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Thread: Pregnant 2012-2013
January 21st, 2013 06:44 PM #71Senior Member
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- May 2012
As a surgeon, what is your view on how many c sections are safe to have? It just seems not safe to me to have multiple surgeries on the same area of your body!!Mom to Cuyler Reese Holcomb and anxiously awaiting Avery Daniel Alexander in August 2013!
Girls: Claire Elisabeth Louisa, Sophia Adelaide Kate, Elise Madeleine Joy, Zoe Anneliese Jayne, Juliet Amelia Rose
Boys: Asher Morgan James, Morgan Everett Nathaniel, Weston Jude Elias, Gabriel
January 21st, 2013 08:10 PM #73
I think there are two very important, equally valid ways of looking at your question. It brings up the fascinating interplay of maternal and fetal interests in obstetrics. From the point of view of the individual baby you are carrying-- a c-section is nearly always the best option. Short of some extremely unusual mistake, a baby delivered by c-section will always arrive safely, with no labor trauma, no oxygen deprivation, no cerebral palsy, no placental abruption, no exsanguination. For your son, who was truly stuck, you could perhaps have continued to labor for a few more days and eventually have extracted him. Perhaps not. He would have been dead, but you could have delivered him. For him, as an individual, a c-section was his only chance. [I know you feel that had your labor been allowed to progress differently he would not have ended up in that position, and that might well be true, but I'm starting at the end-scenario where he was rammed against your pubic bone with a hyperextended neck in the OP position].
For you, in that situation, a c-section was also the best option. You might well have died-- plenty of women did and do, all over the world-- with a stuck baby. Maybe someone could have performed an internal repositioning, but the trauma to your tissue would likely have been quite severe and you could have ended up with large fistulae, uterine prolapse, fecal/urinary incontinence, etc; not to mention the terrible emotional trauma of having a dead or severely disabled child.
But no one-- last of all obstetricians, honestly-- prefers cesarean birth over vaginal birth. C-sections are surgical procedures. You could have a wound infection, intraabdominal adhesions, you have a uterine scar, you're at risk for subsequent uterine rupture, uterine atony, placenta accreta, placenta percreta, other disorders of placentation-- lots and lots of problems. Vaginal birth isn't without its risks, but without any caveats it always wins, hands down.
So the second half of the equation is you. I really wish I could find the data because I remember reading it but don't know it cold, like an OB would. The risk of uterine rupture increases dramatically with each subsequent c-section (I think something like 10% after 5 sections, but again I don't know for sure!), but the bigger, genuine risk is placenta accreta. By 3 c-sections the risk of previa is 70% (where the placenta covers the exit of the womb, making a c-section 100% necessary) and accreta-- where the placenta grows into the scar, dramatically heightening your risk of hemorrhage-- is nearly 10%. It's a vicious cycle because you absolutely full-stop cannot even trial labor in a patient with a complete previa, as it will 100% result in the death of the baby and cause a serious hemorrhage in the mother. So you have another c-section. And then for a subsequent pregnancy, your chance of previa/accreta is even higher.
The other issues you raise are those of patient autonomy. Again, this is what makes obstetrics so unique. As a general surgeon, you can come into my clinic and I can explain that you have appendicitis, or liver cancer, or irreversible heart failure, and you need an operation. You can absolutely refuse that operation, leave my clinic, and that's the end of it. As long as I feel you have decision-making capacity and truly understand the risks you are undertaking by refusing my treatment, I have no qualms about it. In obstetrics, however, you're not just making decisions for yourself, you're making them for your unborn baby. And there is a very strong precedent of professionals, or the government, "intervening" in poor decision-making by parents, in order to protect the interests of the defenseless children (social workers, lawyers, police, doctors, teachers, etc all have a duty to protect children in their care). As your pregnancy progresses and the fetus becomes a baby, viable and capable of independent existence, the rights of the baby become more and more important. Many OBs feel quite reluctant to provide care, or allow the mother to choose a care pathway, which puts that baby at elevated risk when the baby has no say in the matter. TOLAC in one such thing-- but, many OBs are equally eager to avoid placing the mother at increased risk to her health via multiple repeat cesareans (esp if she plans many pregnancies), so feel a monitored TOLAC is a perfectly safe option that balances both interests, as well as honors the mother's right to determine her own care.
There is a teaching in psychology that a negative comment, or a negative interaction, or a negative outcome, is 9x as powerful as a positive one. That is, if someone insults you, it takes 9 compliments before the effect is negated. I know personally, in my practice and training, that is absolutely true. When something terrible happens to a patient-- esp something preventable, in hindsight-- it is extremely psychologically affecting. Unnecessary uterine rupture with unncessary fetal complications is SO affecting, especially since obstetrics is a field that deals almost entirely with healthy young patients and happy outcomes. Seeing one baby suffocate to death after a uterine rupture would be enough for some OBs to simply say it's not worth it. Again, the younger ones are more likely to have positive experiences and good outcomes re: monitored VBACs, so they'll be much more comfortable giving you a trial.Blade, MD
XY: Antoine Raphael (3.1.2012)
XX: Cassia Viviane Noor (11.30.2013)
January 21st, 2013 08:40 PM #75Senior Member
- Join Date
- May 2012
Blade- that was a lot to wrap my head around! According to my doctor my son's head/neck was not hyper-extended(I'm assuming you were meaning tipping up and backwards?) He was face-up, with his head simply cocked to the side so he was not coming down straight on. Am I mistaken in thinking that this is not as severe a situation as hyper-extension? After all the research and reading I've been doing on positioning and things a laboring mother can do to help get baby in right position, it seems like there would have been a very high chance that if I had not simply been lying in bed in one position for so many hours in a row (12 plus if I remember correctly) his head would have been straightened out and put in line thus allowing me to get him past the -1 or -2 station where he was stuck. Of course, we never will know for sure, but to me it seems like a very good possibility he would have been delivered vaginally. I know several people who delivered face-up babies, it just took much longer for them to push out the baby so I don't think that was the main factor. It was the angle of his head. My doctor also said if he would come down a little more she could help reposition him as he came down which would have helped with the long face-up process.
I just wish that someone could have suggested this as a possible problem and suggested that I move around. I would have tried it for sure, even if it meant turning off my epidural! I just didn't think of this option on my own unfortunately! I was pretty much falling asleep while I was pushing. My mind was turning off on me, I was in a haze from being up for so many hours! I hope my labor is much shorter this time!
January 21st, 2013 08:55 PM #77
Sorry, I misunderstood what you said about positioning.
Here's the thing-- you are probably right, if your son's head had been positioned normally relative to the exit of the womb, your chances of a successful vaginal delivery would have been much higher. [OP is perfectly manageable. I personally delivered my son, who was OP, vaginally, albeit with a vacuum extraction].
But you don't have an ultrasound constantly in place while you're laboring, right? So no one can see exactly what the baby is up to. All we have are markers of whether or not the baby is tolerating the labor OK, specifically, that his oxygen supply isn't being compromised and he's not got an infection. If you were laboring well, progressing along the labor curve as you should, baby's heartbeat remained reactive and reassuring, you didn't have a fever, etc... then everyone would think things were going great. It was only at the very end, when his head ended up in the position it ended up in and you were unable to progress, that anyone was aware of a difficulty.
Try to conceptualize your uterus contracting during labor. The whole thing contracts in a uniform fashion, top to bottom, to propel the baby down to the exit, then out. [most of the time, the head is already 'engaged' in the pelvis a couple of weeks before labor starts, so his position is somewhat set then]. The strength of your uterine contraction is by far the most important factor to successfully laboring and then pushing the baby out-- much more so than gravity. In fact, if you had been in a position where the forces of gravity weren't equally distributed, like laying on one side, the chance of fetal malpresentation might theoretically be higher, as the uterus would be contracting in one vector line but gravity would be pulling the baby differently.
I think different positions can help manage pain, or get things going again if your labor has somewhat stalled out. But I can't conceptualize a way that they would position a baby inside a contracting uterus any better. You want him to be straight-on, smallest diameter of the head to be right at the cervical os. Actually theoretically laying flat on your back seems the best way to ensure that presentation.Blade, MD
XY: Antoine Raphael (3.1.2012)
XX: Cassia Viviane Noor (11.30.2013)
January 21st, 2013 08:58 PM #79Senior Member
- Join Date
- Aug 2011
I let facebook family and friends know today about the baby =) I was going to wait a little longer but being 12 weeks today I figured it was most likely safe enough to let people know and not have anything happen. I did however, get my first naming suggesting from a great aunt... a good southern " Lily Ruth" cute and I know why she pulled it Lillian is my great grandma and Ruth is my deceased grandma. But not us, I have considered using Ruth but my sister is Anna Lillian and I believe a another cousin is a Lillian middle to. But the name we have picked is a first we love and a middle that is a variation from my mom's first....and to be honest naming after my mom who I nearly lost is much more important than the grandma who I don't remember who died when I was 4, I know she was a big part of my life before she passed but again. So a nice way to say something or just announce the name when we find out gender or when baby is born.I'm Alix Louise
Wife to Skyler James since 4/28/12
Mommy to Daphne Valora since 8/02/13
When we have another
Boy : Sebastian, Jasper, Edgar
Girls: Sonia, Matilda