There is this idea that if you don’t VBAC and you schedule a repeat cesarean, that you will be safe from complications. This is because during a “VBAC counsel,” women are often told of the risks of VBAC, namely uterine rupture, but they are rarely told the risks of repeat cesareans in their current and future pregnancies.
Abnormal placental implantation is one risk of cesareans that only present themselves when you get pregnant again.
Women who expect to only have two children, and thus opt for a repeat cesarean, might think that not VBACing is the safer, and more controlled choice, for them.
But what happens if you get pregnant again? Now you have had two cesareans, your risk of placenta accreta (where the placenta grows through the uterus), placenta previa (where the placenta grows over the cerivx), and placental abruption (where the placenta prematurely separates from the uterine wall) all go up. And here women think they are making the SAFER choice by having a repeat cesarean.
This news article from Canada illustrates this point.
I’ve underlined parts for those who like to skim.
By Sharon Kirkey, Canwest News Service August 1, 2009
Dr. Jan Christilaw was in the operating room the day a routine incision was made into a young mother’s abdomen to deliver her baby.
What happened next, Christilaw says, "is something we never want to see."
Normally, the placenta separates from the wall of the uterus after birth. It’s lacy almost, and not like solid tissue. "You can take your hands and sort of scoop it up, it’s like breaking cobwebs as you go," says Christilaw, an obstetrician and president of B.C. Women’s Hospital and Health Centre in Vancouver.
But the placenta had eroded through the wall of the uterus, a condition known as placenta accreta. As soon as they stretched the opening of the uterus to deliver the baby, "the placenta started bleeding everywhere," Christilaw says.
They couldn’t get the bleeding to stop. The woman was losing two cups of blood every 30 seconds.
The only way to stop the bleeding was an emergency hysterectomy. The woman was in the operating room for eight hours and lost 15 litres of blood.
It used to be that obstetricians might only ever see one or two cases of placenta accreta in their lifetime. Although still rare, obstetricians across Canada say one of the most feared complications of pregnancy is increasing as a direct consequence of the nation’s rising cesarean section rate.
Virtually all placenta accretas occur in women who have had a previous C-section, and the risk increases with each additional surgical delivery. The placenta attaches to the old C-section scar. Scars don’t have a proper blood supply to feed a placenta, so it keeps burrowing into the uterus until it finds one, sometimes pushing through the uterus completely and into the bladder or other organs.
The condition can be detected by ultrasound, but not always. "You almost never see it in a woman who has not had a C-section," Christilaw says.
Today, about 28 per cent of babies born in Canada are delivered by caesarean. In 1969, Canada’s rate was five per cent.
More than 78,000 caesarean sections were performed in Canada last year, making it the single most frequently performed surgery on Canadian women.
"We don’t know what the ideal rate is," says Dr. Mark Walker, a high-risk
obstetrician at the Ottawa Hospital and senior scientist with the Ottawa
Hospital Research Institute. "I think it’s fair to assume it’s lower than
where we are now."
Walker says changing demographics — older first-time mothers, more multiple births from fertility treatments, more mothers with hypertension, diabetes, obesity and other health problems — are not enough to explain an almost doubling in the C-section rate since the early 1990s.
Neither is there evidence to support the idea that women are seeking
C-sections on demand. Studies from Ontario suggest less than one per cent of caesareans are for "maternal request."
The Society of Obstetricians and Gynaecologists of Canada says the vast
majority of caesareans are done for medically valid reasons. But there are concerns that too many are being ordered because labour isn’t progressing quickly enough, and that thousands of "routine" interventions are now being done that increase the odds of a woman needing a surgical birth.
What’s more, the number of women who give birth vaginally after a previous C-section is dropping dramatically, meaning more and more women are having repeat C-sections.
Dr. Michael Klein calls it the industrialization of childbirth, where, in
today’s risk-averse society, women in labour are being treated "as an
accident waiting to happen" and where doing something is always better than doing nothing.
"Physicians and society have helped women basically believe that childbirth is no longer a natural phenomenon, but an opportunity for things to go wrong," says Klein, emeritus professor in the departments of family practice and pediatrics at the University of British Columbia.
"But the fundamental issue is, we aren’t improving outcomes by doing more C-sections. For the first time in Canada, we are seeing the key indicators for mothers and babies going in the wrong direction."
Risks to babies range from accidental lacerations when the surgeon cuts into the uterus, to neonatal respiratory distress. Research suggests two times as many babies born via C-section will end up in an incubator with water on their lungs, or with serious respiratory problems compared to babies delivered vaginally, because a C-section interferes with the normal hormonal and physiological changes associated with labour that prepare a baby to take its first breath.
Risks to women include higher risks of hemorrhage requiring a hysterectomy, major infections including blood infections, wound infections and bladder infections, and blood clots in the lungs — and every C-section increases the risk for another.
"If you have a caesarean section for the first birth, the probability of
having one the second time around is huge, because of the difficulty women have in getting a doctor to look after them once they have a uterine scar," Klein says.
The worry is that the scar will pull apart during labour, causing a uterine
"If you have a catastrophic rupture, you can get into big trouble,"
Christilaw says. "You can have a negative outcome for mom or baby. In severe situations, the baby can die or become damaged — but that’s a very rare outcome."
Her hospital is encouraging more VBACs — vaginal births after caesarean — in carefully selected women. "In those women who attempt a VBAC, our success rate is well over 80 per cent."
But less than one in five women in Canada with a previous C-section
delivered vaginally in 2007-08. Eighty-two per cent had a subsequent
Christilaw says the only thing preventing Canada from seeing "horrific"
complication rates from C-sections is the fact women are not having as many babies as they once did.
"A C-section can be a life-saving manoeuvre for a mother or baby. Nobody is saying differently," she says. "What we’re trying to say to people is, a C-section is not a benign thing. If you need one, that’s different. But you should not be doing this unless you absolutely have to."
C-sections are frequently the end result of a cascade of interventions that
often starts with inductions.
Tens of thousands of women in Canada have their labours artificially induced every year, often via intravenous infusion of artificial oxytocin. Oxytocin is naturally produced by the human body. It’s what creates contractions in labour. Today in Canada, one in five women who gives birth in hospital is induced.
What doctors fear are stillbirths. But alarmed by the rising rates of
inductions, the Society of Obstetricians and Gynecologists of Canada
recently urged doctors not to consider an induction until a woman is at
least one week past her due date.
Claudia Villeneuve says that women are getting induced "if they’re two,
three, four days overdue."
"Inductions are rampant," says Villeneuve, president of the International
Cesarean Awareness Network of Canada. "You have a perfectly normal mom who comes in with a perfectly normal baby, and now you put these powerful drugs into her system to force labour to start."
The "humane" thing is to offer an epidural, she says. With an epidural, a
woman can’t feel pain in the lower half of her body. But epidurals slow
labour, sometimes so much that labour stops. "Now you have to get this baby out," Villeneuve says. Two-thirds of first-time C-sections are done for "failure to progress."
Klein says epidurals are too often given before active labour is
"The majority of women today get their epidurals in the parking lot."
Kayla Soares had been in mild labour at home for 24 hours when her
contractions suddenly stopped. Doctors told the Edmonton mother she would have to be induced. She was three centimetres dilated when they started the oxytocin drip.
"It was the worst pain I’ve ever felt in the world," she remembers. "I
wasn’t having contractions at all and then they put me on the oxytocin and every half-hour they would boost it up, so the contractions were coming every minute, pretty much. It was like going from nothing to being in crazy, absolute labour, and in so much pain." Eleven hours later, she was still just three centimetres dilated. "That’s when they said it was enough, and they were doing a C-section.
"I didn’t want to do it. I was asking, could we just have more time?"
Three weeks later, she still couldn’t get out of bed without help. Her
incision had become infected. "It felt like I was ripping apart every time I
moved. It was a pretty brutal recovery."
Soares had her second baby in June. "I was dead set on having a VBAC," a vaginal delivery after cesarean. "It was a fight, an uphill battle the whole time with doctors." One obstetrician asked her her shoe size. "She said that because I was a size five and smaller framed that I definitely was going to have another caesarean and that a VBAC wouldn’t happen. She said that because I was a ‘failure to progress’ the first time I’ll be a ‘failure to progress again.’"
Two weeks before her daughter was born, Soares started going in and out of labour. "They had me convinced it was causing stress to the baby even though the tests said everything was fine. They had me convinced it was enough, because I was overdue and they said my incision was going to rupture," she says.
"They just kind of scared me into having another C-section."
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