Articles
On June 1st, 2000, I walked into a hospital for a scheduled repeat cesarean for breech at 39 weeks and 3 days, more than a week earlier than my first two babies chose to be born. Unfortunately, I did not have the foresight to have them check my baby’s position before they started the surgery. I was watching in the rim of the OR light when the OB opened my uterus and I saw my daughter’s little hand pop out. My first reaction was “Hi baby!” to be quickly followed by “That’s not going to work.”
Not Your Typical Cesarean, an Intro to Special Scars
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.
The Accuracy of Operative Reports
“Why did my OB tell me that I had a classical incision but my operative report says that I have a low transverse?” If I had a dollar for every time I’ve heard this, I wouldn’t be rich, but I probably could take my family out to dinner.
Why VBAC After a Special Scar? Quotes from the women of Special Scars
What Does It Take to VBAC After a Special Scar? by Katie Perez
When planning my VBA3C (with inverted T), I knew there was a huge road with lots of obstacles and mountains ahead. I began with research, reading everything I could. I wanted to know what people did who had successful VBACs, knowing I would need to do everything I could to set myself up for the very best chance of success. This was my last shot at this, and I didn’t want to have any regrets! This leads to my personal list of recommendations.
Finding a Care Provider After a Special Scar by Katie Perez
After a Special Scar cesarean, it can be a challenge for the woman to grapple with what has just happened to her. She may feel betrayed, violated, angry, or even lucky, and just thankful her baby is alive. The Special Scar cesarean is almost always coupled with this phrase: “You can never ever attempt a VBAC, or you will certainly rupture, and you and your baby will die.” There is also a discussion about future pregnancies being limited to anywhere from 36-39 weeks. I remember this. I hadn’t even left the OR, and was hazy and disoriented from all the drugs, when the still-masked doctor peered over the screen and told me those words.
Things to Consider
Before Attempting a VBAC with a Special Scar
I wrote up this list of questions as a help to other women trying to decide what their risks were.
These are the things that I went over (and over and over) with my midwives, my husband and in my own mind. Please use this list as suggestions ONLY, you are the only one who can decide if attempting a VBAC is safe for you and your baby. Certainly use this list as conversation starters with your care providers.
The Emotional Side of Special Scars Quotes from the women of Special Scars
Studies
The de Costa Review
This is a historical review of studies that looked at risk of rupture after a classical cesarean.
Certainly the literature suggests that some classical scars might be more prone to rupture than others. However the risk of rupture of a single well-healed classical Caesarean section scar during a subsequent TOS (Trial of Scar) cannot be determined from any of the studies cited above. It does appear that where there has been no postpartum febrile morbidity and where the placenta in both the current and Caesarean section pregnancies has not been sited under the incision, the risk of rupture for a woman attempting vaginal birth after a single classical Caesarean section might be not much greater than that associated with TOS following one lower segment Caesarean section, and might be similar to that for TOS after two lower segment Caesarean sections, now an acceptable practice. It might also be that in many cases, the scar of a prior classical Caesarean section has already shown its strength by reaching the point of spontaneous labour intact.
The Landon
Study
This study is the most recent study that includes any information about the risk of rupture
for classical, inverted T and J incisions.
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.
The Lin Study
The original purpose of this study was "to determine the risk of uterine rupture in patients induced with oxytocin or misoprostol
anfter 1 or more previous cesarean sections."
No uterine ruptures occurred in patients with classical or low vertical scars.
The Shipp Study
This study compared the risk of rupture between TOLs after low transverse incisions and low vertical
incisions.
Conclusion: Gravidas with a prior low vertical uterine incision are not at increased risk for uterine rupture during a trial of labor compared with women with a prior low transverse uterine incision.
The Sciscione Study
The objective of this study was to determine if women with a history of a previous preterm cesarean
delivery experienced an increased risk of subsequent uterine rupture compared with women who had a
previous nonclassic term cesarean delivery.
Conclusion: Women who have had a previous preterm cesarean delivery are at a minimally increased risk for uterine rupture in a subsequent pregnancy when compared with women who have had previous term cesarean delivery.
The
Patterson Study
The objective of this study was to estimate the maternal and perinatal morbidity associated with cesarean
delivery involving the upper uterine segment compared with that of low transverse cesarean delivery.
Conclusion: Classic cesarean section has a higher maternal and perinatal morbidity than inverted T cesarean and much higher than low transverse cesarean. There is no increased maternal or perinatal morbidity if an attempted low transverse incision has to be converted to an inverted "T" incision compared to performing a classic cesarean section.
