Expert: Catherine Beier MS CBE - 4/6/2009

Question
QUESTION: I had an abdominal myomectomy in July 2008 and am now 17 weeks
pregnant with my first child. My doctor plans to do a c-section at 39 weeks,
but I would like to understand the pros and cons of having a vaginal birth, if
that is even an option. Do you have any information, research or other
resources on this topic? I can find a lot of info on VBAC, but I'm not certain
the stats are the same for VBA surgery and am finding it difficult to find
information.

Thank you!

ANSWER: Michelle,


In the case of abdominal myomectomy, a vaginal birth can still be an option for many women, whether they are told this or not.  C-section does not guarantee a better outcome and has significant risks of its own, especially if you plan on having more children.

You're correct that it's difficult to find information on vaginal birth after myomectomy, mainly because most doctors will automatically schedule a c-section without presenting any other options, not because it's safer or better for you, but because they're afraid of liability.  It's much easier for them to defend a poor outcome when they did a c-section than a vaginal birth, although the research finds that over half of all c-sections performed each year are unnecessary.

Another reason there is little research in this area is that cases are highly individual depending upon what area of the uterus is affected and how the incision was made.  


In your particular case, your answer will really depend upon what type of incision you had and its location, as well as how far it was into the uterine wall.

Basically, any time you have a surgery via incision in the uterine wall, it inflicts the same type of trauma on the uterus that a c-section does.

So, the risks after abdominal myomectomy are similar to a VBAC after a single c-section.  In other words, the risks are relatively small to prevent attempting a vaginal birth.


The largest risk of a vaginal birth would be uterine rupture.  However, this risk exists during your entire pregnancy, not just during labor, as many women are commonly led to believe.  Any time the uterus has been cut, it can be more prone to rupture, whether it was a c-section or a different surgical incision.

So, the cons would be very similar to those of a VBAC including:

up to 9% (0.4-9%) chance of a uterine rupture total (including
ruptures that occur prior to active labor, i.e. rupture at 28-34
weeks)

If the uterus was to rupture there is a:

* 1 in 3,300 births chance of the baby dying, and a
* 1 in 5,000 risk of hysterectomy

The risk of uterine rupture is 1 in 500 even with planned repeat
cesarean versus 1 in 10,000 with an unscarred uterus.


The pros of a vaginal birth are avoiding a major abdominal surgery that may be completely unnecessary.  You will have a faster recovery, less pain, and reduce your risk of developing complications as well as reducing the risk of complications to your baby.

Babies born via c-section are twice as likely to have respiratory distress after birth and twice as likely to develop asthma by age 8.

Also, you will be reducing the risk of complications in future pregnancies.  After each vaginal birth you have, your risk of future complications decreases, whereas, they increase significantly with each c-section you have, becoming extremely high after 4 c-sections.


If you do pursue a vaginal birth, then you should not be induced by any artificial means, as this skyrockets your risk of developing complications or having a uterine rupture as seen in the stats below for VBAC:


1 in 625 with a planned repeat cesarean,
1 in 192 with starting labor on their own,
1 in 130 with an induction of labor but without using prostaglandin
to soften the cervix first,
1 in 41 with labor inductions that included prostaglandin.



So, based on your history, I'd ask why you can't try a vaginal birth, and why they are being so aggressive not even discussing your options with you.  

Doctors are responsible for making sure you give informed consent to any and all procedures.  You cannot give informed consent to a c-section if you haven't been told of its pros/cons and if you haven't been fully made aware of your options for a vaginal birth, including the positives and negatives of that choice.



Best,
Catherine

---------- FOLLOW-UP ----------

QUESTION: Catherine,

Thank you so much for your quick and very helpful response. If I had five
incisions to the uterus during my abdominal myomectomy, should I consider
this the same as 5 cesareans (meaning my research should focus on VBA5C)?
Can you suggest any resources for finding doctors that support VBAC (I am
located in New York)?

Grateful for your help,
Michelle

Answer
Michelle,

You must have had some very serious fibroids.  5 incisions complicates matters much more, which is probably a factor in why your doctor just automatically wanted to schedule a c-section.

With that number of incisions, you will most likely need to have a c-section.  

You'll find no data on VBAC after 5 c-sections - it's just not done.  VBAC mostly occurs after 1-2, and rarely, 3 c-sections.

With that much trauma to your uterus, going into labor on your own could pose more risks than a scheduled c-section would.  In your case, the benefits of a c-section may truly outweigh the risks.

I think you'll need to really sit down with the doctor who performed the myomectomy and go over what was done and the extent of the incisions to determine whether a vaginal birth is a viable option in your case. You can also request a copy of your surgical report to take with you to any providers you interview.

If you are looking for a doctor who is supportive of VBAC, you can contact ICAN, the International Cesarean Awareness Network at ican-online.org to connect with a local group in your area who can give you more specific information on the providers in your area.

I do wish I had better news, but in light of this additional information, c-section may be the best route in your individual situation.


Best,
Catherine