Wednesday, June 13, 2018

The Lipedema Series

Sculpture by Marie-Madeleine Gautier
Over the years I have written a series of blog articles on lipedema (also spelled lipoedema), sometimes known as "painful fat syndrome" or "big leg syndrome." These have become some of my most popular articles.

Since June is Lipedema Awareness Month, I think it's time to add a link where you can find all of the series listed in one place.

Lipedema is a fat storage disorder. In lipedema, an abnormal accumulation of fat occurs in the legs and lower body. Over time, it may develop to include the arms and other parts of the body as well. It is usually progressive, though why it progresses severely in some and not in others is one of its great mysteries. 

Here is what we have covered so far:

Part One - Typical features of lipedema and how to differentiate between lipedema and lymphedema

Part Two - Different stages of progression, and why it's so important to be aware of lipedema

Part Three - Types of fat distribution patterns, pictures illustrating type and stage of lipedema, how lipedema is diagnosed

Part Four - Possible causes of lipedema, medical conditions associated with it

Part Five - Possible treatments for lipedema, broken down into several sub-posts

    Traditional Medicine Treatments - Manual Lymph Drainage, Compression
    "Weight Control" and Special Nutritional Approaches (trigger warning)
    Tumescent Liposuction - Specialized liposuction to take out diseased fat cells
    Alternative Medicine Treatments - Acupuncture, herbs, etc.
    Summary of Treatment Options - Summary of all the various treatments

Part Six - Coping with clothing challenges

Part Seven - Weight Bias in Lipedema Care (Part of the Turkey Awards Series)

Part Eight - Living Your Best Life with Lipedema

In addition, there have been some other miscellaneous posts about lipedema. These include:

References and Resources


Info About Lipedema and Support Groups

*Trigger Warning: Many of these sites are not fat-friendly or promote dieting behaviors


Tuesday, June 5, 2018

Ketogenic Diets and Lipedema: Apply Caution

Sculpture by Madeleine-Marie Gautier
Be smart; do your research before jumping on the ketogenic bandwagon
One of the biggest trends in lipedema treatment world right now is the ketogenic diet. Folks in lipedema communities are all a-flutter over it, considering it practically a cure. There are tons of sessions about ketogenic diets at the lipedema conferences and it's being heavily promoted on lipedema websites and support groups.

I have decidedly mixed feelings about this. On the one hand, I'm a big believer in people being in charge of their own healthcare, and if this is something they want to try, it's okay with me. It's good to consider different therapeutic modalities. On the other hand, it bothers me to see people promoting it so strongly online, as if it is a proven therapy, as if it is a cure. It's NOT.

In fact, we have little actual evidence about ketogenic diets for lipedema, mostly just the word of a few doctors and therapists who believe it is "the answer." We have the stories of some people who are in the honeymoon phase of weight loss on the diet. We have no long-term evidence that it helps lipedema.

What is a Ketogenic Diet?

A ketogenic diet is a dietary approach that promotes a high fat intake and a moderate protein intake, while keeping carbohydrate intake to a bare minimum (no more than 50g per day). In other words, you can have plenty of meats, fats, and low-carb vegetables, but grains, fruits, and higher-carb veggies are not allowed. You can have lots of bacon, steak, and nuts but no rice, bread, pasta, peas, corn, apples, grapes, pears, or bananas, etc.

It's a nutritional plan designed to trigger ketosis in your body. Your body uses glucose for energy, which is largely created from the carbs you eat and then stored as glycogen. If you eliminate carbs from your diet, your body uses up its stores of glycogen, runs out of energy, and needs to find a replacement. So it turns to its stores of body fat and starts consuming them. The by-product of this process is ketones.

Ketosis (ketones in your system) results from the burning of fat for energy when the intake of other energy (carbohydrates) is too low to supply the body's needs. To see if you are spilling ketones in your urine, you can buy testing strips from most pharmacies. You pee on them and they will tell you if you are in ketosis and if so, how much. The aim of the diet is to get you into major ketosis territory so your body will hopefully burn up the lipedemic fat.

Ketogenic diets do very well at producing a quick and very strong initial weight loss. Much of it is water weight but muscle and fat is also burned, leading to more weight loss, at least for a while. Some people report feeling marvelous on it, while others report feeling terrible (the "keto flu"). Sometimes this effect is temporary (the first few weeks) and sometimes it never resolves.

Reservations About Ketogenic Diets

When looked at historically, it can be seen that dietary approaches rotate in popularity. Vegetarian, vegan, alkaline, low-fat, low-carb, no grain, no carb, Paleo, eating "clean" ─ all are dieting/weight loss trends that have cycled in and out of popularity over the years. None show any better long-term results than the others.

If you lower calories, your body will initially lose weight for a while, and then it will slowly adapt its metabolism to the new lower intake and the weight loss slows down and stops, then starts reversing. Sometimes you can overcome these plateaus for a while but nearly always the weight eventually returns, often with friends. There are a few people who manage to sustain large weight losses over many years, but they are statistical outliers, and many do it at the price of eating-disordered behaviors around caloric intake and exercise.

Remember that there is NO research proving improvement of lipedema with a ketogenic diet. Nor is there any research proving long-term permanent weight loss with ketogenic diets. The current push for ketogenic diets is the lipedema and medical community pretending to be size-friendly and pro-health but still exhibiting an underlying diet and weight loss mentality. The paradigm is just too ingrained in them to let it go:

  • Sure, we know that lipedema is really not your fault ─ but don't you dare let up on your relentless focus on dieting and exercise or you'll blow up like a balloon! 
  • Sure, it's not just a matter of restricting calories ─ but you really should restrict certain toxic foods. If you don't, you'll make your lipedema worse and you'll end up in a wheelchair!

Caregivers and far too many patients are still stuck in the same old guilt/shame/scare/restrict dieting mode, even if they no longer call it a diet. They may call it a "lifestyle change" but it really is just another diet. 

For a while it was an anti-inflammatory diet that was supposed to lessen the effect of lipedema. Now that has started to go out of fashion and it's all about the ketogenic diet. Pretty soon the ketogenic diet will go out of fashion too and something new will be "the" fix. But whatever the latest trendy approach, it's all still dieting, bottom line.

That's not to say that you should just "let yourself go." There's nothing wrong with focusing on healthy habits and nutrient-dense foods. No one is saying that people with lipedema should pay no attention to their health. You don't want to exacerbate the lipedema. But we do need to be cautious not to let that care become part of the Diet Fixation that is so prevalent in our society.

Be especially leery of nutritional approaches that take out entire food groups, that are highly restrictive in intake, that cast foods into "good" and "bad" categories. Foods aren't moral or immoral; they have no value judgment. Some are healthier for you than others, some work better with your particular body than others, but everyone is an individual. Sweeping dietary restrictions don't generally work very well for groups. Moderation and variety seems to be the best keys.

Remember the profit motive of this latest trendy diet. Although the "keto experts" are well-meaning, the patient often ends up paying hefty amounts for advice. And the so-called experts usually spin their approach into a whole cottage industry that makes them all kinds of money. Keto lifestyle coaches abound online these days and have many "packages" available for lifestyle advice. All of it is for a profit. It colors everything they say. Even caregivers who consider themselves neutral often have financial interests in the weight loss industry that influence their views. View everything with a giant grain of salt.

Look beyond the salesmanship, the scare tactics, and the short-term personal testimonials. Ask what real evidence we have on ketogenic diets. Keep asking about this on lipedema groups promoting ketogenic diets and listen to the deafening silence or culture of denial. It's very revealing.

What Does the Research Say?

Bottom line, there does not seem to be any studies on ketogenic diets and lipedema. 

All the claims online about how effective ketogenic diets are for lipedema seem to come from anecdotal stories. A few isolated case reports exist, which are essentially anecdotal evidence too. Although we should not dismiss anecdotal evidence out of hand, neither should we consider such a therapy proven. It's not proven at all.

The ketogenic diet does have some uses in fields other than lipedema. It's important not to dismiss it completely. It was first used in 1920 to help people with epilepsy. It has been shown to be extremely helpful in children and adults who experience chronic severe seizures ─ but perhaps at a price. There seems to be some cognitive decline in young children on a ketogenic diet, but whether that's worsened because of the repeated seizures or whether a combination of repeated seizures and a ketogenic diet makes things worse is unknown.

The ketogenic diet has also been shown in some limited research to be helpful against certain types of brain tumors (glioblastoma). It's not a cure, but it may help at least delay progression. However, although there is lots of speculation and pressure for its use with other cancers, there is no conclusive proof of its utility on other cancers at this time.

A low-to-moderate carbohydrate diet has been shown to improve certain cardiac risk factors in newly diagnosed diabetics, but follow-up is generally only about a year, not long enough to judge its long-term usefulness. Still, it may well lower insulin levels long-term, so that is potentially a benefit to some.

However, while ketogenic diets typically improve triglycerides, HDL cholesterol, and blood sugar temporarily, some data suggests they may worsen LDL cholesterol. Whether that is truly risky or not is unclear.

Furthermore, many people report significant G.I. issues like nausea, vomiting, and constipation with a ketogenic diet. Other potential risks may include kidney stones or other kidney problems, electrolyte imbalances, dehydration, vitamin deficiencies, muscle loss, leg cramps, and decreased bone density. Bad breath, fatigue, and sleep problems have also been reported. While a ketogenic diet is probably not super-risky, neither is it without harm in the literature. Many dieticians recommend against it.

Ketogenic diets get good buzz because there are often significant drops in weight in the first few weeks of the diet. This is largely due to fluid loss, not fat loss. Since women with lipedema often retain serious fluid in their bodies, they can experience really big drops in weight ─ at first. But will it last? As two dietitians note in an article on the keto diet:
"As you limit carbohydrates, your body produces less insulin, and glycogen stores (how carbs are stored) in the muscles and liver are depleted. For every 1 gram of glycogen that's depleted, you lose about 3 grams of water." This causes the kidneys to flush out more water, and along with it, electrolytes your body needs like magnesium, calcium, sodium, and potassium. "Imbalanced electrolytes can lead to muscle cramps, irregular heartbeat, fatigue, cognitive distortions, and lack of body temperature control," Turoff says...
"I wish people knew that the weight loss they will initially experience on this diet is largely due to water loss," Brown says. That means you're most likely not actually losing fat in the first couple of weeks, but instead losing water that will come back in the form of glycogen stores if and when you start eating carbs again.
As far as weight loss goes, a meta-analysis of a number of studies found that ketogenic diets resulted in greater weight loss than low-fat diets ─ but a review of this meta-analysis noted that the difference was only about 1 kg (2.2 pounds), and once the participants reached the 24 month mark, any significant difference between groups disappeared. Not exactly impressive results.

This is typical of nearly all weight loss research. There is an initial period of significant weight loss, lasting anywhere from a few months to around 1-2 years, and then the weight is slowly regained. Often the person regains to a higher weight than their starting weight. The question becomes whether people are better off for having lost the weight and regained it, or if they would have been better off being stable at a higher weight.

Reviews note over and over that a ketogenic diet is generally quite difficult to sustain long-term. Many "long-term" ketogenic studies actually only last 6 months to a year. Drop-out rates are extremely high because it is such a hard diet to follow, and this makes it difficult to interpret what data there is.

Conclusion

One of the trendiest things in lipedema care these days is the ketogenic diet. It is routinely being promoted as a "must try" fix. Physically, it rewards participants with a large quick weight loss, and emotionally, it gives a feeling of control over the uncontrollable. People are glad to at least be doing something in hopes that it will help. It's understandable that it's so appealing to many and has caught on so quickly. But the reality is that it's just another unproven diet fad, cycling around for another turn on the Diet Wheel of Frustration.

That's not to say that the ketogenic diet is never useful. Clearly, it has been very useful in those with serious seizure disorders. But for lipedema? That is completely unproven at this point.

But I'm not going to tell you to not do this diet. You control your own body and your own healthcare decisions. I'm not the Diet Mafia. If you want to do the ketogenic diet, go right ahead. My advice if you try it is to avoid extremism, consult a dietitian so you do it more wisely, take supplements, drink lots of water, and stay flexible. Give it your best shot but don't feel bad if you find it difficult to sustain this diet or if you don't get the long-term results you were hoping for. Lots of other people have had similar issues.

Many people try the ketogenic diet for a while, lose fairly significant amounts of weight pretty quickly, sometimes even from the legs ─ then find the weight comes back no matter what they do. Or they simply cannot live with the extremes of the diet and stop following it after a while because it is so difficult to sustain long-term.

That was pretty much my experience with the ketogenic diet, years ago as a young adult when I was still riding the diet merry-go-round. I lost 50 lbs. on it in six months, but in the end began gaining weight uncontrollably even while still on the diet. Eventually I found it to be simply unsustainable and stopped. I found that after my ketogenic diet, I actually had more lipedemic fat (though I didn't know what to call it then) than when I started, particularly around my belly. That really turned me off of it. It had good initial results but they didn't last any better than any other diet or "lifestyle change" I did. In fact, it made things worse in the long run.

That was my last really big diet. After that, I turned to the Health At Every Size approach and stopped yo-yo dieting. I found I was so much healthier in my food choices, my lab numbers improved, my weight stabilized, and I just FELT so much better, both physically and emotionally. I tried to emphasize more exercise and eat moderately but didn't guilt myself too much about it. Everything in moderation ─ including moderation ─ became my motto.

Some people swear by the ketogenic diet, and if it works long-term for you, more power to you. But stop promoting it as if it has been proven to be a cure for lipedema. It hasn't. It hasn't been shown to result in long-term weight loss either. You can mention to others that you are trying it, you can talk about the pluses and minuses, you can share your experience with it, but please refrain from making unproven claims and stop pressuring other people to try it.


Thursday, May 24, 2018

Advocating for Yourself at the Doctor

My family had to switch insurance recently. That meant doing the thing that I hate the most ─ finding a new primary care provider. I dreaded it and stressed over it for months. Then I had my first appointment this week.

I needed to get in quickly to get a particular vaccination, so I took the first available appointment with the first available doctor. He was not one I would have picked for myself, since he specialized in men's health and sports medicine. Ugh ─ my experience is that sports specialists are very biased about people of size. I uneasily anticipated a fight over weight loss, weighing regularly, and lectures about nutrition, dieting, etc. I went in primed for a fight.

I am so happy to report I was totally wrong. Not that we were in total agreement about everything, but he listened very respectfully to my point of view and conceded some arguments. He took a very long time in my appointment, much longer than I expected, in order to get a very complete history, and he was very gentle and caring overall. What a tremendous relief!

To advocate for myself, I brought  the Health At Every Size Information for Providers cards from the blog Dances With Fat. That opened the conversation on a productive note; he appreciated me sharing my concerns so he could address them. The good thing about the cards is that they give a quick summary of Health at Every Size and there are research citations with links to the research. That kind of thing resonates with care providers and shows that HAES is not just about “giving up and letting yourself go” but truly about promoting health. Care providers respond better when they realize that.

Another thing I did was take informational handouts about Lipedema from the Fat Disorders website. Some doctors know about lipedema now, but it's surprising how many do not. And of those who do know about, many have only cursory information. It's very helpful to have a handout with details and research citations about lipedema if this is an issue for you. We had some interesting discussions about lipedema as a result. I think he learned a little bit more about it from me.

I also took in a one-sheet summary of my medical history. It lists all of my care providers (with contact info), any health conditions, all of my medications (with current dosages), and any history of surgery (with the year) etc. I don't have a lot of family medical history because I'm adopted, but what information I do have is very revealing, so that is on the sheet as well. The doctor was very impressed at having such a quick Cliff Note's version of my medical history and was happy I provided it. I highly recommend having a summary like this.

One thing I didn't need to do was question his care recommendations for me. That was so refreshing! He stuck to the issues at hand and didn't automatically recommend weight loss. Nice! When a doctor recommends weight loss and you are not interested, the best question to ask is, If I were thin, what tests and treatment would you recommend and why? Challenge the doctor to see you and treat you like any other patient, without seeing and trying to treat the fatness first.

I didn't do one of the most common things recommended to patients of size ─ bring along an advocate ─ but then I know how to advocate for myself pretty well these days. However, if you have trouble standing up for yourself or just need someone in your corner, I highly recommend taking an advocate to an appointment, either to get better care or just to take notes for you. I have done so in other types of appointments and it was very helpful.

 I think it also helps to look for specialties that tend to be more holistic, like a D.O. instead of an M.D. (both are fully qualified, just from different organizations), or who have a bigger picture of health, like a family doctor instead of an internist. Many practices now have Physician's Assistants and Nurse-Practitioners, and they often are more holistic and understanding than the M.D.s in the practice. Remember that midwives can also do gynecological care; many women of size choose to get their annual pap smears and care from a good nurse-midwife practice instead of an OB.

Never assume size-friendliness from a person's initials and certifications, however. Always ask lots of questions and don't assume that a certain title means size-friendliness. There are many wonderful doctors available and sadly, there are some very fat-phobic nurses and family doctors out there. Start with the least invasive, least high-tech specialty, but do your homework and ask lots of questions before making a final decision about the best care provider for you.

The Tricky Issue of Weighing


One of my main concerns in going to a new doctor was not having to weigh every time I visit. I was fine with getting on the scale for our initial appointment because I believe it's useful for them to have a baseline weight on record. However, I informed the doctor I would refuse to be weighed on repeat visits unless there were a pressing medical need for it (like impending surgery, weight-based dosing of certain drugs, certain conditions like Congestive Heart Failure, etc.).

He agreed that I always had the right of informed refusal, and he listened to my reasons of why I find it so triggering and objectionable. He said the med techs might still ask me each visit because it is so part of their routine, but that he would put in the chart that I should not be harassed or pressured about it (which has happened in the past). After a discussion we came to my usual compromise; I would be free to decline the weighing every visit, with the understanding that if there were large changes in my weight I would report them (because that can be a symptom of a medical problem), and if there was ever a legitimate medical need for weighing I would agree to do it. Weighing itself doesn't bother me, and I don't care what the number on the scale says. For me, it's the act of being weighed in public that is just very triggering and stigmatizing. It's part of my personal empowerment to refuse such unneeded requirements.

I should note that I've written about this before and people noted in the comments that when they refused to be weighed, some med techs told them they did not have the right to refuse, that the insurance companies required it in order for the visit to be paid for. This is baloney. Weighing is like any other test or "measure of health;" you always have the right to informed refusal. If you are firm in your boundaries, most of the time they will back down. I've had some fights over this but have always won because of the right of informed refusal. If all else fails, state strongly, "I DO NOT CONSENT." This has more legal heft because it could potentially lead to being sued. Most of the time they will stop badgering you.

However, according the comments on my previous post, once in a while there is a doctor who will dismiss you from the practice and refuse to provide care if you refuse to weigh at every visit. Even in the face of legitimate protests, some won't back down. All I can do is sympathize and say is you are better off without a provider like that. You have to decide if avoiding weigh-ins is worth it to stay with that particular provider. Generally speaking, a provider that doesn't respect the basic right of informed refusal is not worth having as a care provider anyhow. I would worry what other medical procedures or interventions they might try to bully me into. I would not want to stay with a provider who used such strong-arm tactics. They are not trustworthy. It would be a giant red flag to me.

If you don't have any other choice than to see that provider, do your utmost to challenge the decision. Don't make it easy on them to disregard your rights. Write letters to the practice manager, to the insurance company, to the hospital, etc. If you really do not have a choice, make it clear you are weighing under duress and launch a social media campaign against the practice. Do what you must to get the care that you need, but don't take medical bullying lying down. Even if you don't succeed in getting this rule changed right away, you might with time. At the very least, you put pressure on the doctor and force him to defend why he is disregarding the patient's right to autonomy in their medical decisions.

Concluding Thoughts

Image from Dances with Fat blog, link here
Print this out and take it to your first visit with your provider
Finally, I just wanted to note that sometimes people of size avoid doctors because they are afraid of battles like these, of mistreatment and fat-phobic treatment. I know it's tempting to just avoid the battles altogether, but it's not wise. I would like to urge my readers NOT to avoid going to the doctor. As we age, it really is important that we go see a care provider regularly. It is very important to get regular lab work done to track the results over time, to catch any problems early, and to have a provider with a broad base of knowledge look for issues if needed.

Even though your past contacts with medical providers might be negative, it doesn't mean it will always be that way. You might luck into a truly size-friendly provider, or at least find a size-neutral provider who is willing to discuss things and compromise with you. More and more practices are trying to be open to a more size-neutral approach. There ARE good providers out there.

I learned that this week. I was all ready for a fight, and I was sooo pleasantly surprised that I didn't need one. My intent had been to use this doctor for the purpose of my vaccination, then switch to one of his colleagues, but now I think I'll stick with him. Finding a size-friendly provider can happen. It's best to be ready, just in case, but remember, you might be pleasantly surprised too. 

Sunday, May 13, 2018

Happy Mother's Day

Happy Mother's Day to all! Here is some mother-child artwork in honor of this day. Hope you had a wonderful day with your families.

Artist: Mary Cassat
May you treasure your time with your children. Be with them as much as you can.

Artist: Diego Rivera
Embrace the now, for all too soon, your children will be all grown up. It will go by in a heartbeat, I promise you.

Artist: David Foggie
Your parenting season feels long at times when you are in the middle of it, but when you near the end of it, it feels like it was the most brief moment in time. Be sure you take time to enjoy it as you go.

Artist: Albert Anker
Live into each moment, as deeply as you can. You will never get it back.

Haitian birth, artist unknown
Deepest gratitude to those who attend women in their pregnancies and births, and who help them through it with respect and care.

Photo from Amnesty International
You make such a difference to so many, in ways you may not realize for a long time.


Extra hugs to those whose own mothers are no longer living or in their lives. Special loving to those whose have lost children through adoption, miscarriage, stillbirth, or death at any age. We honor your pain. You and your experiences matter too. You are loved.

Monday, April 30, 2018

VBAC after VBAC: Decreased Risk


A large new study on VBAC after prior VBAC has just come out, and it affirms what we've seen before, that risk for subsequent labors goes down and success rates go up after a previous VBAC.

Krispin 2018 Study

This is a large retrospective cohort study from Israel. It looked back at all women who attempted a VBAC at a major hospital over a period of 7 years (2007-2014).

The study group (n=1,211) contained the women with at least one prior VBAC. The control group (n=2,045) was comprised of women pursuing their first VBAC.

As we've seen before, a prior VBAC increases the chances of another VBAC. So it was in this study, too. Those with a prior VBAC had a 96% subsequent VBAC rate. (I think that's the highest VBAC rate of any study I've ever seen!)

However, even the women pursuing their first VBAC had a high rate, nearly 85%. This suggests that the Israelis are doing something right when it comes to attending VBACs, because their VBAC rates are much better than those of many U.S. hospitals.

Induction of labor was associated with reduced VBAC rates, cutting the VBAC odds by half, but induction rates were fairly low compared to some practices. This allowed the success rate to stay high overall.

The study confirmed that a prior VBAC greatly lessens the risk for uterine rupture (UR). The uterine rupture rate in those with a prior VBAC was 0.7%, whereas it was 1.6% in the women with their first Trial of Labor (TOL).

The take-home from this study is that when other variables were controlled for, having a prior VBAC cut the odds for uterine rupture in half in subsequent labors. 

Even so, both groups of UR numbers seem a little high, probably because the hospital used prostaglandins (PGE2) to induce their VBACs. Prostaglandins (and especially prostaglandins plus pitocin) have been shown to increase the risk for uterine rupture. Unfortunately, the study did not share the rupture rate in the induced groups vs. the rupture rate in the spontaneous labor groups. That would have been illuminating.

It's also important to point out that the risk for rupture wasn't zero. Even after a VBAC, uterine rupture is still a potential risk and has been known to occur. Neither is prior VBAC a guarantee of subsequent VBAC outcomes; there's always a chance of another cesarean because unpredictable things happen in labor.

But it's good to confirm again that the risk for uterine rupture is substantially lower once you've had a VBAC, and that your chances of having another VBAC are very good indeed.

Other VBAC after VBAC Studies

This is not the first study on successive multiple VBACs. Prior research also shows improved outcomes with previous VBAC. For example, Shimonivitz (2000) found the risk for uterine rupture "decreased dramatically" once a woman has had a VBAC.

Some women have reported being told that risk for uterine rupture goes back up again after a certain number of VBACs and that therefore only a few VBACs can be allowed before a woman is required to have repeat cesareans again. This claim is not based in research at all and flies in the face of common sense.

The most definitive study on this claim is Mercer (2008), who studied multiple successive VBACs in 19 hospitals in the MFMU network. They found that UR rates dropped after the first VBAC and remained low thereafter:
Among 13,532 women meeting eligibility criteria, VBAC success increased with increasing number of prior VBACs: 63.3%, 87.6%, 90.9%, 90.6%, and 91.6% for those with 0, 1, 2, 3, and 4 or more prior VBACs, respectively (P<.001). The rate of uterine rupture decreased after the first successful VBAC and did not increase thereafter: 0.87%, 0.45%, 0.38%, 0.54%, 0.52% (P=.03). The risk of uterine dehiscence and other peripartum complications also declined statistically after the first successful VBAC. No increase in neonatal morbidities was seen with increasing VBAC number thereafter.
The other consideration is that if a woman is not "allowed" to VBAC, she ends up with multiple repeat cesareans, which carry significant risks of complications such as placenta previa, placenta accreta, bladder and bowel injuries, hemorrhage, and hysterectomy (Silver 2006). The risk is dose-dependent, meaning that the risk increases with every successive cesarean a woman has. If a woman is planning a large family, the evidence clearly shows that repeated VBACs are far safer than repeated cesareans.

As Mercer et al. conclude:
Women with prior successful VBAC attempts are at low risk for maternal and neonatal complications during subsequent VBAC attempts. An increasing number of prior VBACs is associated with a greater probability of VBAC success, as well as a lower risk of uterine rupture and perinatal complications in the current pregnancy. There is no reason to place a limit on the number of VBACs a woman can have.
Summary

Once you've had a VBAC, you have an even better chance than before at another VBAC. It's not a guarantee, of course, but most studies show the VBAC after VBAC rate to be above 90%.

The uterine rupture rate after prior VBAC seems to fall between 0.4% and 0.7%. However, it will vary depending on how much induction is used, what induction methods are used, how aggressive providers are with augmentation, and any other other risk factors present. Whatever the exact number is, studies show that the uterine rupture rate decreases strongly after a prior VBAC but there should always be an awareness of the possibility.

The bottom line is that the risk for poor outcomes goes down with successive VBACs, while the risk for poor outcomes goes up with multiple repeat cesareans. In most cases, VBAC after VBAC offers far more advantages and should not be restricted. 


References

J Matern Fetal Neonatal Med. 2018 Apr;31(8):1066-1072. doi: 10.1080/14767058.2017.1306513. Epub 2017 Mar 27. Association between prior vaginal birth after cesarean and subsequent labor outcome. Krispin E, Hiersch L, Wilk Goldsher Y, Wiznitzer A, Yogev Y, Ashwal E. PMID: 28285573
OBJECTIVE: To estimate the effect of prior successful vaginal birth after cesarean (VBAC) on the rate of uterine rupture and delivery outcome in women undergoing labor after cesarean. METHODS: A retrospective cohort study of all women attempting labor after cesarean delivery in a university-affiliated tertiary-hospital (2007-2014) was conducted. Study group included women attempting vaginal delivery with a history of cesarean delivery and at least one prior VBAC. Control group included women attempting first vaginal delivery following cesarean delivery. Primary outcome was defined as the rate of uterine rupture. Secondary outcomes were delivery and maternal outcomes. RESULTS: Of 62,463 deliveries during the study period, 3256 met inclusion criteria. One thousand two hundred and eleven women had VBAC prior to the index labor and 2045 underwent their first labor after cesarean. Women in the study group had a significantly lower rate of uterine rupture 9 (0.7%) in respect to control 33 (1.6%), p = .036, and had a higher rate of successful vaginal birth (96 vs. 84.9%, p < .001). In multivariate analysis, previous VBAC was associated with decreased risk of uterine rupture (OR = 0.46, 95% CI 0.21-0.97, p = .04). CONCLUSIONS: In women attempting labor after cesarean, prior VBAC appears to be associated with lower rate of uterine rupture and higher rate of successful vaginal birth.
Similar Studies on VBAC After VBAC

Mercer BM, Gilbert S, Landon MB. et al. Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Obstet Gynecol. 2008 Feb;111(2):285-291. PMID: 18238964 You can read the entire study here.
OBJECTIVE: To estimate the success rates and risks of an attempted vaginal birth after cesarean delivery (VBAC) according to the number of prior successful VBACs. METHODS: From a prospective multicenter registry collected at 19 clinical centers from 1999 to 2002, we selected women with one or more prior low transverse cesarean deliveries who attempted a VBAC in the current pregnancy. Outcomes were compared according to the number of prior VBAC attempts subsequent to the last cesarean delivery. RESULTS: Among 13,532 women meeting eligibility criteria, VBAC success increased with increasing number of prior VBACs: 63.3%, 87.6%, 90.9%, 90.6%, and 91.6% for those with 0, 1, 2, 3, and 4 or more prior VBACs, respectively (P<.001). The rate of uterine rupture decreased after the first successful VBAC and did not increase thereafter: 0.87%, 0.45%, 0.38%, 0.54%, 0.52% (P=.03). The risk of uterine dehiscence and other peripartum complications also declined statistically after the first successful VBAC. No increase in neonatal morbidities was seen with increasing VBAC number thereafter. CONCLUSION: Women with prior successful VBAC attempts are at low risk for maternal and neonatal complications during subsequent VBAC attempts. An increasing number of prior VBACs is associated with a greater probability of VBAC success, as well as a lower risk of uterine rupture and perinatal complications in the current pregnancy.
Isr Med Assoc J 2000 Jul;2(7):526-8. Successful first vaginal birth after cesarean section: a predictor of reduced risk for uterine rupture in subsequent deliveries. Shimonovitz S, Botosneano A, Hochner-Celnikier D. PMID: 10979328
...Although a vaginal birth after a cesarean is considered safe in modern obstetrics, it is not known whether repeated VBACs increase the risk of rupture, or whether the first VBAC proves the strength and durability of the scar, predicting further successful and less risky vaginal deliveries. OBJECTIVES: To evaluate the effect of repeated vaginal deliveries on the risk of uterine rupture in women who have previously delivered by cesarean section. METHODS: In this retrospective study, 26 VBAC deliveries complicated by uterine rupture were matched for age, parity, and gravidity with 66 controls who achieved VBAC without rupture... We found that the risk of rupture decreases dramatically in subsequent VBACs. Of the 40 cases of uterine rupture recorded during the 18 year study period, 26 occurred during VBAC deliveries. Of these, 21 were complicated first VBACs. We also found that the use of prostaglandin-estradiol, instrumental deliveries, and oxytocin had been used significantly more often during deliveries complicated with rupture than in VBAC controls. CONCLUSIONS: Once a woman has achieved VBAC the risk of rupture falls dramatically. The use of oxytocin, PGE2 and instrumental deliveries are additional risk factors for rupture, therefore caution should be exerted regarding their application in the presence of a uterine scar, particularly in the first vaginal birth after cesarean.
Risks of Multiple Repeat Cesareans


Obstet Gynecol. 2006 Jun;107(6):1226-32.National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Maternal morbidity associated with multiple repeat cesarean deliveries. Silver RM,  et al.  PMID: 16738145
...METHODS: Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999-2002). RESULTS: There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively. CONCLUSION: 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.

Thursday, April 19, 2018

VBAC after Cesarean for Arrest of Descent or Cephalo-Pelvic Disproportion

Your pelvis is NOT defective
A cesarean for "Arrest of Descent" means a cesarean done after a woman has dilated fully and pushed for a while without the baby descending. The amount of pushing time required for the diagnosis varies from source to source but is usually at least 1-3 hours.

When a woman has a cesarean for Arrest of Descent, she is often told something is wrong with her pelvis. She might be told she has:
  • A "flat" sacrum 
  • A "prominent" sacrum
  • A pubic arch that is "too narrow"
  • Ischial spines that are "too prominent" 
  • A pelvis that is "too small"
  • "Too much soft tissue" (fat) lining the vagina/pelvis
  • A pelvis that is the "wrong shape" 
  • A baby that was "too big" for her pelvis 
  • "Cephalo-Pelvic Disproportion" (baby too big and pelvis too small, causing baby to not fit)
Often women who have been told these things are strongly discouraged from trying for a Vaginal Birth After Cesarean (VBAC). There are documented cases where women have been told their pelvis is too flat or too small to have a VBAC, that they have "soft tissue dystocia" (a.k.a. "fat vagina"), that their pelvis is the wrong shape, or that since they couldn't push out a baby before, chances are they never will be able to because CPD is a recurring condition:
Yesterday, at my appt, while speaking with one of the midwives - she asked if I wanted her honest opinion & that if I was unable to push out a 7 and 1/2 pound baby and 2nd babies are normally larger then she didn't think it would be successful. 
The bottom line is that providers that are not truly VBAC-supportive often make women believe that something is wrong with their bodies and that they have little chance of having a vaginal birth, implying it's better just to schedule a repeat cesarean. Then the care providers conveniently have fewer VBAC labors to attend.

However, many women who have been told they have an abnormal pelvis or soft tissue dystocia or who have had a cesarean for Arrest of Descent or CPD have gone on to have VBACs anyhow.

And a new study just out confirms that many women with a prior cesarean for Arrest of Descent do indeed go on to have a VBAC and should not be discouraged from trying.

New Study on VBAC after Arrest of Descent

A recent American study (Fox 2018) shows that VBAC after prior Arrest of Descent is often successful.

In the study, one hundred women who had one prior cesarean for Arrest of Descent had a "Trial Of Labor After Cesarean" (TOLAC or TOL). A whopping 84% ended up having a VBAC. This is an excellent rate and better on average than many VBAC studies.

The authors concluded (my emphasis):
This suggests that arrest of descent is mostly dependent on factors unique to each pregnancy and not due to an inadequate pelvis or recurring conditions. Women with a prior CD [Cesarean Delivery] for arrest of descent should not be discouraged from attempting TOLAC in a subsequent pregnancy due to concerns about the likelihood of success.
The fact that the authors state this so strongly in an obstetrics journal is a big deal because it goes against what is commonly taught to many OBs, so let's reemphasize those points:
  • Arrest of Descent is NOT usually due to an inadequate pelvis
  • "CPD" is not necessarily a recurring condition
  • Women with this history should not be discouraged from trying for a VBAC
Many women can and DO have VBACs after diagnoses of CPD and Arrest of Descent. Yet strong discouragement away from VBAC is exactly what happens to many of these women, even today. 

Other Similar Studies

Was this study just a fluke? What do other studies on Arrest of Descent say?

There are only a couple of studies that specifically use the term "VBAC after Arrest of Descent" so you have widen the search a bit. Other search terms to consider include "CPD + cesarean," "cesareans after full dilation," or "cesareans done during second stage of labor" (pushing), or "prolonged second stage," or similar terms. Carefully vetted, these are essentially Arrest of Descent cesareans too.

If you just look at studies that examine VBAC after a cesarean for CPD, research reviews show that about two-thirds of women will have a VBAC. This rate is lower than for those whose first cesarean was for breech or fetal distress, but is still a very good rate. If all those women had been discouraged from VBAC or pressured into repeat cesareans, two-thirds of them would have had unnecessary cesareans!

There is very little data on women who have had more than one cesarean for CPD. However, one 1989 study did contain some data on women like this. If you crunch the data in the full text of the study, women with 2 prior cesareans for CPD had a 56% VBAC rate. So although we don't have a lot of data on this, what we do have suggests that even among women with more than one cesarean for CPD, more than half will have a VBAC.

The doctors who like to discourage VBAC cite a discouraging 1997 study that found a low VBAC rate (13%) in women who had reached full dilation and pushed in their previous labor. However, the rest of the research is much more encouraging.

In one Californian study from 2015, 54% of women with no prior vaginal birth and a prior cesarean during pushing stage went on to have a VBAC. In other words, they were just as likely to have a VBAC as not.

Similarly, a Danish study found a 59% VBAC rate in women whose cesareans occurred at 9-10 cm of dilation (9 cm often represents a fully dilated woman with a cervical lip, likely due to fetal malposition). Again, more than half had a VBAC and avoided the risks of additional surgery.

But some studies have results even better than that. In a New York study, 74.5% of women with prior pushing-stage cesareans went on to have a VBAC, some of them with forceps help, which suggests that fetal malpositions were an issue for quite a few.

Echoing those numbers is a Canadian study that found a 75% VBAC rate in those with a prior second stage dystocia cesarean. A very small, older Irish study found a 73% VBAC rate in those with a prior cesarean in the second stage.

Similarly, an older Dutch study found an 80% VBAC rate in those with a prior Arrest of Descent cesarean. This echoes our current Fox 2018 study that found an 84% VBAC rate after prior Arrest of Descent.

In summary, the majority of the research clearly supports the idea that women with a prior cesarean that occurred after full dilation and pushing can be offered a "trial of labor after cesarean" and will have a quite reasonable chance for a VBAC.

In the end, the decision whether to go for a VBAC is the mother's, but she should be reassured that she is just as likely to have a VBAC as not, and in many practices, especially with proactive care regarding fetal position, her chances are even better.

The Importance of Fetal Position

So what causes Arrest of Descent? Why does it happen in some births but not others in the same mother? The answer is usually fetal position.

In Arrest of Descent/CPD cesareans, the problem is usually the BABY'S POSITION, not the mother's pelvis.

If the baby is not well-positioned, labor tends to be slow and extra painful. It often slows or stalls between 4-7 cm of dilation. Often the mother eventually dilates fully but there is little or no progress during pushing. Fetal distress may occur.

Some providers become impatient and intervene with procedures (like breaking the waters) which may do more harm than good. Frequently, they are too quick to move to surgery when more patience might see the position resolve or the baby be born just fine in the "less-optimal" position. Recent research suggests that more than three-fourths of women with prolonged pushing stages (more than 3 hours) will deliver vaginally if just given a little more time.

What kind of fetal positions can cause problems? Read here for illustrations and specifics of the different fetal positions. The Spinning Babies website also has many helpful articles and illustrations on fetal position and how to help create maximum room in the pelvis. In the meantime, below is a brief introduction of the most common fetal malpositions.

Keep in mind that Presentation refers to which part of the baby is presenting first, and Position refers to how the baby is oriented in the mother's body in a head-down position. Also keep in mind that when describing fetal position, obstetric texts reference the back of the baby's head (the occiput) and which way the occiput is oriented in relationship to the mother. Most laypeople find it easier to understand by thinking of which way the baby is looking, so I use both in my descriptions.

Both the Spinning Babies website and The Labor Progress Handbook by Penny Simkin et al. have many ideas for various ways to help malpositioned babies resolve their position, and for creating more space in the pelvis. We will discuss this further in future posts.

Occiput Anterior (Easiest for Birth)


Occiput Anterior or OA
The easiest fetal position for labor and birth is usually Occiput Anterior. This is abbreviated OA and means the baby is head-down with the back of the baby's head against the mother's front; in other words, the baby is looking towards the mother's back. This position is considered the norm and the vast majority of babies will be born in this position.

Direct OA is when the baby is looking directly back at the mother's sacrum. LOA is when the baby is mostly facing the mother's back but his back is a bit towards the left side; ROA is the same but a bit towards the right side.

Ideally, the baby's chin is tipped towards its chest so the smallest possible diameter of its head presents. If the baby's head is not well-flexed, the presenting diameter is a bit larger. If the baby's head is tipped to one side or the other, it can be even larger. More on that below.

Occiput Posterior 


Illustration by Gail Tully, Spinning Babies
One of the most common fetal positions that can cause problems during labor is the Occiput Posterior position. This is abbreviated OP; the back of baby's head is against your back and baby is looking at your tummy. If the baby is directly facing your back, that's direct OP; if it's a little to the right or left, then that's ROP or LOP.

Although many babies enter labor in less-ideal positions like OP, only about 5% stay posterior all through labor and deliver that way. Babies that come out in the OP position are sometimes called "Stargazers" or "Sunny Side Up."

By itself, an OP position does not have to mean a cesarean, since most OP babies turn during labor and become OA before birth. The labor may be a little longer and more painful but it often proceeds just fine with a little patience. However, babies that are persistently posterior all the way through labor and birth have a high rate of problems.

Research clearly shows that persistent posterior babies have higher rates of cesareans for CPD or Arrest of Descent. This is because the presenting head diameter of a baby in OP position is larger than the baby in an OA position. In addition, the back of the baby's head is against the mother's back and that makes for a more painful labor, with lots of back labor and a slower dilation. This in turn often means lots of interventions from care providers that may make the situation worse, like breaking the waters, which takes away the cushion for baby to turn more easily and may lead to fetal distress.

However, OP babies do not always end with cesareans. With time and patience, an OP baby with a flexed head (chin to chest) can often be born vaginally. Alternatively, a vaginal birth may be possible if the care provider is patient and allows extra time for the baby's head to mold enough to descend into the pelvis. When it hits the pelvic floor, it often then rotates from OP to OA on the perineum and may be born quickly. Often an OP baby can be helped to rotate to OA through manual rotation, an instrumental delivery, or maternal postural changes like the all-fours position.

But because of the impatience of many providers, the fetal distress that can occur, and the extra-painful, longer labors associated with OP babies, many persistent OP babies end up being born by cesarean.

Deflexed Heads

If a baby's head is deflexed (not chin to chest), this can cause problems as well. A deflexed head makes the baby's presenting head diameter larger. This means the baby may not fit through very well, or the baby needs extra time for its head to mold enough to get through. OA babies with mildly deflexed heads experience longer labors, but with a little patience, are usually able to be born vaginally.

However, significant problems can occur if deflexion is extreme. Extreme examples of deflexed heads include a brow (forehead first) or face (face-first) presentation. Although vaginal births of brow and face presentations have been documented, most often they end in cesarean these days unless the baby's position can be resolved. Fortunately, brow and face presentations are quite rare.

Deflexed babies in an OP position are fairly common and result in many long, difficult labors. OP babies already start out with a larger presenting head diameter; when they also have deflexed heads (known as a "military" position), this makes the head diameter even larger. Big OP babies often have deflexed heads, making their head diameters even larger. These babies often have extremely long and hard labors, and many end in cesareans. Turn the baby around and/or tip its chin towards its chest so that the head is flexed and the baby would likely fit much better; many cesareans could be avoided.

Occiput Transverse/Transverse Arrest

Occiput Transverse, which can result
in Transverse Arrest
When a baby's head is directly sideways, facing the hip, this is called Occiput Transverse or OTOften OT positions are able to resolve to OA, but sometimes they do not and result in a vacuum extraction, forceps delivery, or cesarean.

OT often occurs when the baby was posterior earlier in labor, tries to rotate to anterior, and gets stuck in the process of turning. Sometimes it is iatrogenic (caused by the provider). If labor is slow, the care provider may break the mother's waters in an effort to speed up labor. This removes the buoyant cushion that can make it easier for the baby to finish its turn and the baby may end up "stuck" in this position. This is called "Transverse Arrest." A fair amount of cesareans are caused by transverse arrest.

Compound Presentation

A nuchal hand presenting alongside the head
Babies who have their hands up by their faces (a "nuchal hand" or sometimes a nuchal elbow/arm) can present another challenge.

The baby is basically OA and in a great position for birth, but the hand or arm beside the head causes larger-than-average presenting parts that must fit through at the same time. If the care provider can get the baby to pull back its arm/hand near birth, the baby is likely to then be born quickly. If the arm/hand remains by the baby's head, pushing is likely to be slow, painful, and difficult. Usually babies with nuchal hands can be born vaginally, but there may be quite a bit of tearing and damage to the mother. If the provider is not patient during a slow pushing stage with a nuchal hand/arm, it may result in a cesarean.

Asynclitic Heads

Asynclitic baby in OA position

Similarly, babies who have their heads tipped to the side instead of straight ("asynclitic") also have difficulty fitting. Instead of the top of the head presenting first, their parietal bone (bony side of head) presents first. The tipped head causes a larger than average head diameter that doesn't fit as easily.

Many asynclitic babies will correct the tilt of their heads if the mother's waters are kept intact and she is able to be mobile in labor. Asymmetric birth positions may help correct the tilt. Once the tilt is corrected, the baby is often born fairly quickly.

If the baby is not able to correct the tilt of its head on its own, then the care provider may be able to help through the use of a vacuum extractor or forceps. Sometimes the tilt of the head goes undiscovered or is not able to be resolved during labor; these babies often are born by cesarean.

Summary

Unfortunately, many women with a prior cesarean for CPD or Arrest of Descent are discouraged from even trying to have a VBAC. They may be told they have little chance at a VBAC and they should just schedule a planned repeat cesarean rather than risk another cesarean during labor. One woman was told:
You've already proven you can't get a baby out of your pelvis.
Obviously, that OB believed that the pelvis itself was the issue, not the baby's position, but the recent Arrest of Descent study suggests it is likely not true.

This kind of misleading "guidance" from care providers is not evidence-based. Most women with a prior CPD or Arrest of Descent cesarean who go through with labor actually have a reasonable chance at a VBAC, as this woman found:
The OB that did my c-section told me that my pelvis was small and also tilted and that because of that, a vaginal birth wouldn't be possible. Well, I...went for a VBAC anyway and it's a good thing I did because I had a wonderful amazing and natural VBAC with my next baby. And she came out in about 4 pushes. It was so easy! I had my second VBAC with my son a year ago and it went perfectly as well!
Here is a link to the story of another case where a woman who had a cesarean was told that her pelvis was too small to birth a baby and to forget about a VBAC. She went on to birth a 9 lb. baby ─ with a nuchal hand ─ as a VBAC. The Birth Without Fear blog has an awesome picture of it in their birth stories section.

That's not to say that CPD is never real. Sometimes it is. Although most cases of "CPD" are actually situational (caused by a malposition), sometimes there are rare cases of true CPD. These are usually a result of significant malnourishment in childhood, severe scoliosis, a history of rickets, or a history of a bad fall or accident where the pelvis was damaged. And sometimes, women don't have any of that in their background, really do try everything, and still end up with a cesarean because the baby just didn't fit. It does happen and it's important to acknowledge that.

But far too often, women who have had a cesarean after not being able to push out a baby are told that their pelvises are too small or defective, and they'll never be able to push out a baby. This is not true. Many women with this history can have a vaginal birth, if given an adequate chance to do so. Anecdotally, many women who have been told this benefit from having a good chiropractor evaluate their back and pelvis to help maximize the space in it and get it well-aligned. See my story below.

Women with a history of cesareans for Arrest of Descent or CPD should be offered the chance at a VBAC if they want it. Chances are good they will have one. There are never any guarantees, but research clearly shows that trying for a VBAC is a very reasonable choice in this group and should not be discouraged.

My Story

Again, many women have had cesareans for arrest of descent and yet gone on to have a VBAC. Conventional wisdom is that you need a smaller baby to get a VBAC, but some women do have VBACs with a baby even bigger than their cesarean baby. Again, fetal position is key.

This includes me. I had my first cesarean after a difficult induced labor. I dilated to 10 cm and pushed for two hours in stirrups, but ended up with a very traumatic cesarean. With my second baby, I had a relatively easy spontaneous labor where I did all the "right" things including position changes but still had FIVE HARD HOURS of pushing with little descent of my deflexed OP baby. I ended up with a second cesarean for CPD.

Both of my babies were big. I was told I had a "marginal" pelvis by my first care provider, and unless I had a smaller baby I would probably not have a vaginal birth. After my second birth, a nurse-midwife told me I probably had a pelvic shape predisposed to posterior babies and my babies would likely always be posterior. After two CPD cesareans at full dilation and after hours of pushing, I was told I was extremely unlikely to have a VBAC. The "VBAC Calculator" gave around a 20% chance of having a VBAC if I tried again.

All these declarations were wrong in the end but it was difficult to have faith. In my third pregnancy, I wavered between choosing to labor again or just going straight to a repeat cesarean. The baby was consistently posterior again all through pregnancy and I had no desire to go through a long hard labor only to end up with another cesarean ─ but neither did I want to go through another surgical recovery. I was also worried about the increase the risk of placental issues from another cesarean if I decided to have another baby in the future.

Near the end of my third pregnancy, I found a chiropractor who did a lot of work on my pelvis, including the Webster Technique and releasing the round ligaments that attach to the uterus. She felt my history of car accidents was highly relevant to the malpositions going on. According to her, the significant back and pubic pain I was having indicated "in utero constraint" that was making it hard for my babies to be in the easiest position for labor. The chiropractic adjustments eased a lot of my discomfort and the baby moved pretty quickly into a more optimal OA position for the first time in three pregnancies!

I went on to have a VBAC after 2 cesareans (VBA2C), something many providers would have told me would be extremely unlikely with my history and risk factors (short, old, "morbidly obese," big babies, two prior CPD cesareans, no prior vaginal births). Instead of pushing for 2 hours or for 5 hours as I did with my first two children, I pushed for 12 minutes with that baby. The doctor didn't even make it to the birth.

And it wasn't just a lucky fluke. Several years later, I had another VBA2C, this time with a baby that was a pound larger than either of my cesarean babies. I only pushed for 24 minutes with that baby.

Afterwards I asked my midwife to evaluate my pelvis and tell me honestly if it was truly marginal or not. She examined me and said it absolutely was not. Either the prior evaluation was wrong or chiropractic care really did create more space in my pelvis ─ or maybe a little of both. I do feel that the chiropractic care was integral to my VBACs, given that I never had an anterior baby until I had chiropractic care.

Remember, each labor and birth is unique and previous problems do not necessarily happen again.

Even a history of more than one Arrest of Descent or CPD cesarean does not mean it will continue to happen, especially if the mother is very proactive about fetal position. I had a history of TWO cesareans for Arrest of Descent and still went on to have two VBACs.

I have known women who have had VBACs after 1, 2, and even 3 prior CPD cesareans, including full dilation and pushing for hours each time with no vaginal birth. Yet they still eventually had a VBAC. The International Cesarean Awareness Network (ICAN) has a number of stories of women who have had a prior cesarean (or more) for CPD or Arrest of Descent and yet went on to have a VBAC. You can see some of them in their "Question CPD" video below.

There are never any guarantees, of course, and there are important risks to consider with both VBAC and an Elective Repeat Cesarean. However, if you choose to labor, your VBAC chances are good, anywhere between 50-80% based on the research. Don't let care providers convince you out of trying for a VBAC based on a past history of CPD or Arrest of Descent. In the end, it's your decision.



April is Cesarean Awareness Month. For more information on cesareans and VBACs, see the International Cesarean Awareness Network. 


References

J Matern Fetal Neonatal Med. 2018 Feb 27:1-5. doi: 10.1080/14767058.2018.1443069. [Epub ahead of print] Vaginal birth after a cesarean delivery for arrest of descent. Fox NS, Namath AG, Ali M, Naqvi M, Gupta S, Rebarber A. PMID: 29455594
...This was a retrospective cohort study of all patients delivered by a single MFM practice from 2005 to 2017 with a singleton pregnancy and one prior CD for arrest of descent. We estimated the rate and associated risk factors for successful VBAC. RESULTS: We included 208 patients with one prior CD for arrest of descent, 100 (48.1%) of whom attempted a trial of labor after cesarean (TOLAC) with a VBAC success rate [of] 84/100 (84%, 95% CI 76-90%). Among the women who attempted TOLAC, women with a prior vaginal delivery >24 weeks' had a significantly higher VBAC success rate (91.8% versus 71.8%, p = .01). Maternal age, body mass index, estimated fetal weight, induction of labor, and cervical dilation were not associated with a higher VBAC success rate. CONCLUSIONS: For women with a prior CD for arrest of descent, VBAC success rates are high. This suggests that arrest of descent is mostly dependent on factors unique to each pregnancy and not due to an inadequate pelvis or recurring conditions. Women with a prior CD for arrest of descent should not be discouraged from attempting TOLAC in a subsequent pregnancy due to concerns about the likelihood of success.
J Matern Fetal Neonatal Med. 2017 Feb;30(4):461-465. Epub 2016 May 5. Prolonged second stage in nulliparous with epidurals: a systematic review. Gimovsky AC, Guarente J, Berghella V. PMID: 27050812
...A systematic review of the literature was performed... for case series evaluating the morbidities of prolonged second stage of labor. Search terms used were "prolonged", "second stage", and "labor". Prolonged second stage was defined as three hours or more. Retrospective case series of prolonged second stage in nulliparous women with epidurals were identified. The primary outcome was the incidence of cesarean delivery. RESULTS: Two retrospective series with 5350 nulliparous women with prolonged second stage were identified. 76.3% (4 081/5 350) had an epidural. Of all nulliparous women with an epidural, 11.5% (4 081/35 469) had prolonged second stage. Cesarean Delivery occurred in 19.8% of these cases (782/4 081), while 80.2% had a vaginal delivery. CONCLUSIONS: Over three quarters of nulliparous women with epidural diagnosed with a prolonged second stage deliver vaginally.
VBAC After CPD Diagnosis

J Obstet Gynaecol Can. 2003 Apr;25(4):275-86. Vaginal birth after Caesarean section: review of antenatal predictors of success. Brill Y, Windrim R. PMID: 12679819
"...Even with a history of CPD, two-thirds of women will have successful VBAC, though rates decrease with increasing numbers of prior CS...There are few absolute contraindications to attempted VBAC. Attempted VBAC will be successful in the majority of attempted cases."
Obstetrics and Gynecology. February 1989. 73(2):161-5. Twice A Cesarean, Always a Cesarean? Phelan, JP et al.  PMID: 2911420
[My summary of highlights from the full text] 501 women with 2 or more previous cesareans had a TOL, and 69% had a VBAC overall. Women who had had at least one previous cesarean for CPD had a 64% VBAC rate. Those who had had 2 successive labors both ending in c/s for CPD still had a 56% VBAC rate. In other words, even those women with a previous 'failed' trial of labor had a better chance of a VBAC than another cesarean in labor.
Other Studies on Arrest of Descent or Similar Definitions
  • Am J Obstet Gynecol. 2015 Dec;213(6):861.e1-5. doi: 10.1016/j.ajog.2015.08.064. Epub 2015 Sep 6. Effect of stage of initial labor dystocia on vaginal birth after cesarean success. Lewkowitz AK, Nakagawa S, Thiet MP, Rosenstein MG. PMID: 26348381
  • Acta Obstet Gynecol Scand. 2013 Feb;92(2):193-7. doi: 10.1111/aogs.12023. Epub 2012 Nov 5. Cervical dilation at the time of cesarean section for dystocia -- effect on subsequent trial of labor. Abildgaard H, Ingerslev MD, Nickelsen C, Secher NJ. PMID: 23025257
  • Obstet Gynecol. 2001 Oct;98(4):652-5. Should we allow a trial of labor after a previous cesarean for dystocia in the second stage of labor? Bujold E, Gauthier RJ. PMID: 11576583
  • Obstet Gynecol. 2000 Apr;95(4): S38. https://doi.org/10.1016/S0029-7844(00)00660-8 Obstetrics Prognostic indicators for successful vaginal birth after cesarean delivery. Marshak J, Cooperman BS, Fried WB, Shi, Quihu. Available here.
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