Not Your Typical Cesarean

My very first article written for Special Scars women everywhere!  

An Intro to Special Scars by Jessica Tiderman

Most people know at least one person that has had a cesarean. Not many realize that there are a variety of incisions that can be used on the uterus during that cesarean. The most typical incision is a low transverse incision, which is a horizontal cut in the lower portion of the uterus usually called the lower uterine segment (LUS). Due to the lack of shorthand to describe the more unusual uterine incisions such as classical, inverted T, J, upright T or any cesarean incision other than the low transverse incision, I started calling them Special Scars. Without a way to describe these incisions, women weren’t getting the information and support that they needed.

An inverted T incision starts out with a low transverse incision and then the OB makes a vertical incision upward in the center of the uterus. A J incision also starts out with a low transverse incision but the OB makes the vertical incision up along the side of the uterus rather than the center, perhaps because the placenta or the baby was in the way. An upright T incision can happen in two ways; either the OB started with a low vertical incision and then needed more room at the top of the incision or started with a low transverse incision and made a vertical incision down toward and sometimes reaching the cervix. These three incisions are usually used for babies that are severely malpositioned and/or very stuck. The vertical portion of these incisions can range from a few millimeters to several centimeters. These are also usually contained within the LUS, but can extend into the upper uterine segment (UUS).

Classical incisions are vertical incisions and can be placed just about anywhere on the midline (middle) of the uterus but tend to be in the UUS. There is some dispute about the standard placement of a classical incision. They are still commonly used for early preterm cesareans although some doctors have switched to using the low transverse incision for those as well. Finally, low vertical incisions are simply that, a vertical incision on the midline that is contained within the LUS. This is used when the baby is in a transverse lie or if the placenta is in a location where they would typically cut.

Clearly, the Special Scars are a more complicated matter. The cesareans that end up in these incisions tend to take longer due to baby’s position, which leaves the mom more vulnerable to infection or other adverse effects from being open for so long. Moms with these incisions are more likely to have a host of problems that are less likely to occur with low transverse incisions – wound infection, endometritis, septicemia, transfusion, ICU admission, hysterectomy, and maternal death. These incisions can also increase the mother’s length of stay in the hospital. Babies born from these incisions also have increased risks – stillbirth, neonatal death, APGAR less than 7 at 5 minutes, ICU admission.(1)

Emotionally, the moms may suffer from postpartum depression or post-traumatic stress disorder. It is very likely that they were told many times during their stay in the hospital after their cesarean that they would never be able to have a vaginal birth after cesarean (VBAC) after that particular surgery. They likely heard that statement so many times that they believe it. When they find out that it is possible to have a vaginal birth after their Special Scar they may feel shocked, angry, betrayed or any combination of those. Sadly, there is no research about the emotional effects of these incisions on women.

Once the woman decides she wants to have a vaginal birth it can be very difficult to find a care provider who is willing to assist a VBAC after a Special Scar (VBASSC). The search usually requires calling many doctors and/or midwives before locating one that will attend a trial of labor. When a care provider is not initially open to the idea, it is usually best to not even try talking them into it. It is unlikely that you will be the one to change his or her mind. University hospitals tend to be more willing to assist due to their size and staff. Some home birth midwives are willing to attend VBASSCs when not legally restricted from doing so by their state.

Many care providers are unwilling to assist a VBASSC because the risk of rupture is slightly higher than the risk of rupture after a low transverse incision. The generally accepted risk of rupture for low transverse incisions is 0.4-0.9% while the risk of rupture for inverted T, classical and J incisions is 1.9%.(2) Interestingly, low vertical incisions have no more of an increase in the risk of rupture than low transverse incisions.(3) If the cesarean was performed preterm there is a minimal increase in the risk of rupture.(4) As we know from Dr. Sarah Buckley’s writings, if a woman is allowed to labor unhindered her birth much more likely to go as it was designed.

Clearly, there is a need for further studies on these scars, the effects on future pregnancies and the effects on the mother emotionally. The few studies that are available used a relatively small number of subjects. Therefore, without clear evidence of exceptional risk the woman and her partner should be the ones to make the decision whether or not she attempts to have a vaginal birth. Care providers should not be making decisions about VBASSC due to a level of fear or a lack of information. Indeed, if the care provider does have that much fear he or she should excuse themselves from serving the woman and let her find a care provider who is willing to serve her and trust her body to work as it was designed. There are already a number of women who have succeeded in having a VBASSC. To read their stories, for more information about this topic and access to the studies that I have mentioned, please visit http://www.specialscars.org.

(1) Patterson et al. Maternal and Perinatal Morbidity With Cesarean.Obstet Gynecol 2002;100:633-7
(2) Landon et al. Trial of Labor after Prior Cesarean Delivery. N Engl J Med 2004;351:2581-9.
(3) Shipp et al. Intrapartum Uterine Rupture. Obstet Gynecol 1999;94:735-40.
(4) Sciscione et al. Preterm Cesarean Delivery and Uterine Rupture. Obstet Gynecol 2008;111:648-53.

First published in Whole Woman Magazine, Winter 2011.

Respect for OBs...

This was originally posted on my old blog on May 5, 2010.

I'm sure you are all familiar with the brain fog that coincides with the last few weeks of pregnancy and how exciting it is when it lifts even if only for a few minutes. :-) I had one of those moments this morning while responding to a post on BBC forums and I wanted to share.

The title of the post was "New respect for my OB". (Oh come on, you knew I'd have to respond to THAT.) The poster just had her 36 wk appt and her OB was talking about the 5 successful VBACs he had the previous week. Good for him, I'm glad he does them. He went on to tell her that he has to be immediately available for VBACs and exactly what that meant (that he be in the hospital the entire time the patient is in labor in the hospital). He went on to tell her that he lost $3000 because he had to cancel 2 days of appointments because of all these VBACs. "And he just does it because it's the right thing to do. He did say that its getting to the point where he is going to have to limit the number of VBACs that he accepts because its just too much and he doesn't want his wife getting out the divorce papers." She went on to say that she's sooooo happy to have found such a good doc and suggested that ins cos should provide incentives to docs who do VBACs, etc. All the responses that she got were yay, cool, good for you, etc.

Here's what I posted:

"Immediately available is an ACOG rule, which many hospitals/OBs use as an excuse to have VBAC bans. I think it was bad form, however, for him to try to elicit sympathy from you by telling you how much money he lost last week by having "so" many VBACs. If ACOG would encourage OBs to lower the primary c-section rate they wouldn't have so many VBACs to worry about.

And finally, I can understand the wife of an OB getting frustrated because of the amount of time that he spends away from the family, but that is his freaking job. If he already was an OB when they got married, she knew before she married him. If he decided to go to school while they were married, I'm sure they had many discussions about his future schedule. As a student midwife, I've already had many conversations with my husband about the fact that I might be gone for days at a time, might have to leave in the middle of sex, dinner, birthday parties, we might have to drive separately if we are going somewhere and I have a mom that's due. It's part of the job and you have to prepare yourself and your family for it. If you don't it's your own damn fault and if you do and then they get resentful either they didn't fully understand or they don't get the importance of what you're doing.

Sorry - overdue and getting pissy here. I just get tired of the OBs "Oh poor me" attitude because of what their trade union (ACOG) makes them do. If they don't like it they should leave the union or fight for changes in policy. *sigh*"

Almost 40 wk Update

This was originally posted on my old blog on April 29, 2010.

I'll be 40 wks tomorrow.  Can't say yet if anything exciting is going to happen or not.  Doubt it given my history, but this little boy acts like he's going to be doing things his own way.  I just hope that my pelvis doesn't start hurting anymore than it does right now.  Feels pretty good at the moment so...

Student Midwife update:  I'm on hiatus at the moment.  I did finish Phase 2 and had sort of started Phase 3 before I started this hiatus.  I'm still working through the Midwifery Explorations class, would have liked to have finished it before the baby came, but diapers are a little more important.  lol

The diapers, well that has been a long project that started over a year ago.  When I was pregnant with my nearly 3yo I had bought 36 Bum Genius (BG) cloth diapers, 12 pink, 12 white, 6 yellow and 6 green.  I love them, they make cloth diapering so easy!  However, after nearly 2 years of use I noticed the elastic in the legs wasn't as snappy as it used to be.  Being the crafty do-it-yourselfer that I am, I took one diaper apart to see how hard it would be to change that elastic.  It was fairly easy, just take out one seam and the old elastic, put in new elastic (guessing how long that should be was kind of tricky) and sew the seam back up.  So, winter before last I replaced the elastic in maybe two-thirds of the diapers.  My daughter was only using them about half time so I didn't really *have* to fix them all.  I got pregnant again last fall and new I would have to finish fixing the rest of the diapers.  I heard that you could get the new BG diapers with snaps rather than velcro and was a little jealous.  The only thing I don't like about my BGs is the velcro, it's just a pain in a variety of ways.  I had just bought a snap press last year for some other sewing projects.

Then I found out I was having a boy.  No way!  Me?  A boy!?  Are you sure??  lol  I looked at my diapers and knew I had a lot of work to do.  I ordered some fabric dye, which was tricky trying to find the right dye that would stick to a synthetic material.  So now, I knew that I had to finish replacing the elastic in the legs, dye at least the pink diapers, AND take all the velcro off and put snaps in.  :-)  At this point, I've finished replacing all of the elastic, the last four diapers that needed to be dyed are in the dye soaking at the moment, and I only have about 12-15 that still need snaps.  I'm so proud of myself, they look really nice.  I just hope that the dye really does hold.  We still have plenty left so we can re-dye if necessary, but I'd rather not have to do that on a frequent basis.

That's where I am for now.

P.S. A little note, there are some people that comment on my blog Anonymously, can you at least put your first name in your comment so I have some idea who you are??  lol  It's bugging me that someone is talking to me and I have no clue who it is.