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Posted 10 August 2019 - 02:47 PM
During my appointment with the midwife this week, we also spoke to the consulting OB about a few things.
I am opting to have a Caesar this time around after having a rectocele prolapse repaired two years after DS’s birth, he’s nearly 6.
The Dr is happy to accommodate my request given my history, but I also have an 18 month old vertical laparotomy scar on my abdomen due to another surgery. He spoke about possible complications with the bowel, bladder etc and then seemed to be steering me back towards a vaginal birth.
I don’t think he’d been fully briefed on my prolapse because he was discussing it was though it’s caused by pregnancy itself, not just pushing, and that I could consider having it fixed post birth ... anyway.
Are these risk a real and serious possibility given my specific previous scarring, or are they more the general risks associated with the c section surgery in general?
Posted 10 August 2019 - 09:09 PM
I think if you haven’t got the information you are asking from your OB, you either need to be going back and asking these questions again and making sure the OB answers clearly, or getting a second opinion from another OB and/or the surgeon that did your prolapse surgery. It never hurts to get a second opinion.
I agree with PP that it’s a pretty concerning attitude to have towards something as life affecting as a prolapse can be.
I understand that pregnancy can contribute to your risk of prolapse as well, even if you have a caesarean. The baby’s weight puts pressure on your pelvic floor over the course of your pregnancy and is what can increase the risk. However, I think the risk would be lower than with a caesarean. Certainly, pushing can increase your risk of prolapse too. I’m not sure what your specific circumstances are previously but both pregnancy and vaginal birth could increase your risk of recurrence. I think only a doctor familiar with your case could answer your other question about your scarring and other increased risks.
At a minimum, I think it’s definitely be worthwhile asking your midwife if you can speak to the OB at your next visit. If it’s a different OB, all the better as they may be able to explain it more clearly. I would write down your specific questions beforehand so you can make sure they are answered.
Posted 10 August 2019 - 09:14 PM
The main risk of the laparotomy scar is to do with the scar tissue inside your abdomen. If there is extensive scar tissue and adhesions inside that incorporate your other organs, it could be tricky to identify them properly and thus they are at risk of damage if they are in the way. There is no way to know the extent of the scarring until you are opened up. If there is not too much scarring or adhesions inside, the laparotomy scar in itself shouldn’t significantly add to your risk of surgery as after 18 months it should be more or less fully healed. I will add there is also a risk of hernia through that scar (or any scar for that matter) with pregnancy but that is regardless of how you deliver.
Something that could vary your risks/recovery from surgery is how they actually perform the caesarean itself. Usually, a Caesar is performed through a Pfannenstein incision (bikini line) but sometimes they do a midline incision if required, or potentially to avoid giving you an extra scar. Did the doctor discuss how they would do the operation? A Pfannensteil has an easier recovery and lower risk of adhesions, and also a lower risk of post-op hernia through the scar than a midline, predominantly due to the direction of the forces in your abdomen (midline wants to separate whereas a transverse incision naturally pulls together). There are also some differences in risks based upon the incision on your uterus also, but I imagine they would do a normal lower uterine segment (LUSCS) unless they were forced not to as the risks of a classical/midline are dramatically higher. These risks have less to do with the bowel and bladder though and more to do with future pregnancies.
With regards to standard risks of Caesar (or any laparotomy for that matter) the risks are there regardless of the site of incision (though potentially to varying degrees due to the location), they are:
-bleeding and treatment of the bleeding (including blood transfusion and life-saving hysterectomy)
-damage to other structures intra-abdominally (bowel, bladder, ureters, blood vessels, Fallopian tubes, ovaries etc.)
-impact on future pregnancies due to the presence of a scar
-other standard operation risks like blood clots and anaesthetic risks
What the doctor said about the risk on the prolapse existing due to pregnancy regardless of the mode of delivery has an element of truth to it; the forces from a constant burden on the pelvic floor in pregnancy can cause prolapse without a labour or vaginal birth, especially on an already weakened pelvic floor. It is, of course, profoundly worse with vaginal birth though, and having a scar on your posterior vaginal wall will inherently affect the tissue’s ability to stretch and accommodate the baby’s head. However, the attitude of “oh well, we can fix it later” is atrocious, in my opinion- it should definitely be taken into consideration.
I think there are pros and cons of each and you need to be fully counselled before making a decision- you certainly shouldn’t be signing a consent form until you completely understand what you are in for. I would be requesting an appointment with a senior doctor who can actually explain these things properly as soon as possible so you can make the right decision.
Sorry for the long winded answer, I hope it helps rather than confuses you more!
Posted 10 August 2019 - 09:25 PM
Op it is not clear how far along you are and whether there is still a few appointments for the doctor to be clear, but I think it is worrying that you need to ask these questions. You OB should be very clear. The “seemed to be” seems strange to me.
I would be going back asking questions or seeking another opinion.
Posted 10 August 2019 - 09:59 PM
Thank you for the responses.
I am currently 19 weeks, so this was really just an initial meeting to give me and indication of what I could/should expect. There is absolutely more time for me to go back with further questions.
My Gyno who performed the repair 4 years ago was clear that any further births should absolutely be by C section, but at the time we didn’t go through risks, and of course having had surgery since, he didn’t go through that aspect either.
400 thank you for all of the detail above. This is really helpful.
I wasn’t bothered about clarifying with him the nature of the prolapse, given this was just an initial consult and he happened to be the Dr on on the day. I don’t think he realised that I’ve already had it repaired, and it wasnt pertinent in the moment to clarify my position more clearly.
I think what I’ll do is make an appointment to go back and see my Gyno and ask for his advice (he jointly performed the more recent op too). If the hospital is happy to support my decision either way, I’m likely to get the most accurate information from him and can go back to them more informed.
Posted 11 August 2019 - 11:53 AM
That sounds like an excellent plan, I think the gyno that has been involved in both operations is completely the right person to advise you on the best course of action. You could also request that he write a letter to communicate with your obstetric team also so that everyone is on the same page.
Posted 11 August 2019 - 04:42 PM
Not too much more to add than has been said already but if I was you I'd be leaning very heavily towards C/S even though it is a toss up as to whether pregnancy or vaginal delivery is the major stuff up factor.
A lower uterine C/S incision generally does not encounter too much scar tissue from intra abdominal surgery ( your laparotomy)...just scar tissue from previous bladder or pelvic surgery. Of course it will depend on how extensive any surgery you did have at your laparotomy was.
I hope you can get some clarity from your gynaecologist and you will feel happy and confident heading into your delivery.
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