From Another VBAC Consult Misinforms:
[My OB] did not mention risks to repeat c-sections. When I brought it up he said there aren’t any except the obvious risks that come with any surgery.
It’s because some OBs continue to mislead their patients about the risks of cesareans that I share this excellent cesarean section consent form created by the Coalition for Improving Maternity Services dated February 2010. You can download a PDF here. The consent form is the last two pages of the PDF. Citations for the risks listed below can be found here: The Risks of Cesarean Sections.
It’s also important to remember than many of the risks of cesareans increase with each cesarean. Silver (2006), a 4 year study of 30,000 women looking at up to six repeat cesareans, found:
Increased risks of placenta accreta, hysterectomy, transfusion of 4 units or more of packed red blood cells, [bladder injury], bowel injury, urethral injury, ileus [absence of muscular contractions of the intestine which normally move the food through the system], ICU admission, and longer operative time were seen with an increasing number of cesarean deliveries…. After the first cesarean, increased risk of placenta previa, need for postoperative [maternal] ventilator support, and more hospital days were seen with increasing number of cesarean deliveries.
One might think that information about birth is only relevant to women of childbearing age, but really, it’s important information for everyone to know. Women who are in the post-babies stage of their life are often sought out by younger folks for info and it’s always good to have the facts at your fingertips. Additionally, I’m sure many husbands and partners would want to understand the risks of a cesarean so that they may help their sweet wife avoid an unnecessary surgery through education and carefully selecting a care provider.
About the Risks of Cesarean Section
A Checklist for Expectant Mothers to Read During Pregnancy
Birth is a normal, natural, process and the vast majority of women can have safe, normal, vaginal births. There are health conditions where a cesarean birth is necessary for the well being of the mother or her baby. However, more and more mothers these days are giving birth by cesarean section for non-medical reasons. A cesarean poses risks as well as benefits for mother and baby, and should not be undertaken lightly. This educational material is provided by the Coalition for Improving Maternity Services (CIMS) to help all expectant parents become better informed about the risks of cesarean section.
To give the expectant mother time to reflect on this information and consider the impact of cesarean surgery on her health and the health of her baby, care providers are encouraged to introduce and discuss this evidence-based information throughout pregnancy and no later than at 32-34 weeks. The expectant mother is encouraged to take the form home, read and initial the statements, discuss the information with her partner, and raise any questions or concerns she may have with her care provider. The form may then be placed in her chart.
Expectant Mother’s Name: _________________________________________________
Care Provider’s Name: ____________________________________________________
A cesarean section is an operation by which a baby is born by making a cut in the mother’s lower abdominal wall (abdominal incision) and a cut in her uterus (uterine incision). I understand that a cesarean operation may be more dangerous than a vaginal birth for my baby and me.
POSSIBLE PROBLEMS FOR ME WITH A CESAREAN AS COMPARED TO A VAGINAL BIRTH:
1._____ I am more likely to have more blood loss and a longer recovery time.
2._____ I am more likely to have accidental surgical cuts to my bladder, bowel, or gastrointestinal tract.
3._____ I am more likely to have a serious infection in my incision, uterus, or bladder.
4._____ I am more likely to have thick scarring (adhesions) inside my abdomen that may cause chronic pain years after my cesarean. This scarring can make any future abdominal operation I may need more difficult.
5._____ I may have uncontrolled bleeding and need an emergency hysterectomy (removal of the uterus) if the bleeding cannot be stopped.
6._____ I am more likely to have complications from anesthesia.
7._____ I am more likely to develop serious and life-threatening blood clots that can travel to my lungs (pulmonary embolism) or my brain (stroke).
8._____ I am more likely to be admitted to intensive care.
9._____ I am more likely to need to return to the hospital for complications from the cesarean operation.
10._____ I am more likely to feel pain and/or numbness at the site of the operation for several months after my surgery.
11._____ I am less likely to breastfeed successfully. I may lose out on the health benefits of breastfeeding for myself, including: weight loss, reduced risks of cancers, heart disease, diabetes, and osteoporosis.
12._____ I am less likely to have a satisfactory birth experience. I am more likely to have emotional problems such as post-partum depression and post-traumatic stress. Many women experience a profound sense of happiness after a normal birth that flows naturally into bonding with the baby and breastfeeding.
13._____ I am more likely to die.
POSSIBLE PROBLEMS WITH A CESAREAN FOR ME WITH A FUTURE PREGNANCY AS COMPARED TO A VAGINAL BIRTH:
14._____ I am more likely to have trouble becoming pregnant again.
15._____ I am more likely to have complications in a future pregnancy due to the scar in my uterus. If the new placenta attaches over my previous scar, it is more likely to cause serious problems, including: serious bleeding, placenta coming in front of the baby (placenta previa), placenta growing into or even through the wall of the womb (placenta accreta), miscarriage, or pre-term birth.
16._____ I am more likely to have a baby with a congenital malformation, central nervous system injury, or low birth weight due to problems with the placenta.
17._____ I am more likely to have a stillbirth.
18._____ I am more likely to require major surgery to remove cells from the lining of my uterus that may grow outside my womb (endometriosis).
19._____ Since it is difficult to find a physician or hospital supportive of a vaginal birth after a cesarean (VBAC), I am more likely to have a repeat cesarean for the birth of all my future children, although a vaginal birth after a cesarean birth is usually safe. Each additional operation I have increases the odds for complications.
20._____ Research shows that having a cesarean will not protect me from urine, gas, or stool incontinence in the future, or from future sexual problems.
21._____ I may not be able to get healthcare coverage since some insurance providers consider a cesarean to be a pre-existing condition.
POSSIBLE PROBLEMS FOR MY BABY:
1._____ My baby is more likely to be born prematurely if the cesarean surgery is performed anytime before labor begins. A premature baby is more likely to experience the following:
• -admission to the intensive care nursery
• -trouble breastfeeding, digesting food, and regulating body temperature
• -developing jaundice
• -brain development problems and difficulties in learning in school
2._____ My baby is more likely to face complications from anesthesia and postpartum pain medication.
3._____ My baby is more likely to be accidentally cut during surgery.
4._____ My baby is more likely to have breathing difficulties since labor contractions clear the lungs.
5._____ If I agree to a scheduled cesarean, it is normally best to wait for labor to begin before performing the operation.
6._____ My baby is more likely to have difficulty breastfeeding. My baby is less likely to benefit from skin-to-skin contact with me and is less likely to get the health benefits from breastfeeding including: reduced risk for asthma, allergies, respiratory infections, Type 1 diabetes, childhood leukemia, and SIDS (sudden infant death syndrome). If I do have a cesarean, I can request special care to help me and my baby breastfeed successfully before I am discharged from the hospital.
I have read and discussed this information with my care provider.
Expectant Mother’s Signature: _______________________________ Date: ________________
Care Provider’s Signature: __________________________________ Date: ________________
This information is provided for expectant mothers and their care providers by the Coalition for Improving Maternity Services (CIMS). CIMS strongly recommends that cesarean surgery be reserved for situations when potential health benefits clearly outweigh the risks. Please see the The Risks of Cesarean Section, a CIMS Fact Sheet for the references that support this form, available as a free download from www.motherfriendly.org.
now that’s what i call informed consent, wish consent forms in hospitals looked like this!
VERY good stuff!! I’d also like to add this one (it’s happened to me, and my latest OB informed me it’s common): “I am more likely to be manually dilated so I can bleed vaginally after the surgery. This will leave my cervix scarred, and possibly unable to dilate in a VBAC attempt.”
I had no idea my first OB had done this to me, but when I was in labor with my VBAC baby and not progressing (we’re talking DAYS of laboring at home and being stuck at 5 cm for over 24 hours), I went to the hospital for some answers. The OB on call found the scarring and massaged it to break it up, allowing me to have my VBAC. We discussed it at my PP appt, and I’d been researching every possible cause of the scar tissue. I concluded there was no other cause for mine BUT the C-section. That’s when she informed me it must have been the manual dilation, since I was not dilated or even in labor when I was sectioned! I was dumbstruck and horrified by this news.
Thankfully I had been using Evening Primrose Oil orally and vaginally from week 37; I truly believe this allowed my scar tissue to become supple enough to dilate!
We have all of our pregnant ladies sign this. If we can prevent the primary cesarean then we don’t have to go thru the VBAC issues. Let’s all work at preventing just one primary cesarean and see how that changes birth.
I continue working on the VBAC/HBAC Consent Form, too… almost finished! This information was absolutely incorporated.
Yes, yes! Prevention IS the key.
With permission, may I re-print on my blog?
Great job, Jen & CIMS. As always.
Of course, re-print away! It’s CIMS’ document and they give permission to distribute.
The question at top reminded me of an old post by “Rebirth Nurse”, in which she answered a question from a woman who was upset that her legs were “frog-legged” and people were looking between her legs. In the post, the blogger answers that they were removing any blood clots from her uterus, so they wouldn’t cause problems later, but that the woman should have been told this was going to happen, so she wouldn’t have felt so surprised and vulnerable. Anyway, perhaps this is common, with the cervix being manually dilated if the woman hasn’t gone into labor and gotten far enough dilated on her own, but I don’t know.
Lauren wrote>
“I am more likely to be manually dilated so I can bleed vaginally after the surgery.” Perhaps I am interpreting your words incorrectly as it appears that you think that manual manipulation of the cervix is required for post partum cesarean moms to pass lochia. No mechanical “help” is required!
Lauren,
I’m confused by your post. At what time did you have the dilation done? I had a cesarean without labor and without dilation. So do most women who have their c/sections scheduled at 37 and 38 weeks. At the time of the c/section, they vacuum out much of the blood. In 22 years of birth activism, I have NEVER heard of a women being manually dilated after the cesarean to allow the blood to flow out. NEVER!!! Have you a copy of your medical records. I’d love to see what the doctor wrote in your chart.
I have heard of women being examined after a VBAC. This was done historically to check the integrity of the original scar. Unfortunately the doctors were often sticking their fingers through a very thin uterus…necessitating abdominal surgery. So the practice was abandoned…about 25 years ago. Doctors will do manual exams for retained placentas…but I’m really stretching to understand why your doctor would do a manual dilation of the cervix after the c/section. Women bleed every month without dilation of their cervix.
I’m really curious. if you find out more..Jen will keep me posted.
First off , love the website. I find it a great resource of collected data on VBAC, which I am a supporter of, and member of ICAN.
In the interest of balance, I wonder if we should not also include the benefits of CS (or the risks of vaginal) birth, since information on both sides of the coin is important. I have had moms who successfully VBAC complain to me that they did not fully understand all the risks of vaginal delivery as well, mostly in the perineal laceration department, and I realize that we focused so much on the VBAC issues that we somewhat ignored the risks of successful vaginal delivery.
Should we not include risks & benefits on the same document? Its all about informed CHOICE.
Just my 2c.
Dr. Dorn,
Thank you so much for your comment and the link to your website http://www.drdorn.com. I really enjoyed reading about your background especially your experience working collaboratively with midwives internationally and within the United States.
I agree that it’s all about informed choice. It is not the purpose of this website to provide all the information that is otherwise available, but instead to complement, amplify and supplement other texts and sources. There are so many topics I would love to write about and am in the process of writing a book, but my time, as a full-time stay-at-home mom to two children, is quite limited.
Fortunately, Childbirth Connection maintains a page entitled Harms of Cesarean vs. Vaginal Births, A Systematic Review. Their PDF entitled “Vaginal Birth and Cesarean Birth: How Do the Risks Compare?” contains a great table comparing the risks to mom and baby in a cesarean, a vacuum/forceps vaginal birth, and a vaginal birth. The only thing I don’t like about it is that it’s just a list of risks, much like the document above.
One of the reasons that I started this website was that I like to know the actual rate of complications and how they compare and many documents readily available to lay women are more generic. But it’s still a good starting point and if people want a list of published research on birth after cesarean, my bibliography is pretty comprehensive.
Thank you again for visiting!
Warmly,
Jen
Wow…
I never saw anything like that…
Would probably discourage elective c-sections… And increase desire for VBACS!
Yes, some OB’s do routinely do a manual dilation of the cervix using a double gloved finger from above following an elective c/s. It is done to provide more of an opening for the uterus to drain. I realize that women menstruate every month, but during pregnancy, the cervix closes. If you are having an elective c/s before any labor, then the cervix is still high and tight and there needs to be some place for the blood, clots and tissue to go. A study was done to find if the process of manual dilation reduced maternal morbidity and infection. Additionally, following a c/s, the uterus remains higher and larger for longer than after a vaginal birth due to surgical trauma. This results in longer bleeding times for some women.
The manual dilation practice has most recently been looked at as a cause for cervical scar tissue. I myself had experience with this. When I went in for my vba2c with contractions right on top of each other I was found to be at 1 cm. When the doctor checked later, I was still at 1 cm. She then got a speculum and LOOKED up there only to ask me if I had ever had anything done, because she could clearly see that my cervix was full of scar tissue. I had nothing done except 2 c sections. She manually broke it up and I was able to dilate normally after that.
Oh…..and I would be surprised to find if you could actually get a doctor to USE this form. It’s great, but it lists all the things they really don’t want to acknowledge about c/s.
Even the OB above, Dr. Dorn, is defensive. He suggests listing all the risks of vbac as well. Fine. But how many doctors talk to their patients about the risk of placental abruption or cord prolapse? How many of them concede that both are more likely to happen during any vaginal birth than a uterine rupture during vbac? So, do doctors tell patients that every woman should be sectioned because a cord prolapse MIGHT happen? No. But do they tell patients that they shouldn’t attempt vbac because a uterine rupture MIGHT happen? Yes, they do. And how many doctors will honestly tell their patients that a c section is more likely to kill them than a vaginal birth? None.
Why is that? Fear of liability. Plain and simple. Doctors don’t get sued for doing c sections because of a signed consent form. They can say they were in a woman’s abdominal cavity up to their elbows and it’s not their fault they couldn’t save her. What more could he have done? It’s all fear driven care and has nothing to do with what’s medically best for moms and babies.
C sections can be great life saving tools. But that’s where they should end. The WHO says we should not have a c/s rate over 15% because after that point maternal and fetal outcomes get worse. And yet, in the USA the c/s rate is over 30%! Over 1/3 of US babies are being pulled out surgically. I don’t believe for a minute that over 1/3 of US moms or babies are facing life threatening conditions in labor. It’s done for convenience, profit, and fear. I can’t think of ANY woman who would choose a c/s if they were told that it could cause them severe pain from adhesions every day for the rest of their life. But women aren’t told that….they are just greeted with one unpleasant surprise after another following a surgery they probably didn’t need. It’s not right.
I wish it was MANDATORY for hospitals to have the consent form you have above. Women need to be armed with the truth before they get on that table.