Re: Failed Home VBAC after 3 previous C/S - Stillbirth--LOL
From: ainsron (ainsron@sbcglobal.net)
Tue Apr 25 14:57:10 2006
I sent it to you off list
Ronald E. Ainsworth, MD, FACOG
-----Original Message-----
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Heidi
Streufert
Sent: Tuesday, April 25, 2006 9:58 AM
To: Multiple recipients of list OB-GYN-L
Subject: Re: Failed Home VBAC after 3 previous C/S - Stillbirth--LOL
Since the only Practice Bulletin that I keep is #6 regarding postterm
pregnancy (and actually I see my copy is from 1997 and has been
superseded by a newer version, #55, from 2004) can anyone give me the
actual cites for the references below? (9,26,27) Just the date and
last name of the author would suffice.
This is closer to the information I provide to people who ask, but
still ignores the studies that have shown no increased risk. I'd also
like to know the level of evidence (ABCs and I, II, IIIs?) if anyone
would oblige. If not, I can probably go to NIH to find it...
This also does not address the risk of rupture versus asymptomatic
dehiscence and since many of these studies lump those together it may
be misleading, IMO.
Thanks for posting the correction, Dr. Ainsron. I appreciate it.
Heidi Streufert, CD CPM Student
On Apr 25, 2006, at 11:18 AM, ainsron wrote:
> Inaccurate - perhaps, but not wildly so. Those numbers were from
> the ACOG
> Practice Bulletin #5, July 1999. It was revised in 2004 and I
> failed to
> update the numbers in my consent form on VBAC. This is the current
> statement from ACOG Practice Bulletin #54, July 2004:
> More Than One Previous Cesarean Delivery
>
> Women who have had 2 previous low-transverse cesarean deliveries have
> traditionally been considered candidates for a trial of labor.
> However, the
> few studies that address this issue report a risk of uterine
> rupture ranging
> between 1% and 3.7% (9, 26, 27). In the only study that controlled
> for other
> potential confounding variables, the risk of uterine rupture during
> labor
> was nearly 5 times greater for women with 2 previous cesarean
> deliveries
> when compared with women who had 1 previous cesarean delivery (27).
> Women
> with a previous vaginal delivery followed by a cesarean delivery
> were only
> approximately one fourth as likely to sustain uterine rupture
> during a trial
> of labor (27). Therefore, for women with 2 prior cesarean
> deliveries, only
> those with a prior vaginal delivery should be considered candidates
> for a
> spontaneous trial of labor.
>
> Sorry about the misleading numbers, but the point is the same, it is
> significantly greater than VBAC after a single C/S
>
> Ronald E. Ainsworth, MD, FACOG
>
> -----Original Message-----
> From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of
> Heidi
> Streufert
> Sent: Tuesday, April 25, 2006 7:24 AM
> To: Multiple recipients of list OB-GYN-L
> Subject: Re: Failed Home VBAC after 3 previous C/S - Stillbirth--LOL
>
> On Apr 25, 2006, at 9:52 AM, ainsron wrote:
>
>> Not slightly higher, significantly higher. 4-5% chance for two
>> previous C/S, I don't remember seeing exact figures for higher
>> orders, but if you extrapolate the curve, I wouldn't like to play
>> the odds..
> This citation is wildly inaccurate compared to anything I have ever
> seen, Dr. Ainsron. Where did you find that figure?
>
> I have an extensive list of research related to this issue, and I
> can't find a single reference that quotes a figure that high unless
> your look at fundal (classical) incisions.
>
> Caughey (1999) comes close with a 3.7% rate, but no study I have seen
> found a 5% rate. Pruett in 1988 also had a high rate of dehis. (no
> ruptures) in his pitocin group, however not a single rupture or
> dehis. in the non-pit group of women with multiple pcs.
>
> There are also multiple studies that showed NO increased risk or
> relationship between number of prior c/s.
>
> So, please can you share the research upon which you share this
> information with patients? I would like to be sure I am properly
> informing the women who ask about this issue (and I get inquiries
> several times per week).
>
> Heidi Streufert, CD, CPM Student
>
