Chandler, Arizona
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Sweet Pea ​Births
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Uterine Rupture: Assessing the Risks
Posted on April 26, 2016 at 10:18 AM |
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Uterine rupture is a topic that came up when I was pregnant with
Otter that I was not ready to allow into my consciousness until she was
safely in our arms. After enough time
had passed and we have proven to ourselves that homebirth can be a safe option
when a person is healthy and low risk, I am ready to write about it.
I gave Stephanie Stanley, former facilitator of the East Valley
ICAN group, byline credit for this because I am using her research from a
uterine rupture presentation she did at a meeting for my post today. ICAN, the International Cesarean Awareness
Network, is a non-profit organization that strives to improve maternal-child
health by preventing unnecessary cesareans through education, providing support
for cesarean recovery, as well as educate about Vaginal Birth After Cesarean
(VBAC) and options for what is called a "gentle cesarean" where the event is honored as a birth even though it's via a surgery. ICAN’s goal is to see a healthy
reduction of the cesarean rate that is patient-driven. By providing education and support, they hope
that more women making evidence based, risk appropriate childbirth decisions
will lead to an overall reduction in the rate of cesareans performed.
Uterine rupture seems to be the leading reason why care providers are
hesitant to allow a mother to have a trial of labor (TOL) after a previous
cesarean. In Arizona, a licensed midwife or certified professional midwife can attend a homebirth
with a mom who is striving to have a VBAC only if the mother meets certain criteria. Arizonana for Birth Options is leading a grassroots efforts to change this so
that as per the ICAN vision, women living here can make evidence based and risk
appropriate decisions. They want all
options to be available: for a hospital birth if mom feels that is the best
option, or a homebirth if both mom and midwife agree that they are a good
candidate for VBAC.
Uterine rupture is defined as an anatomic separation of the
uterine muscle with or without symptoms.
What this means for baby is that the uterus ceases to function as a sealed protective container from the rest of the blood and organs surrounding the baby. The function of the placenta and umbilical
cord may also be compromised. Mom is
subject to blood loss and shock. A
decision also has to be made about repairing the uterus or performing a
hysterectomy.
Another term used when talking about uterine rupture is
“dehiscence”. A dehiscence is the
splitting or incomplete opening of the cesarean scar. It can happen without complication for mom or
baby and sometimes it is only discovered after the delivery. It is also called a “window” by some care
providers.
As it turns out, while uterine rupture is a consideration when you are preparing for a birth after a cesarean, it's not the only one your care provider should be having a conversation about. You can read THIS post to see where the risk for uterine rupture falls in comparison to other risks of pregnancy and labor. So what does the research say?
Here is the overarching conclusion: anyone can be at risk,
whether you have an unscarred or scarred uterus. At most, your risk rate is 2%. 2 percent!
Why then is it that this is such a big deal? I believe it lies with the potentially
devastating circumstance a family will find themselves in if the uterus does
rupture. While 98% of the population
may have a successful VBAC, the worst case scenario of a uterine rupture is
the loss of the baby and possibly a hysterectomy for mom which makes future
pregnancies impossible.
Another point to ponder is that the statistics listed below
are close to other statistics for labor emergencies, such as placenta accreta,
placental abruption, miscarriage; for a longer list click here.
Statistics for the risk of uterine rupture – see links at
the end of this post for references: VBAC: .5% - .7% VBA2C: 1.7% (vaginal
birth after 2 cesareans) VBAMC: 1.2% (vaginal
birth after multiple cesareans) Previous VBAC: .4% - .5%
(if you had a previous successful VBAC) VBAC + Augmented labor:
.9% (stats for first attempt) VBAC + Induced labor: 1%
(stats for first attempt)
Here is a link to the comparison of risk rates for VBAC,
CBAC (a cesarean birth after a trial of labor) and ERC (elective repeat
cesarean)
http://www.sciencedirect.com/science/article/pii/S0002937808004213
The risk factors when considering whether or not to do a
trial of labor after a cesarean are: The type of scar you have: the most favorable is a low
transverse scar. Classical T-shaped
scars, vertical scars or high uterine scars are said to have a higher risk of
rupture.
Induction of labor using cervical ripening agents, i.e., Cytotec,
Cervidil: the prostaglandins that soften the cervix may also soften the scar
tissue. In addition, ripening agents can
cause uterine hyperstimulation, meaning contractions that are much more intense
and frequent than the uterus is designed to withstand in the course of an unmedicated
labor.
More than one cesarean: as you can see from the statistics
above, there is a slight increase of risk.
Among factors that are disputed in medical literature are: - Age of mother: if a mother is over 30 she may be considered
at higher risk for uterine rupture. - Obese women - Size of baby: more than 8 pounds, 14 ounces - Post-term baby: 40+ weeks gestation from last menses To compare, here are the stats and risk factors for an
unscarred uterus: “The normal, unscarred uterus is least
susceptible to rupture. Grand multiparity, neglected labor, malpresentation,
breech extraction, and uterine instrumentation are all predisposing factors for
uterine rupture. A 10-year Irish study by Gardeil et al showed that the overall
rate of unscarred uterine rupture during pregnancy was 1 per 30,764 deliveries
(0.0033%). No cases of uterine rupture occurred among 21,998 primigravidas, and
only 2 (0.0051%) occurred among 39,529 multigravidas with no uterine scar. A meta-analysis
of 8 large, modern (1975-2009) studies from industrialized countries revealed
174 uterine ruptures among 1,467,534 deliveries. This finding suggested that
the modern rate of unscarred uterine rupture during pregnancy is 0.012% (1 of
8,434). This rate of spontaneous uterine rupture has not changed appreciably
over the last 40 years, and most of these events occur at term and during
labor. An 8-fold increased incidence of uterine rupture of 0.11% (1 in 920) has
been noted in developing countries. This increased incidence of uterine rupture
has been attributed to a higher-than-average incidence of neglected and
obstructed labor due to inadequate access to medical care. When one assesses
the risk of uterine rupture, this baseline rate of pregnancy-related uterine
rupture is a benchmark that must be used as a point of reference.” If you choose to have a VBAC, or realistically for any woman
in labor since the statistics show she has a slight risk, here are the signs that may
help you recognize that a uterine rupture is occurring or may have occurred: - Excessive vaginal bleeding - Extreme pain between contractions – these may or may not
be felt through an epidural block, though due to severity of pain it’s possible
they may be felt - Contractions that slow down or become less intense - Abdominal pain or tenderness - Baby’s head moves back up the birth canal - Bulge in the abdomen, bulge under the pubic bone, or
pressure on the bladder where the baby’s head may be coming through the tear in
the uterus - Sharp onset of pain at the site of the previous scar - Uterus becomes soft - Shoulder pain - Heart decelerations in the baby - Maternal tachycardia (rapid heart rate) and hypotension
(low blood pressure)
If you have a true uterine rupture, then an emergency
cesarean will be required. A Chandler
doctor told the ICAN group that the care provider has 5 – 7 minutes to get the
baby out safely, although in reading for this post I saw some estimates as 10 –
37 minutes. According to a 2010 National Institutes of Health study,
there have been no maternal deaths in the US due to uterine rupture. Overall,
14 – 33% will need a hysterectomy. 6% of
uterine ruptures result in perinatal death, and for term babies this risk was
put at less than 3%. **
If you do have a uterine rupture, it will have an effect on
your future pregnancies. Each cesarean a
mother has increases the risk for future complications of cesarean
surgery. If you have a hysterectomy, you
will not be able to carry any more children.
In today’s medical climate, a uterine rupture will most likely result in
all future pregnancies being delivered via repeat cesarean.
There are a lot of points to ponder as a new mom or as a mom
considering a VBAC. Our Bradley® mantra
is: Healthy Mom, Healthy Baby. We teach
that as long as you make all your decisions with those two goals in mind, you
are likely to make the choices that have a positive outcome for both Mom and
Baby. What are your thoughts on VBAC and/or uterine rupture?
**NOTE: Stephanie’s presentation called out these statistics
as inflated as the Landon study (2004) included women who had pre-labor
stillbirths included in the statistics.
IN other words, women whose babies had passed away before labor and
still delivered via VBAC rather than choosing a repeat cesarean were counted in
the perinatal death statistics. Please
read Henci Goer’s analysis for more information
For the resource list, click here. Disclaimer: The material included on this site is for informational
purposes only. It is not intended nor implied to be a substitute for professional medical advice. The reader should always consult her or his healthcare provider to determine the appropriateness of the information for their own situation. This blog contains information about our classes available in Chandler, AZ and Payson, AZ and is not the official website of The Bradley Method®. The views contained on this blog do not necessarily reflect those of The Bradley Method® or the American Academy of Husband-Coached Childbirth®. |
Coping After A Miscarriage
Posted on January 7, 2012 at 9:40 PM |
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Angels
Posted on August 30, 2011 at 7:42 PM |
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Preparing for Variations and Complications
Posted on April 26, 2011 at 7:23 AM |
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Last evening’s class was the
topic of “Variations and Complications” during Pregnancy and Labor. As much as we all hope and pray for an
easy pregnancy and labor, for some of us, there are some bumps in the road.
The Bradley Method® includes
a class on how to handle those “bumps” so that parents are at least aware of
what the variations and complications are, what the possible reasons are for
them, and the options available to them should they encounter these situations.
We also encourage our students to do additional reading on these situations –
it is never good enough to take an instructors word on these, especially for the decisions that
impact their child. It is
important for students to decide how they would probably want to handle these possible
variations and complications while there is time to consider all the options
and make a thoughtful choice that they can fall back on in case a moment of
decision and/or urgency does arise. In addition, we encourage our
couples to discuss their options with their care team. Each provider has a their own set of
policies and protocols based on their experience as practitioners. It is important that your preferences
match with the practice your care team employs so that you are able to work
with them and have their support for your choices. Our goal is to inform the
parents, give them a basis for a conversation, encourage them to either write
down their decisions or make a mental note, then file that information away and
turn the focus back to having a normal, uncomplicated, low-risk pregnancy and
labor. Here is a great resource to
help a couple do some emotional preparation for labor ~ http://www.birthingnaturally.net/encourage/encourage.html There are several questions
and thoughts to consider as you prepare for different aspects of pregnancy and
labor. Again, the goal is to help
you come to some conclusions, and then set forth an action plan if through the
exercises you realize that there are any unresolved issues or aspects of your
pregnancy and labor that you want to discuss with your care team. Once you face the different
possibilities or the fears you might have and make a plan, the idea is to file
away the information and focus on having the pregnancy and birth that you want
for your family. The one topic that is so hard
to talk about and the situation that none of us want to face is pregnancy
loss. There is an outside
possibility that this joyous time of preparation and anticipation sometimes
ends with a miscarriage, stillbirth, or the loss of a healthy child due to
unforeseen circumstances or events. It is hard for me to get through this
part of class without getting emotional.
It is one of the fears I have and that I try to turn over in prayer
during our pregnancies. If it is hard
for me as the instructor, I can only imagine it is something hard for our
students to face and talk about, too. I provide this resource list
today with the prayer that you (or anyone close to you) will never have to use
it. On what I hope and pray is a
very outside chance that something unthinkable happens, here are several
organizations and providers that offer counseling, comfort and free services to
support the grieving family. Arizona Perinatal Loss
Bereavement Resource Banner Desert Medical Center 1400 S. Dobson Road, Mesa,
85202 480-512-3595 Provides a network of support
for those experiencing a pregnancy or infant loss. This resource gives parents
a statewide network of support, current bereavement literature on a variety of
topics, educational opportunities and resources in the community, state and
national level. The Compassionate Friends http://www.compassionatefriends.org The Compassionate Friends
assists families toward the positive resolution of grief following the death of
a child at any age and to provide information to help others be
supportive. They offer a
safe place for bereaved parents, grandparents, and siblings to meet and talk
freely about your child and your grief issues. M.I.S.S. Foundation www.missfoundation.org The M.I.S.S. Foundation
provides immediate and ongoing support to grieving families through community
volunteerism opportunities, public policy and legislative education and
programs to reduce infant and toddler death through research and
education. M.E.N.D. Mother's Enduring
Neonatal Death http://www.mend.org M.E.N.D. (Mommies Enduring
Neonatal Death) is a Christian, non-profit organization that reaches out to
families who have suffered the loss of a baby through miscarriage, stillbirth,
or early infant death. HAND Helping After Neonatal
Death http://www.handonline.org HAND is a resource network of
parents, professionals, and supportive volunteers that offers a variety of
services throughout Northern California and the Central Valley. SHARE Share Pregnancy and
Infant Loss Support, Inc http://www.nationalshare.org The mission of Share
Pregnancy and Infant Loss Support, Inc. is to serve those whose lives are
touched by the tragic death of a baby through early pregnancy loss, stillbirth,
or in the first few months of life. Now I Lay Me Down To Sleep http://www.nowilaymedowntosleep.org They offer the free gift of
professional portraiture and remembrance photography to parents suffering the
loss of a baby. “The NILMDTS
Foundation is there for parents and families to help aid them in their Healing,
bring Hope to their future, and Honor their child. It is through Remembrance that a family can truly begin to
heal.” They feel that these images
serve as an important step in the family’s healing process by honoring their
child’s legacy. Placenta Encapsulation –
Wendy Diaz, PBi™ PES http://naturallybirthing.webs.com Her encapsulation services
are free for bereaving mothers.
Wendy will also add herbs to the capsules that help dry up the milk
supply. Recommended Reading: Empty Cradle, Broken Heart:
Surviving the Death of Your Baby by Deborah L. Davis, Ph.D. Product Description from
Amazon.com: The heartache of miscarriage,
stillbirth, or infant death affects thousands of U.S. families every year.
Empty Cradle, Broken Heart offers reassurance to parents who struggle with
anger, guilt, and despair after such tragedy. Deborah Davis encourages grieving
and makes suggestions for coping. This book strives to cover many different
kinds of loss, including information on issues such as the death of one or more
babies from a multiple birth, pregnancy interruption, and the questioning of
aggressive medical intervention. There is also a special chapter for fathers as
well as a chapter on "protective parenting" to help anxious parents
enjoy their precious living children. Doctors, nurses, relatives, friends, and
other support persons can gain special insight. Most importantly, parents
facing the death of a baby will find necessary support in this gentle guide. If
reading this book moves you to cry, try to accept this reaction. Your tears
merge with those of other grieving parents. A purpose of this book is to
let bereaved parents know that they are not alone in their grief. With factual
information and the words and insights of other bereaved parents, you can
establish realistic expectations for your grief. Empty Cradle, Broken Heart is
meant to help you through these difficult experiences by giving you things to
think about, providing suggestions for coping and encouraging you to do what
you need to survive your baby's death. Whether your baby died recently or long
ago, this information can be useful to you. Disclaimer: The
material included on this blog and this site is for informational purposes
only. It is not intended nor
implied to be a substitute for professional medical advice. The reader should
always consult her or his healthcare provider to determine the appropriateness
of the information for their own situation. This blog and this
site contain information about our classes available in Chandler, AZ and
Payson, AZ and is not the official website of The Bradley Method®. The views
contained on this blog and this site do not necessarily
reflect those of The Bradley Method® or the American Academy of Husband-Coached
Childbirth®. |
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