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Warning…I am
having a rant! I have read thru the
study in question and picked out some interesting things for possible
discussion: women who underwent a trial of labor were more likely
to be less than 30 years of age, black, unmarried, nonobese, and in receipt of
government assistance (Medicaid or Medicare), and to have a preterm delivery
(delivery before 37 weeks of gestation) or a delivery at 41 or more weeks of
gestation. As
mentioned by Cas from C-Aware; there doesn’t seem to be an equality of
the two study groups here…as the elect cs women were not described in the
same way as the vbac group. This would
lead me to believe that the support, education, sense of control or involvement
of the vbac would not have been sufficient. Women who fall into the lower
socio-economic bracket do have lower favourable outcomes. There were 124 cases of uterine rupture among women
who underwent a trial of labor (14 after vaginal delivery, and 110 identified
at the time of cesarean section). Interesting….usually
a dehiscence would be detected after a cs is required for a non-rupture related
need for surgery. (EG open up mum and there is a ‘window’) I know the study defined rupture as different
to a dehiscence but you would think that a true rupture would be identified
before the time of cs. I would like clarification as to whether all 124
ruptures are true to their definition. The rate of uterine rupture did not change
significantly during the study period. The rates of rupture were 105 of 14,483
(0.7 percent) for women with a prior low transverse incision, Australia’s ESTIMATED 0.3% and this did not include any
Perinatal deaths. 2 of 102 (2.0 percent) for those with a prior low
vertical incision, and 15 of 3206 (0.5 percent) for those with an unknown type
of prior incision. Two uterine ruptures were recorded in 105 women (1.9
percent) with a prior classical, inverted T, or J incision who either presented
in advanced labor or refused a repeated cesarean delivery Risks of
miscarriage after an amnio not far from this stat of 1.9% but yet they get as
much media attention? Are they not offered frequently? The three maternal deaths among women who underwent a
trial of labor were due to severe preeclampsia with hepatic failure, sickle
cell crisis with cardiac arrest, and postpartum hemorrhage. Would cs
have helped these women? Would not being a vbac made any difference to their outcomes? Why would this be of importance to the
outcomes of a vbac trial? Of the seven
maternal deaths among the women who had elective repeated cesarean delivery,
two could be attributed to cesarean section (one resulted from hemorrhage and
the other from anesthetic complications). Of the five remaining deaths, four
were caused by suspected amniotic-fluid embolism and one by aortic dissection. I need to
know what an amnio-fluid embolism is and an aortic dissection –
dissection means cut doesn’t it?
Would that have anything to do with the scalpel used during the cs and
if so then why wouldn’t that complication be a direct link to the cs?
There was no mention of the difference between the maternal death rates of the
two options by the paper. The focus on
safety is once again only addressing the baby. Four cases occurred after the induction of labor, two
occurred after augmentation, and six occurred with spontaneous labor without
the use of oxytocin. Interesting
how the vbac management is not spelled out: are there fasting, time
restrictions, continuity of care, use of epidurals etc. All these things can and do impact on the
outcomes of a spontaneous labour. With regard to the observed increased frequency of
term antepartum stillbirths, some of these probably occurred after 39 weeks
before the onset of labor and might have been avoided by a scheduled repeated
operation. Alternatively, some of this increase might be due to the
encouragement by care providers of a trial of labor after the recognition of
stillbirth. Alternatively, some
of this increase might be due to the encouragement by care providers of a trial
of labor after the recognition of stillbirth. Slight over
site on a critical issue! Once again there is
no evidence to show that any of these women had sufficient support, education
continuity of care and so forth. We keep
on studying the outcomes of vbac on labour wards in tertiary locations that
have high cs rates anyway, with restrictive, unsupported care and the use the
data to negate midwifery or birth centre care. I
am calling on anyone who is in the position or even thinking of embarking on
research to look at outcomes of vbac from midwifery/birth centre model. One that includes continuity of information,
carer, support, education, natural active birth and then see what the outcomes
are! We need to have something to show
that vbac is NOT dangerous to all: other than the tertiary medically managed
‘care’ that is studied. We
need outcomes of current vbac supportive models to be published! If we do not act soon, the right for women to
access this safe and valid option will be denied by knee-jerk reactions of
hospitals after reading such sensationalist journalism backed by questionable
‘expert’ opinion. (Abby- you thought you were the only one
with a soap box! ha ha) Also, I am very
keen to have people correct or clarify for me anything that I have said. I
don’t claim to be an expert and appreciate feedback even if it is
correcting what I have said. I certainly
do not want to passing on opinions that are based on incorrect information or
be guilty of interpreting things to suit my pre-determined beliefs…god
only knows there are those who already do enough of that in public
forums!!! Not naming names!!! Cheers Jo --- |
