Taking obstetric advice from a doula is like taking architecture advice from a cleaning woman.
Sure, a cleaning woman cares for a home, business facility or skyscraper, but she knows nothing about how to build any of those things, and only a fool would think otherwise.
Sure, a doula knows how to care for women in labor (rub her back, get her ice chips, encourage her), but only a fool thinks she knows anything about obstetrics.
Case in point: Vicki Markam Williams, the woman who runs the Facebook group Pregnancy and Birth after Uterine Rupture with the aim of encouraging women who didn’t die at their first VBAC [vaginal birth after Cesarean) attempt (although many of their babies did die) to take on the much higher risk of killing their babies and themselves at another VBAC attempt.
Her website explains her philosophy:
Care providers are so filled with fear, and that fear is affecting the women they care for, in attitude and in denial of choice. A section rate of one in three is indefensible, and at that rate is causing MUCH more harm than good.
I think that the risks of VBAC and PAR [pregnancy after rupture] are actually MUCH lower than women are being told. If women are really re-rupturing at the rates given above then their ruptures are not being repaired properly. There is good research to say that tears heal better than cuts (http://www.ncbi.nlm.nih.gov/pubmed/10422908) and so a repaired simple rupture (no healed edges to the hole, no placenta involved) should be stronger than a second planned section scar from an incision by knife. This is clearly being taken on board, because many surgeons are now using ‘blunt extension’ techniques, which in effect means separating the uterine muscle by tearing it along its natural planes, which leads to a stronger repair and less trauma to the tissue.
Williams is referring to a 1999 paper on the Misgav-Ladach method of C-section. First, there is no evidence that the method of tearing the uterus instead of cutting leads to a stronger repair. Second, the Misgav-Ladach technique involves a one layer closure of the uterus instead of the traditional two layer closure. One layer closures have been shown to be associated with an INCREASED risk of rupture in a subsequent pregnancy, not a decreased risk. Third, very few women undergo a Misgav-Ladach C-section, so it is irrelevant to counseling most women about the risk of rupture in a future pregnancy.
I’m expecting that most of the re-ruptures are women who have had windows and scars that have opened during the trauma of a repeat section. We don’t worry about any other scar or injury to the same extent. I think that the ‘dead baby card‘ is just out-and-out blackmail. So few women carry a PAR (because most get a hysterectomy and the rest are told not to try again, of which a significant majority will heed that advice) that we will never have big enough studies to know what the numbers really look like.
I have been told repeatedly that no one has a baby after a rupture, well clearly I did, and I know others who have.
Markham had a spontaneous uterine rupture at 33 weeks* (fortunately the baby survived) and her response was to attempt a VBAC? Even though she knew that a future uterine rupture could kill her baby??!!
Her musing on the risk of future rupture is probably less valuable than the cleaning lady’s musing on what holds up a building. The cleaning lady’s architecture advice is more likely to be correct since she is living in the real world while Williams is clearly just making stuff up to support her ignorance and wishful thinking.
The idea that she was told that no one has a baby after a rupture is bizarre. The issue has been studied. Indeed there is a paper in this month’s edition of Obstetrics and Gynecology on this exact topic, Pregnancy Outcomes in Patients With Prior Uterine Rupture or Dehiscence.
I know you will be shocked, shocked to learn that Williams is spectacularly wrong.
What did the authors find?
Fourteen women (20 pregnancies) had prior uterine rupture and 30 women (40 pregnancies) had prior uterine dehiscence. In these 60 pregnancies, there was 0% severe morbidity noted (95% confidence interval [CI] 0.0–6.0%). Overall, 6.7% of patients had a uterine dehiscence seen at the time of delivery (95% CI 2.6–15.9%). Among women with prior uterine rupture, the rate was 5.0% (95% CI 0.9–23.6%), whereas among women with prior uterine dehiscence, the rate was 7.5% (95% CI 2.6–19.9%).
So, in contrast to the typical risk of rupture at VBAC of less than 1%, these women had a dramatically increased risk of rupture. And that was in patients who were NOT allowed to labor! I shudder to think what the risk is in women who actually attempt VBAC.
Williams, of course, believes that the fact that she didn’t kill her baby and herself in a subsequent pregnancy indicates that VBAC after rupture is safe. Of course, if your definition of safe is that you are not 100% guaranteed to die, even Russian roulette is “safe.”
Williams concludes her piece with this:
It is so wrong to tell women that if their babies die it will be their fault and that surgery will save everyone, because it doesn’t and it won’t
Kind of like your cleaning lady telling you that is “wrong” to tell people that violating building codes leads to unsafe buildings. The claim is untrue, and there’s no reason why anyone should listen to her in any case.
Williams is criminally ignorant. She shouldn’t be allowed to care for a houseplant, let alone a pregnant woman.
*Williams’ rupture was not associated with an induction for stillbirth as originally reported.