Fw: VBAC in BMJ/Guardian - long !

[Guest guest]

I know will not mind me forwarding this here. Cheered me up

now end. I think the BMJ piece is the same one the Guardian based

their piece on.

Lesley

ANT, tr BFC, Mother, Wife, Friend, Mender of Broken Hearts,

Keeper of Secrets, Chauffeur, Cook, Maid, Writer. Overweight, Over

thirty, Over here in Worthing..

" Believing Oneself to be perfect is often the sign of a delusional

mind! " Star Trek.

Re: VBAC in BMJ

> > /anyone, have you read this? Its a bit worrying and I am

sure

> > will be snapped up by anti VBAC obstetricians!

> >

> > http://www.bmj.com/cgi/content/full/323/7304/68

>

> What worries me is this - the study itself was useful, but the

accompanying

> press release, on which the BMJ article was based, is almost

Orwellian in

> its mis-statement of the facts. I think this comes from the study

authors,

> who provided the press release, rather than the BMJ - which was just

being

> lazy and parroting the press release. I'll copy another similar

article

> after my sig.

>

> The study didn't tell us anything new, and in fact confirmed a lot

of things

> which VBAC/natural birth advocates have been saying for a while.

For

> example - that the rate of rupture in a spontaneous VBAC labour was

only

> around 0.5% (it may be lower, but there are problems with the

methodology of

> this study which would tend to exaggerate the rate) - you'll often

hear

> opponents of VBAC saying it is 'at least 1%', so it was good to have

yet

> another result showing it is safer than that. The study also found

that the

> rupture rate is significantly higher in induced labours.

>

> Where a mother experienced a uterine rupture, the death rate for

babies was

> around 5%. This is a lot lower than many people have been led to

believe -

> the impression often given is that if you have a uterine rupture,

your baby

> WILL die or will be severely disabled. Of course, this death rate

applies

> to uterine rupture in hospitals, where emergency CS is theoretically

rapidly

> available, and there isn't enough information to enable us to draw

> conclusions about outcomes if a uterine rupture occurred at home.

But given

> the absence of induction at home, and the presence of an observant

midwife,

> I think an actual rupture at home would be vanishingly rare. I do

know that

> some have occurred - there are apparently two women on the uterine

rupture

> support email list who had ruptures and had planned home births, but

I've

> been unable to find out any more details. It is not clear whether

the

> actual ruptures occurred before or after transfer to hospital.

>

> So, the study itself did not really say anything new - if anything,

the

> figures it produced for VBAC outcomes were a bit better than working

> estimates had been in the past. Yet the accompanying press release

included

> some Total Testicles statement along the lines that " We used to

think VBAC

> was virtually risk-free, but now we realise it is not " . Another

quote,

> apparently from the press release:

>

> ''By no means does our study suggest that no woman should have a

vaginal

> birth after a Caesarean. What it says is there are risks of doing

that that

> we didn't fully appreciate,'' said one of the researchers, Dr.

R.

> Easterling.

>

> One has to wonder where Dr R Easterling has spent the last

ten years

> or so. Certainly not in a medical library keeping up with the

research on

> VBAC, or he would have fully appreciated the risks. And any mother

who

> asked about a VBAC at home has been left in no doubt about the risk

of

> uterine rupture, as obstetricians always seemed fully to appreciate

them,

> and indeed were able to explain them, in graphic and gory detail.

>

> Another bit of the blurb which I find highly objectionable:

>

> " The incidence of infant death was 10 times as high among the 91

women who

> had uterine rupture as among the 20 004 who did not (5.5% v 0.5%). "

>

> Uh-huh. So they are saying that, **among women who had a rupture**,

the

> death rate was 10 times higher than among those who didn't. Right -

are we

> supposed to be surprised by that? That's a bit like saying that the

death

> rate where a cord prolapse occurred was - whatever - 50 times higher

than

> where it didn't. Or, alternatively, that where you have a car

crash, you

> are - what- 100 times more likely to die than if your car didn't

crash.

>

> Nobody is disputing that uterine rupture is a life-threatening event

for the

> baby, but this statistic is not very informative. What we need to

know is

> the overall death rate from babies born by elective repeat CS

compared to

> those born after an attempted VBAC. Actually, we need to know more

than

> this. It is known that repeat CS shifts *some* of the risks from

*this*

> baby, on to all the mother's future babies. It increases the risks

of

> placental abruption, placenta praevia, and ruptured uterus, no

matter how

> the mother plans to have her future children. The risks of all

these

> life-threatening complications increase with the number of

caesareans a

> mother has, so a repeat CS for baby number 2 leaves babies 3 and 4

at

> substantially increased risk compared to the mother having a VBAC

for baby

> number 2. We need to know the outcomes really over a mother's

childbearing

> career. I think that many people simply assume that a mother will

only want

> to have two children, but for many couples a large family is very

important.

>

> And another objectionable bit:

>

> ''Strictly speaking, if the question you're asking is, 'What is

safest for

> the fetus?' There's no doubt repeat Caesarean is safest,'' Greene

said.

>

> As far as I've been able to see so far, the study does not actually

show

> this, since it doesn't give overall mortality rates from elective CS

and

> VBAC attempts. We do know that there are risks for the baby with

CS - see

> www.radmid.demon.co.uk/csbaby.htm . The biggest risk is respiratory

> problems for babies born by scheduled CS, ie those who have not

experienced

> labour. This can be life-threatening.

>

> Oooh, the next bit that really annoyed me:

>

> " He said some women may opt to try a vaginal delivery for the birth

> experience

> or because of the faster recovery "

>

> Hmmm- well, that 'faster recovery' covers a lot of things. Like the

mother

> recovering from a hysterectomy, as 1 in 90 multiparas having

caesareans have

> to, according to St 's Hospital in Tooting (Emergency

Obstetric

> Hysterectomy - an increasing incidence' by Gould et al, 1999). Or

maybe

> the, fortunately few, mothers who won't recover at all. See

> www.radmid.demon.co.uk/csrisks.htm for more info.

>

> So anyway... I reckon this study itself is quite useful, although it

says

> nothing much which is new. I am very worried by the way it was

described in

> the press. Somebody reading that line about the death rate being

10x higher

> for mothers who experienced a rupture, might think it referred to

the death

> rate from VBAC attempts being 10x higher.

>

> The study certainly doesn't add much to the debate over home VBAC.

What

> should there be to debate anyway? It is for women to make their own

> informed decisions, and for their healthcare providers to support

them in

> that. has mentioned before that nowadays we place a lot of

emphasis

> on all the research showing that home birth is safe for 'normal,

low-risk'

> women, but that shouldn't mean that women who aren't 'normal',

aren't

> 'low-risk', cannot have a home birth. If you are high-risk, going

into a

> consultant unit does not automatically mean that all your problems

vanish.

> You are still high-risk, still at increased risk of adverse

outcomes.

>

> There is not any research, as far as I'm aware, comparing outcomes

of

> higher-risk pregnancies at home or in hospital. There have been a

couple of

> studies which found that, where higher-risk women had home births,

the

> overall home birth mortality was higher than it is for home birth in

> general. Well, surprise, surprise. See for example 'Perinatal

Death

> associated with planned home birth in Australia' by Bastian et al.

>

> Women who are high-risk still need to weigh up the risks and

benefits of

> each of their birth choices, and decide what is best for their

families. I

> just don't think the tone of this article contributed to encouraging

> informed choice at all. , go and cheer yourself up by reading

some of

> the stories of home births after two or three caesareans, at

> www.homebirth.org.uk/vbac1.htm

>

>

> Cheers,

> Horn

> Not a c/s mum, but a supporter

> VBAC pages: www.vbac.org.uk

> Home birth reference site: www.homebirth.org.uk

>

> ---------------

> Study: Labor Risky After Caesarean

>

> By STEPHANIE NANO

> .c The Associated Press

>

> (July 4) - Mothers who have had a Caesarean section increase their

chances

> of

> rupturing their uterus if they attempt vaginal delivery during their

next

> pregnancy, especially if labor is induced, according to a new study.

>

> For years, doctors advised women who had Caesarean sections to

deliver all

> their babies by C-section because of the scars left on their uterus.

But

> more

> recently, women have been encouraged to attempt to deliver vaginally

after a

> Caesarean and approximately 60 percent of them try labor.

>

> From 1989 to 1996, the rate of vaginal births after a Caesarean

increased 50

> percent in the United States to 28 per 100 women. By 1999, it was

down to 23

> per 100 women.

>

> The rate of Caesarean births has remained at about 22 percent during

the

> same

> 10-year period.

>

> Questions persist, however, about whether labor causes problems such

as

> uterine rupture, an uncommon but serious complication. A tear in the

uterus

> can result in a hysterectomy, blood transfusions or death for the

mother and

> brain damage or death for the infant.

>

> Researchers at the University of Washington in Seattle studied this

issue by

> looking at 20,095 women who delivered their first baby by Caesarean

section

> and then had a second child. There were 91 cases of uterine rupture,

> according to the findings reported in Thursday's New England Journal

of

> Medicine.

>

> Compared to women in the group who had a repeat C-section without

labor, the

> researchers said those who went into labor spontaneously were three

times

> more likely to have a uterine rupture. Women whose labor was

induced - but

> not with a class of drug known as prostaglandins - were nearly five

times

> more likely to have a rupture and those induced with a

prostaglandin, which

> is more potent, were 15 times more likely.

>

> ''By no means does our study suggest that no woman should have a

vaginal

> birth after a Caesarean. What it says is there are risks of doing

that that

> we didn't fully appreciate,'' said one of the researchers, Dr.

R.

> Easterling.

>

> He said some women may opt to try a vaginal delivery for the birth

> experience

> or because of the faster recovery. Those who try labor should do it

in a

> hospital that can quickly perform a C-section should it become

necessary, he

> said.

>

> ''Women need to talk to their provider about their own individual

pregnancy

> and their health,'' said Mona Lydon-Rochelle, another researcher.

''They may

> have a very low chance of uterine rupture'' and the benefits may

outweigh

> the

> risks.

>

> The data on the 20,095 women was culled from birth certificates and

hospital

> discharge records in the state of Washington from 1987 to 1996. Home

births

> were not included.

>

> ''It's a huge study and it shows quite clearly that there is an

increased

> risk associated with the use of prostaglandins,'' said Dr.

F.

> Greene,

> who wrote an editorial accompanying the study and is director of

> maternal-fetal medicine at Massachusetts General Hospital in Boston.

>

> He said doctors need to tell patients about the risk of uterine

rupture so

> they can weigh the risks and the benefits of a vaginal birth.

>

> ''Strictly speaking, if the question you're asking is, 'What is

safest for

> the fetus?' There's no doubt repeat Caesarean is safest,'' Greene

said.

> --------------------

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