Child]

Here is the protocol for the study. Since it hasn't been published I don't think I can discuss results (I was one of the statisticians who analysed it but wasn't even permitted to discuss results with data collectors or trial coordinators).

Birth after caesarean study - protocol

[Oliando]

Thanks Tuesday but in the exclusion criteria it lists inverted T scars. Also a bit hilariously it also excludes women who have had previous uterine surgery...so....c-sections? :P

Exclusion Criteria
Women with any of the following are ineligible: more than one prior caesarean birth, vertical, inverted T or unknown uterine incision, previous uterine rupture, previous uterine surgery (including hysterotomy or previous myomectomy involving entry of the uterine cavity or excessive myometrial dissection), previous uterine perforation, multiple pregnancy, any contraindication to vaginal birth (including placenta praevia, transverse lie, active genital herpes infection), cephalo-pelvic disproportion as judged by the clinician, lethal congenital anomaly, fetal anomaly associated with mechanical difficulties at birth (such as hydrops, fetal ascites, hydrocephalus, omphalocele or cystic hygroma).
The inclusion/exclusion criteria are based on guidelines recommended by the Society of Obstetricians and Gynecologists of Canada [48], American College of Obstetrics and Gynecology [16], the Institute for Clinical Systems Improvement [49], and the National Institute for Clinical Effectiveness [50], UK.

[RainbowBrite]

Classic cesarean section has a higher maternal
and perinatal morbidity than inverted T cesarean and
much higher than low transverse cesarean.

What is the difference between a classical and intverted T?
I had a classical, which I though was an inverted T?
Sorry for the silly question

[Oliando]

It's not a silly question at all!!

A typical c-section is the lower bikini line cut. A classic cut is a line just down the middle of your uterus, vertical. An inverted T is the lower bikini cut AND the vertical classic cut, making an upside down T shape.

From the outside you will just have the lower cut. The scar on your uterus will be different to the one on your skin.

[Tuesday's Child]

Thanks Tuesday but in the exclusion criteria it lists inverted T scars. Also a bit hilariously it also excludes women who have had previous uterine surgery...so....c-sections? :P

Oops, sorry my bad. I remember a question about the type of uterine incision and I was sure inverted T was listed there. Obviously not.

[RainbowBrite]

That were I get a little confused, mine is written on my hospital notes as a classical c-section but I had the inverted T you discribed...I was told it is more at risk of a rupture because my uterus is cut in two different directions (vertical was all the up my uterus as she was footling breech at 28 weeks). My last bub was an emergency c-section at 25 weeks so I had no choice anyway.
I am not having any more so it is irrelevant but just curious.
Thanks for answering.