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.
Complications worry MDs
Surgery carries risks, doctors say
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
rupture."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
C-section.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
established."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."
© Copyright (c) The Windsor Star
This article is torturing me. I have a friend who was talked into a c/s with her first baby because “at 41 weeks nothing was happening down there”. And now she’s pregnant again, loves loves loves her OB, and I’m 99.9% sure she’s already scheduled. I really want to send this to her, but it will never come across the way I would want it to. Add to it, all of this coming from a girl who has had two c’s of her own…
Like I said, torture.
[...] Posted by doulamama1 on August 3, 2009 This is a very good article from vbacfacts.com. [...]
I am with you on encouraging VBAC’s rather than another c-section for women who are good candidates for one.
I also think it’s important for women that have had multiple c-sections to know that the risks for Placenta Accreta are low. Many women go on to have 4 or more c-sections without any problems at all, and yet I’ve met (and read about) women that have had accreta in a pregnancy after only 1 or 2 c-sections. C-sections don’t have to end a woman’s childbearing years early, but it is good to know the risks to make that decision.
Hi Morgan!
According to Silver (2006), a four year study of up to six repeat cesareans performed on 30,000 women, there is a 2.13% chance of accreta and a 2.41% chance of hysterectomy during a fourth cesarean. In other words, 1 in 47 women will have accreta and 1 in 41 women will have a hysterectomy.
Counter that with the rates in a first cesarean: 0.24% for accreta (1 in 417) and 0.65% for hysterectomy (1 in 154).
The rates for accreta and hysterectomy dramatically increase as the number of cesareans increase.
It’s also interesting to note that the rate of hysterectomy in a second cesarean (Silver, 2006) is the same as the rate of uterine rupture in a spontaneous labor after one prior cesarean: 0.4% (Landon, 2004). Both are the effective end of a woman’s fertility.
Warmly,
Jen
I’m glad i found this. I am not even a week overdue and my ob is insisting on a c-section because I had one previously. I also had a vaginal delivery and feel like I’m being forced into having a c-section. I remember how long it took to recover from the c-section and how I couldn’t even hold my child for the first 2 hours. I don’t want to miss out on that again. Thank-you for this article!
I think it is crucial for women to talk to their doctors about the potential risks associated with cesarean sections. It is also important to acknowledge the number of lives that have been saved by this procedure. Nothing comes without the potential for complications. With improved awareness, screening, planning and management, placenta accreta may have more promising outcomes.
Anna,
Many women and babies have been saved by cesarean deliveries. The problem is that many women and doctors have become so caviler about the risks of cesareans, especially multiple cesareans. This is one of the many variables that colors how doctors counsel women on VBAC vs. repeat cesarean.
The unfortunate reality is that many women are interested in the option of a VBAC, but cannot find a provider. And these hospitals that claim they cannot adequately respond to a uterine rupture, and thus ban VBAC, must now contend with increasing rates of placenta accreta which is a medical emergency of its own right. They are exchanging one complication for another and they both can have catastrophic outcomes.
Most women with prior cesareans are so heavily counseled on uterine rupture as a risk of VBAC that they happily consent to a repeat cesarean. However, if these women were informed on the risk of placenta accreta, and how the risk increases with each cesarean, they would probably give their options more thought.
It’s practically common knowledge that uterine rupture is a complication that accompanies a trial of labor after cesarean. Why are women not equally informed on the risks of cesareans? I suspect it’s because VBAC counsels provided by care providers are often lacking and leave women with the impression that VBAC is excessively risky and repeat cesareans are safe. Really, women should walk out of those counsels understanding that there are real and rare complications that occur with each mode of delivery. They should understand that the risks of VBAC decrease after a successful VBAC, the risks of cesareans increase with each surgery (Mercer, 2008) and the risks of baby dying during a trail of labor after cesarean is almost the same as mom dying in a repeat cesarean (Landon, 2004).
Warmly,
Jen
What an eye opening article. I am a mother of 3 with 3 different birth experiences. My first was born via C-section b/c of fetal distress at 9.5 cm. Dr. could feel baby’s head but baby kept slipping back up birth canal (cord was wrapped around ankle) he was born almost blue, so I have no doubt the section was necessary. The OB told me I could not deliver via VBAC if I had another child b/c of risk.
I did some research and when I became pregnant with my 2nd I was at a military instillation in TX, dead-set on a VBAC and and the Midwives there were amazingly supportive of a VBAC. I was told the hospital discourages C-sections unless medically necessary. I received an epidural at 6cm b/c of the uterine rupture risk and though labor slowed down I was able to have my baby vagionally. Though my daughter’s heartrate dropped just before birth the RNs said “oh, that is normal when baby is ready to come.” That was music to my ears!
My 3rd child was born 3 months ago at a military hospital in Hawaii. I was told horor stories of the OB department where I was delivering, such as… ‘even though I had a seccessful VBAC with a baby a pound heavier than my first, I would have to have a c-section because they would be more comfortable.’ I told them that I would leave AMA and have the baby in the parking lot if I had to.
I arrived in the middle of the night, no midwives on duty but fortunatly I had the best team a gal could ever wish for. C-section never even came up in conversation and the STRONGLY encouraged me to have a natural, unmedicated birth!!!
Thank God for Midwives, OBs and nurses who believe in the VBAC and help you stand your ground when your world is spinning round and round!
Thank you again for publishing such an educational article. A gal I know had to have a historectomy with the birth of her 2nd child due to plecenta accrate and the children were 7 years apart. SCARY!!!
My previous monthly period period began on Nov. 29 and lasted 4 days. It is now December 19th and I’m experiencing very light, brownish bleeding together with minor cramping. I have already been trying to get pregnant for three months’ now. Could this be implantation bleeding? If it is, in how much time could i complete a pregancy test?
I’m not a medical professional, but if I were you, I would wait two weeks and take a pregnancy test. You are on day 20 of your cycle so if you have longer cycles, it could be implantation bleeding. If you have any concerns, I would contact your doctor for further information.
I just gave birth to my daughter April 27, 2011. The doctors found during my c-section that I had placenta accreta. How likely is it to happen again? They were very surprised that I didn’t bleed to death or have to have my uterus removed. I wanted to have another baby, however, the doctors cannot guarentee that this won’ t happen again. Not to mention I have had 2 abortions over 15 years ago and now one c-section. Any advice would be soooooooooo helpful.
thanks in advance
Mrs. Taylor,
Placenta accreta is very serious. The risks of maternal mortality and hysterectomy are high. You can diagnose accreta during pregnancy via ultrasound although a MRI is more definitive.
There is a 10%-25% rate of accreta recurrence according to this article: . (I’m sorry that I don’t have the time right to look up medical studies on this.)
Here is how Dr. Bob Resnik at the University of California San Diego approaches accreta:
Best of luck!
Warmly,
Jen
Jen,
I am currently 29 weeks pregnant with di/di twins. Baby a was a fetal demise at 19 +4 weeks. I also have complete placenta previa with twin A. At my last ultrasound they said the placenta had shrunk and become calcified which could act like an accreta? Apparently I will be requiring a csection of which I am terrified. What are the odds of having to have a hysterectomy?
Valerie,
I’m so sorry. I do not know off-hand the percentage of women with accreta who have hysterectomies, but I recall reading somewhere that it is high. You can read more about accreta here. Also, consider joining the VBAC Facts Community as one of the medical professionals there may be able to give you additional information. Sorry I can’t be more help!
Warmly,
Jen
Hello,
Thanks to everyone for your posts. My question is this: If a c-section scar does not allow a placenta to receive proper blood supply, is there any way to reverse this? There are several methods of increasing blood flow to the uterus (fertility massage, fertility cleansing herbs, acupuncture), but does this blood increase in/through scar tissue as well? Or, is a scar permanent dead tissue? There are also potent systemic enzymes which claim to reduce a c-section scar, but do they simply erase the fibrin on the outside of the scar? Or, do they dissolve excess fibrin IN the tissue of the scar, thus allowing development of new vessels, and creating normal blood flow again? Thanks for any expertise!
Nora
Nora,
I shared your question here. Follow that thread and hopefully some medical professionals will share some knowledge!
Warmly,
Jen
So I’ve been reading all this stuff about vbacs… We are expecting #2 which we are very excited about. My first was a c-sec… My paperwork mentioned CPD. I’ve been told the hospitals around here say they do vbacs and then around week 34 tell you no. Found a real midwife with 20 years experience (is known for vbacs). Husband and I have talked with her and she thinks we would be successful in a home birth. She doesn’t seemed concern with the CPD… What are your thoughts? I’m so torn on which way to go! I did my first labor all natural until my son would not fit ( was 10lbs, 1oz). What are the chances this will happen again? My OB basically said no to vbac. Any advice?
Hi Lisa!
It might be worth it to shop around in your area and talk to other health care providers and get their opinion. Home birth and hospital birth come with their own risks and benefits.
I posted your question on Facebook to get you more feedback.
Best,
Jen