tag:blogger.com,1999:blog-4738062031052371885.post4945384807617493660..comments2024-03-17T10:07:53.205-07:00Comments on The Well-Rounded Mama: Ultrasound Measurement of Cesarean Scar ThicknessWell-Rounded Mamahttp://www.blogger.com/profile/04129621631406155340noreply@blogger.comBlogger16125tag:blogger.com,1999:blog-4738062031052371885.post-73228359145844053632017-08-23T13:59:22.872-07:002017-08-23T13:59:22.872-07:00They told me my scar was less than 1mm thick. Whe...They told me my scar was less than 1mm thick. When they actually opened me up my scar wasn't thin after all. My baby was breech and I could have attempted an EVC and a vbac. I am actually quite pissed.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4738062031052371885.post-22922723395269365702016-02-03T18:50:16.384-08:002016-02-03T18:50:16.384-08:00Gabor, thanks for sharing. I think we have a langu...Gabor, thanks for sharing. I think we have a language barrier on one point, because I'm not sure exactly what you mean by "narcosis." Anesthesia, perhaps? <br /><br />I think you are saying your wife was required to have anesthesia after the VBAC so the doctors could do an internal exam to see if she had ruptured. If that's what you mean, you should know that there is NO research indicating that this practice is beneficial, and indeed it may be harmful. If there has been a rupture, there will be signs indicating a need for exploration. It is NOT recommended in most countries to do a routine exploration unless there are signs indicating its need. <br /><br />It sounds like overall you had pretty supportive doctors, and I'm glad your wife got the option for a VBAC. That's great. I'm just saying that the evidence does NOT support doing routine internal exams into the mother's uterus afterwards to check for rupture, and while this practice was routine years ago when VBAC first became done more often, it is no longer done in most places because doctors recognized they were doing more harm than good.<br /><br />Congratulations on your baby, and I'm glad all went well overall. Well-Rounded Mamahttps://www.blogger.com/profile/04129621631406155340noreply@blogger.comtag:blogger.com,1999:blog-4738062031052371885.post-79522309623173790512016-02-03T05:56:48.347-08:002016-02-03T05:56:48.347-08:00Full version - part2:
The team around my wife was...Full version - part2:<br /><br />The team around my wife was obviously a key to the success. The doctor, a fantastic person who took great care of the mom and motivated her allowed the use of oxytocin. He would tell us monitoring was okay and he could have intervened and fixed the damage in time if needed. If there is a higher risk for a uterine rupture during a VBAC, an operation always carries more risk alone, specially, if it’s a repeated caesarian. 10 days before the birth, the scar was examined via ultrasound and was found to be thick enough (5mm) to let my wife a TOLAC.<br /><br />The success of VBAC mainly because of the rules was not for granted. We tried to gather as much information as we could previously. It only added to the confusion that each doctor had a slightly different opinion and attitude. Exceeding the terminus, inducing the birth was not going to be allowed, my wife would have been forced in the hospital right before the due date for up to a week and it would have ended with a programmed caesarean had nothing started the natural way. The induction was disallowed even by the first team (night shift) which before the one which actually was on site when the baby was born. Reasons were that oxytocin could cause a lot more tension on the scar of the previous c-sect. Statistically, a uterine rupture is slightly more likely for a VBAC than a first vaginal birth, but eg. This article tells you it’s a mountain made out of a molehill: http://midwifethinking.com/2011/02/23/vbac-making-a-mountain-out-of-a-molehill/.<br /><br />Narcosis was not a real factor jeopardizing initial breast-feeding. A couple of hours later mother was allowed to feed the baby. The real hazard is if the narcosis took longer or the baby could suck down the milk to 0 – which is not an issue since a newborn has a stomach as big as a cherry’s core. Officially, you should not breast-feed the baby for 4-6 hours, but since the colostrum already collects long before birth in the breast, for a newborn who can sip only a bit then fall asleep, materials used for anesthesia is not problem. Half an hour after the examination in narcosis, the mother was already awake and was allowed to be with the baby.<br /><br />Three days later, they were out of hospital.<br /><br />Lessons learned: we should have studied which doctor would enable the VBAC the most flexible way – of course not at any cost but to a reasonable extent. Since we only started to look for a pre-arranged doctor who would be on hand when it was needed regardless of hospital schedules. We were lucky to have the best doctor around on his schedule that time.<br /><br />So you’ve got to learn the hospital protocol beforehand and choose a doctor or even another hospital if you can to make sure your desire on a VBAC is supported. Worst case scenario would have been a programmed caesarean, when the mother cannot even start the labor which is told to be needed for both mother and baby, physically and emotionally in a healthy way. If you can choose at least let the contractions start and you can still opt for a c-sect if needed.Anonymoushttps://www.blogger.com/profile/11453583844300249413noreply@blogger.comtag:blogger.com,1999:blog-4738062031052371885.post-37982717621113001542016-02-03T05:56:09.660-08:002016-02-03T05:56:09.660-08:00Full version - part1:
Our first born was an emerg...Full version - part1:<br /><br />Our first born was an emergency C-sect 21 months before, due to pre-eclampsia on g. week #34. My wife (35) preferred a VBAC for baby #2 (also a girl) due January 2016. <br /><br />Towards the end of an uninterrupted pregnancy, at the very end of g. week #39 the amnion must have ruptured somewhere high and the fluid broke. Contractions only began 5-6 hours later. From then on, with a frequency of 5 minutes, contractions repeated for 12 hours. In the last 2-3 hours of labor the amniotic sac was broken behind the cervix manually with a use of an artery forceps to let the remainder of the amniotic fluid leave and help the baby slide closer to the birth canal. Also, my wife was given an infusion of oxytocin to help the contractions be stronger and longer lasting. Also, the frequency of the contractions got higher.<br /><br />In the meantime, taking a shower, surviving the pain of a contraction on an giant inflated ball or taking a shower on that ball was allowed, in fact encouraged despite of previous warnings that a TOLAC can strictly only happen in a lying position, for the entire duration of a labor in that very hospital – the reasons behind I think was the need for constant baby heart rate monitoring – but anyway, this rule was not that strict for us on this occasion. Warm water – not sitting in a bath which can be harmful to the baby but having a long shower proved to be a good pain killer. <br /><br />All went well, the baby heart rate was normal. My wife was asked several times as she started to train for the pushing phase, the movements during the peak of the contractions on whether she can feel any unusual pain on that area where the scar is – which could be hard to tell from the whole pain women experience – since the whole pelvic area: bones, muscles were dilating that time, causing a pain which could be felt even at the waist area. The main thing was to be able to concentrate on if it hurt specifically between the contraction caused pains.<br /><br />The unpleasant part was not to be allowed to consume any food or drinks, even a quarter of a gulp was allowed seldom. All due to the risk of a potential emergency caesarian and the inevitable narcosis after birth which was needed to let the doctor touch the scar on the uterus from the inside to check for any ruptures.<br /><br />At the end, all went okay and our second daughter was born the VBAC way. She and her mother are both healthy.Anonymoushttps://www.blogger.com/profile/11453583844300249413noreply@blogger.comtag:blogger.com,1999:blog-4738062031052371885.post-11031257743038140032015-07-08T16:23:22.502-07:002015-07-08T16:23:22.502-07:00Parul, I'm so sorry you are going through this...Parul, I'm so sorry you are going through this. I'm not a medical provider and I cannot give you advice on what to do. I can suggest some things to consider and further questions to ask your providers, but none of it is medical advice for one option or another. Only you can decide what to do. <br /><br />Yes, it's possible for the uterus to rupture without labor. It's rare, but it does happen once in a while, especially if the placenta is near to the scar. I cannot speak to how reliable a 1.7mm measurement is for predicting a pre-labor rupture if you go to 37 weeks. I doubt it's that reliable to predict pre-labor rupture (esp if the placenta is not near the scar), but neither could I reassure you that it would not rupture while waiting. <br /><br />I agree that the risk of breathing problems for a baby born by planned CS at 35 weeks is high, probably higher than the risk of a rupture between week 35 and 37, assuming no problem with placental placement. However, the chances are that the baby would recover from any early breathing issues with time if born at week 35, and with the steroids, may not have serious breathing problems. The risks of rupture, if it happens, are much more serious and potentially life-threatening...but many of those babies are OK too, if the rupture is caught early, when you look at the research. So it's hard to know what to do.<br /><br />If you are very uncomfortable with considering a 35 week CS, perhaps you could consult another OB and get a third opinion. Perhaps ask for another ultrasound measurement of the scar. One of the important take-aways from the research is that different ultrasound techs often come up with different measurements of the scar. Re-measuring might give you more information to go on. If the measurement goes lower, that might be an indication to do a CS sooner. If not, then perhaps your providers would be comfortable waiting a little longer.<br /><br />If you don't know your placental placement, that's another question that would be critical to know...placental placement near the scar might make a stronger case for an earlier CS, and placement further away might make a stronger case for waiting. But again, it's a judgment call. No advice from me. <br /><br />Another option, if your insurance will cover it or you have the money, is to check into a hospital from week 35 to 37 so you are right there if a problem occurs. A friend of mine (with a different condition, but for whom doctors also wanted an early CS) did this. This was the compromise she and her doctors agreed to after much discussion. That way, if a problem developed, she had immediate help and resources, and if no problem developed, her baby got a little extra time to mature. <br /><br />I'm sorry you are in this difficult position. I'm sorry I cannot give medical advice to help you. Many hugs to you as you consider your options. Well-Rounded Mamahttps://www.blogger.com/profile/04129621631406155340noreply@blogger.comtag:blogger.com,1999:blog-4738062031052371885.post-73986238259045461742015-07-07T22:47:39.637-07:002015-07-07T22:47:39.637-07:00Hi,
Sorry for posting on this old post. I am from...Hi, <br />Sorry for posting on this old post. I am from India and am experiencing problems because in trans vaginal ultrasound it was found that scar thickness from my first c-section pregnancy has thinned to 1.7 mm at 33 weeks. I have consulted two good doctors from Delhi and they both are not willing to take risks of allowing me to even go uptill 37 weeks. I have been given betnesol injection for lung maturation of baby in case if baby is delivered early. I have no pains at all at scar area even while anyone presses it hard. I want to be able to go upto at 37 weeks. I dont want a pre-mature baby but both doctors say I have to have a scheduled c-section at max 35 weeks. They say that uterus may rupture anytime while i m just carrying out daily activities. I have been put on bed rest but still they are not willing to take risks and go upto 37 weeks. Are there concerns right?? Can uterus rupture without labour pains. Forget about VBAC, I just want atleast a 37 weeks baby :( <br /> please reply.Anonymoushttps://www.blogger.com/profile/08617479652198712701noreply@blogger.comtag:blogger.com,1999:blog-4738062031052371885.post-48958360279474772452014-06-11T19:05:50.869-07:002014-06-11T19:05:50.869-07:00I don't know of any studies that provide a rea...I don't know of any studies that provide a really reliable cut-off. Doing a quick search just now I found these studies, which seemed to be the most applicable:<br /><br />http://www.ncbi.nlm.nih.gov/pubmed/20500938 - meta-analysis of studies on u/s thickness of scar<br /><br />http://www.ncbi.nlm.nih.gov/pubmed/23576473 - more recent meta-analysis of scar studies<br /><br />Both meta-analysis found that thinner measurements were somewhat predictive of UR risk, but that determining a reasonable cut-off remains difficult and varies according to study.<br /><br />http://www.ncbi.nlm.nih.gov/pubmed/23103207 <br /><br />The above is an opinion piece which reviewed the evidence and found the same thing. The author concluded:<br /><br />"No cut-off for lower uterine segment thickness, however, can be suggested because of study heterogeneity, and because prospective validation is lacking.... To sum up, we currently lack a method that can provide a reliable estimate of the risk of uterine rupture or dehiscence during a trial of labour in women with caesarean hysterotomy scar(s)."<br /><br />Hope that helps. I encourage you to do your own PubMed search for similar studies.Well-Rounded Mamahttps://www.blogger.com/profile/04129621631406155340noreply@blogger.comtag:blogger.com,1999:blog-4738062031052371885.post-5313164406607991342014-06-11T08:48:50.059-07:002014-06-11T08:48:50.059-07:00Do you know of any studies that have since been re...Do you know of any studies that have since been released to make a solid argument for a "reasonable cut-off measurement" if providers are going to use these ultrasound assessments?Ryanhttp://www.starlightbirthservices.comnoreply@blogger.comtag:blogger.com,1999:blog-4738062031052371885.post-90322189752642248512012-11-17T12:30:20.899-08:002012-11-17T12:30:20.899-08:00I've had three c-sections and dehissed with my...I've had three c-sections and dehissed with my last. I tried to vbac after the first one, and even went into labor with the third one, but the labor stopped and when I delivered via c-section a week later, I dehissed on the operating table. I found this post because I was looking for more information on what they will look for when they check the scar when they deliver the fourth baby due in June. What my surgeon told me is that what really determines the strength of the scar is not the scar itself but the tissue next to the scar. It would seem that there could be some cases in which a thick scar could actually be a risk factor in a rupture. H R Jnoreply@blogger.comtag:blogger.com,1999:blog-4738062031052371885.post-9465454659119458002011-09-03T13:02:13.884-07:002011-09-03T13:02:13.884-07:00Anonymous, I don't think the article ignores t...Anonymous, I don't think the article ignores the potential risks of VBAC at all; it clearly delineates them and how serious a rupture can be. I take that very seriously indeed, having had beloved friends who have experienced ruptures.<br /><br />However, I do think that critics ignore how serious the complications with a repeat cesarean can be. I have good friends who have experienced extremely serious complications with this as well. I recommend you review Silver 2006, with lots of data on the risks associated with accumulating cesareans. Too often, the risks of VBAC are emphasized while the risks of repeat cesareans are conveniently ignored.<br /><br />I agree that it's interesting and a little alarming that there is a trend towards more risk with thinner scars, and I can understand how this might make care providers hesitant or at least nervous. OTOH, the potential of misuse here is very high. Interoperator differences mean that the measurements might vary greatly from one person to another, and studies can't even agree on a common cutoff for increased risk. Nor are the studies large enough to be definitive. So there's potential for a LOT of women to be forced into repeat cesareans they don't really need if these measurements become standard measures by which access to a TOL is decided.<br /><br />I think the information on thin scars can be used to counsel the woman about her potential risks, but as a tool to determine who "gets" the chance to VBAC and who does not, it is far too ill-defined and unreliable, and the potential for abuse is too high.<br /><br />In an ideal world, the woman and her provider evaluate this risk together and decide their course of action from there. However, I disagree that a woman should close her eyes and blindly trust her provider's judgment; too many providers these days use ANY excuse not to attend a TOL and ignore the harms from repeat cesareans. Far too often it's the provider's own benefit that is topmost in their minds, not the woman's. Sad but very true for some providers these days.<br /><br />This information should be just that...information used to discuss potential risk (and benefits) of each choice; just another tool for the purposes of decision-making. It should not be used as a blunt cudgel to take women's decision-making powers away from them. And that's the way it's being used in some places. That I cannot and will never agree with.Well-Rounded Mamahttps://www.blogger.com/profile/04129621631406155340noreply@blogger.comtag:blogger.com,1999:blog-4738062031052371885.post-41662495941997125642011-09-03T12:43:58.832-07:002011-09-03T12:43:58.832-07:00Miss Momma, my heart goes out to you. I'm gla...Miss Momma, my heart goes out to you. I'm glad you and your baby are all right; thank goodness. But I understand how puzzling all of this can be to try and process.<br /><br />I'm not sure I have any definitive answers for you though. I'm not sure even the experts know why some scar separations are relatively benign and others so catastrophic. <br /><br />A lot has to do with other factors, such as whether the baby has protruded into the mother's abdomen after a true rupture. Outcomes are much worse if this happens. This didn't happen to you; you had one thin layer left. Even had that layer not been there, it might not have happened; not all rupture result in the baby protruding into the mother's abdomen. But it's definitely a risk factor for poorer outcome.<br /><br />The main risk factor for poor outcome with rupture is what happens with the placenta. In some ruptures, the placenta abrupts (pulls away from the uterus) and of course this disrupts the baby's oxygen supply etc. This is when rupture becomes truly catastrophic and babies die. Fortunately, this happens only in a very small percentage of true ruptures, and not at all with a dehiscence. So while a potentially very serious risk, it happens only to a very very small percentage.<br /><br />Why do some women experience a dehiscence and it doesn't progress to a full rupture? No one knows. I can't prove it, but I think it often has something to do with placentation. I think a lot of the worst ruptures are associated with abnormal attachment issues. <br /><br />Another factor is whether the uterus is subjected to extra strong contractions, as with induction and augmentation. I think forces beyond the norm for labor stress the uterus more strongly and some scars give way that might not have otherwise. <br /><br />And an unpredictable factor is how the mother healed previously, what kind of stitch/suture materials her doctors used and how her body responded to that.<br /><br />I'm sorry I don't have any real definitive answers for you. The bottom line is that it's a bit of a mystery to the experts too. They just don't know why some people have one outcome and others have a different one. <br /><br />I'm so glad you and your baby are okay.Well-Rounded Mamahttps://www.blogger.com/profile/04129621631406155340noreply@blogger.comtag:blogger.com,1999:blog-4738062031052371885.post-36240865090725223442011-08-19T07:19:44.109-07:002011-08-19T07:19:44.109-07:00I think this article is misleading and does not he...I think this article is misleading and does not help women make a choice. It is dogmatic and ignores the dangers of VBAC. Of course there are women that have a safe VBAC with thin uterus scars and women with thik scars rupture. But if the scar is thin, then the likelyhood of rupture appears to be higher. And even if these studies are not statistically signficant (hence the different results for the cut off), they all seem to point towards one direction: more risk with thinner scars. If this is all the information we have, it is normal to be risk averse when the scar is very thin. But of course there is a grey zone, where it is very difficult to make an informed decision and you just have to trust the experience of your midwife or doctor.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4738062031052371885.post-69337041050222437822011-04-06T23:48:57.453-07:002011-04-06T23:48:57.453-07:00I know this is an old post of yours but it is very...I know this is an old post of yours but it is very interesting and extremely pesonal to me. I had a 10 c dehiscense that was found upon incision. It was a full thickness separation and the only thing keeping baby in place was the peritoneum. This c-section was after a 24 hour TOL for a vba2c attempt. The OB stated that there was very little blood and it looked as though it had happened days prior to labor. I am so perplexed as to how a dehiscence and a rupture can have such different results with such similar descriptions of the uterine findings. In each case the uterus comes apart. In the case of a dehiscense there are no adverse affects, but in the case of a rupture the problems can be devastating for mother and baby. Is there ANY information out there describing the difference between the two and why one might happen and not the other? Any and all information on the subject would be greatly appreciated.Melissa Patehttps://www.blogger.com/profile/17760828291437582107noreply@blogger.comtag:blogger.com,1999:blog-4738062031052371885.post-26806736322846427392010-12-16T05:20:13.667-08:002010-12-16T05:20:13.667-08:00I still think I'd get it done for myself just ...I still think I'd get it done for myself just to know how thick I am. I've had one inverse T and two normal vaginal births before that. I would like to VBAC, but I want to know as much as I can. Thank you for the ideas you present as they gave me something to chew on.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4738062031052371885.post-19491054974665150772009-02-14T07:59:00.000-08:002009-02-14T07:59:00.000-08:00I have a family member who just had a scheduled re...I have a family member who just had a scheduled repeat c/s. She traveled across the state to find a "VBAC specialist", who, in the last few weeks of her pregnancy, informed her that her scar was "very thin" and that her baby weighed over 10 lbs, and that she had a 100% chance of rupture and that either the baby or the mother would die. <BR/><BR/>The baby weighed less than 9 lbs (they were assured that this doctor could predict the baby's weight to within one ounce, because he's so precise and careful with his ultrasounds).<BR/><BR/>With the baby's weight being so far off from what the doctor had estimeted, I can't help but suspect that his estimation of the scar from ultrasounds was also incorrect. And then there's the fact that there's no good research showing us what the scar thickness does for us anyway. <BR/><BR/>Another unnecessarian.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4738062031052371885.post-45198557729024417632009-02-13T17:02:00.000-08:002009-02-13T17:02:00.000-08:00Excellent summary.I would also add that in much of...Excellent summary.<BR/><BR/>I would also add that in much of the research that comes from Bujold, et al., the overall uterine rupture rate runs higher than the generally expected rate (generated from decades of research on this topic, from a multitude of hospitals). I've often wondered what it is about this hospital and these researchers that elevates the overall uterine rupture rate...it does make me think twice about the research that this group publishes.Anonymousnoreply@blogger.com