QuestionWe are having another C-section in July. This will be our fourth. We would love to have 10 children with this spacing. All have been naturally spaced 2 years apart. I have had no complications except that my babies never descend into my hips (even after 26 hours of labor and at 7cm.) My chiropractor said that one of my hips was tilted but now is settled into a normal position after numerous adjustments. Everyone is pushing us to stop having babies because they fear for my future health. I have never had a pregnancy related complication other than anemia which is not a problem as long as I take my iron. I have no other health conditions.
Our current OB has offered to let my husband see my uterus before opening it during this C-section to decide whether or not we will have more children. What should he look for? Is it normal at 39 1/2 weeks to be able to see through the uterine wall? What does a normal uterus look like after 4 pregnancies? What are the dangers of adhesions? Do they get worse with every C/S or is does it just depend on the job that was done last time or my health? Would a VBAC be out of the question?
What would be the things to look for and consider before we decide whether or not to have more?
Thank you so much!- Robin
AnswerRobin,
Let's tackle each question separately.
First, if you want to pursue a VBAC, then this baby would be your last chance. There are very few providers who will try a VBAC after more than 3 c-sections.
This is not because VBAC is risky but because multiple c-sections are.
The more c-sections you have, the more your risks of complications including uterine rupture, adhesions, infection, hysterectomy, postpartum hemorrhage, and placental abnormalities increase. Babies born by c-section are also 3 times more likely to develop complications after birth, including respiratory distress, feeding difficulties and difficulty regulating temperature.
However, after a VBAC, your risks in all these areas decrease and keep decreasing with every subsequent vaginal birth. The same is true for babies - the rates of complication to babies is lower with vaginal birth.
For these reasons, doctors should fully inform patients of the risks involved in having a primary c-section. It is highly unlikely that you will be able to safely have the family of 10 you desire. I've not heard of a woman having more than 6 c-sections and at that point, the risk of hysterectomy has increased over 1375% from 0.65% in a first c-section to 8.99% in a sixth. The odds are very much against you at that point.
A c-section is in essence a uterine rupture, although a controlled one performed by a scalpel. Every time the uterine wall is damaged via c-section, the odds increase that the tissue along the scar will weaken, thus causing an uncontrolled rupture or other serious complications. The risks increase if your pregnancies are closer than 18 months and are dependent on what type of incision was made, and how it was sutured.
If your husband will be looking at your uterus, he should look for signs of weakness, including a "uterine window". This occurs when the tissue has become so weak that it becomes transparent. This is not typical and is a great risk factor for rupture. He should not be able to see through the tissue. It should appear opaque. Also, he should examine the prior incisions - are they well healed or red/stretched? Are the sutures even or pulling?
He should also asked how the previous incisions were made and how they were repaired. Two layers of sutures should be used to ensure the best recovery for the uterus. This is also true for your abdominal tissue.
Adhesions are bands of tissue that form between organs in response to injury caused during the c-section. These bands can be dense, causing internal organs and tissues to bind together, thereby limiting the natural, free motion of organs. This can cause a host of chronic problems including infertility, bowel obstruction and chronic pain. Over 70% of women with a first c-section will develop adhesions and the risks increase with each one performed.
So, some things to consider are:
1. The current condition of your uterus
2. The type of incisions made
3. The type of stitching performed on your uterus.
4. Whether a VBAC is an option (will depend on the above factors, hospital policy and your care provider)
5. An analysis of the risks vs. benefits of repeat c-sections
6. Your comfort level with the increased risks of repeat c-sections
I would also look more closely at the reasons for your past c-sections. Did you labor with each child or just the first? In each case did you have a trial of labor or repeat scheduled c-sections?
What happened in one labor won't necessarily happen with others. Each baby and each labor is unique.
When a baby doesn't descend, it can be due to many factors, including pelvic misalignment, a poorly positioned baby, lying flat on your back during labor rather than staying upright and mobile, and rarely, cephalopelvic disproportion, or a baby that is too big to fit. This is a commonly-cited reason, although the research supports that it is actually quite rare and much overdiagnosed. The same goes for "failure to progress" c-sections: in almost all cases, poor positioning was at fault that could have been corrected during labor, making the c-section unnecessary.
Most of these positioning conditions can be corrected during pregnancy by proper positioning. Also, avoiding interventions in labor such as rupture of membranes (which can cause babies to become malpositioned), lying flat on your back, and coached pushing can also prevent the failure to progress you described.
Still in other cases, a woman will be told she must dilate 1cm per hour or have a c-section. However, there is simply no research to support this practice. These c-sections are not from a "failure to progress", merely a "failure to wait".
From what you wrote, 26 hours of labor and failure to dilate past a 7, it sounds like a classic case of poor fetal positioning. If you had back labor as well, I'd be even more convinced that this was a distinct possibility. When the baby isn't in the right position, the correct amount of pressure isn't placed squarely on the cervix, which is why dilation can stall and the baby doesn't descend.
Your misaligned pelvic bones could have been the culprit, but you've indicated that piece has been resolved.
Other fetal malpositioning can usually be corrected by assuming a hands-and-knees position or full squatting during labor. A birth ball, birthing stool, or even toilet sitting can also help. If you had an epidural, it can make it hard for you to move, which also can contribute to poor fetal positioning. However, with some resourcefulness, it can also be possible to change into more productive positions. You will require support to do so, but it is possible. For a complete discussion of proper fetal positioning, check out http://www.spinningbabies.com and for a discussion of evidence-based birth positioning, check out http://www.givingbirthnaturally.com/birth-positions.html
Good luck!
Catherine
