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Why cesareans are a big deal to you, your wife, and your daughter

I hear a lot, “What’s the big deal about cesareans? What difference does it really make if you have a cesarean?” Of course, if a cesarean is medically necessary, then the benefits outweigh the risks. But in the absence of a medical reason, the risks of cesareans must be carefully considered.

“Once a cesarean, always a cesarean”

If a woman has a cesarean, she is very likely to only have cesareans for future births. This is because while 45% of American women are interested in the option of VBAC (1), 92% have a repeat cesarean (2). Let me say that another way. Only 8% of women with a prior cesarean successfully VBAC.

One might interpret this statistic to mean that planned VBACs often end in a repeat cesarean. However, VBACs are successful about 75% of the time (3-7). The VBAC rate is so low because of the women interested in VBAC, 57% are unable to find a supportive care provider or hospital (1). And I would argue further that even among the women who have a supportive care provider, those women are so bombarded by fear based misinformation masquerading as caring advice from friends and family, they have no chance.  It is shocking to learn how ill-informed both women planning VBACs and repeat cesareans are about their birth options even upon admission to the hospital.  There is a fundamental gap in our collective wisdom about post-cesarean birth options.

Cesareans make subsequent pregnancies riskier

What’s the big deal, right? Who cares if you have a cesarean without a medical reason?

Forget about the immediate risks to mom and baby that cesareans impose. Just set that all aside for a moment.  Much of the risk associated with cesareans is delayed.  Most people are not aware of the long term issues that can come with cesareans and how these complications impact the safety of future pregnancies, deliveries, and children.

It is a well-established fact that the more cesareans a woman has, the more risky subsequent pregnancies and labors are regardless if the mom plans a VBAC or a repeat cesarean.  This was discussed at great lengths during the 2010 National Institutes of Health VBAC conference and was one of the reasons why ACOG released their less restrictive VBAC guidelines later that same year.

Many moms chose repeat cesareans because they believe cesareans are the prudent, safest choice. The fact that cesareans, of which over 1,000,000 occur in the USA each year, increases the complication rates of future pregnancies is often not disclosed to women during their VBAC consult.

A four year study looking at up to six cesareans in 30,000 women reported a startling number of complications that increased at a statistically significant rate as the prior number of cesareans increased:

The risks of placenta accreta [which has a maternal mortality of 7% and hysterectomy risk of 71%], cystotomy [surgical incision of the urinary bladder], bowel injury, ureteral injury [damage to the ureters - the tubes that connect the kidneys to the bladder in which urine flows - is one of the most serious complications of gynecologic surgery], and ileus [disruption of the normal propulsive gastrointestinal motor activity which can lead to bowel (intestinal) obstructions], the need for postoperative ventilation [this means mom can't breathe on her own after the surgery], intensive care unit admission [mom is having major complications], hysterectomy, and blood transfusion requiring 4 or more units [mom hemorrhaged], and the duration of operative time [primarily due to adhesions] and hospital stay significantly increased with increasing number of cesarean deliveries (8).

Because the growing likelihood of serious complications that comes with each subsequent cesarean surgery, including uterine rupture, this study concluded,

Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery (8).

This is because the risks of placenta accreta and previa in particular increase at a very high rate after multiple cesareans (9).

The largest prospective report of uterine rupture in women without a previous cesarean in a Western country,” concurred:

Ultimately, the best prevention [of uterine rupture] is primary prevention, i.e. reducing the primary caesarean delivery rate. The obstetrician who decides to perform a caesarean has a joint responsibility for the late consequences of that decision, including uterine rupture (10).

“Well, I just plan on having two kids…”

Unfortunately, many women don’t think about these future risks until they are pregnant again. And we all know the great difference between intended and actual family size.

According to the CDC, 49% of American pregnancies are unintentional (11). Thus, these theoretical risks quickly and suddenly become a reality for hundreds of thousands of American women every year. How women birth their current baby has real and well-documented implications and risks for their future pregnancies, children, and health.

VBAC bans and emergency response

In light of these increasing risks, VBAC bans do not make moms safer (12). Hospitals are either prepared for obstetrical complications, like uterine rupture in moms who plan VBACs and placenta accreta, previa, and cesarean hysterectomies among moms who plan repeat cesareans, or they are not. It is hard to understand how hospitals can claim that they are simultaneously capable of an adequate response to cesarean-related complications and yet they are unable or ill-equipped to respond to complications related to vaginal birth after cesarean.  Especially in light of the fact that we know motivated hospitals currently offer VBAC even in the absence of 24/7 anesthesia (13).

A recent Wall Street Journal article discusses how hospitals are trying to create a standard response to obstetrical emergencies:

The CDC is funding programs in a number of states to establish guidelines and protocols for improving safety and preventing injury.  And obstetrics teams are holding drills to train doctors and nurses to rapidly respond to maternal complications. They are using simulated emergencies that include fake blood, robots that mimic physiologic states, and actresses standing in as patients (14).

Because hospitals vary so greatly in their ability to coordinate a expeditious response to urgent situations,

Vivian von Gruenigen, system medical director for women’s health services at Summa Health System in Akron, Ohio, advises that pregnant women discuss personal risks with their doctor and ask hospitals what kind of training delivery teams have to respond in an emergency. ‘People think pregnancy is benign in nature but that isn’t always the case, and women need to be their own advocates,’ Dr. von Gruenigen says.

Impact of VBAC on future births

Counter the increasing risks that come with cesareans to the downstream implications for VBAC. After the first successful VBAC, the future risk of uterine rupture, uterine dehiscence, and other labor related complications significantly decrease (15). Thus, family size must be considered as VBAC is often the safer choice for women planning large families.

Bottom line? I defer to two medical professionals and researchers:

“There is a major misperception that TOLAC [trial of labor after cesarean] is extremely risky” – Mona Lydon-Rochelle PhD, MPH, MS, CNM (16-17).

In terms of VBAC, “your risk is really, really quite low” – George Macones MD, MSCE (16-17).

Women deserve the facts

Women are entitled to accurate, honest data explained in a clear, easy to understand format (18). They don’t deserve to have the risks exaggerated by an OB who wishes to coerce them into a repeat cesarean nor do they deserve to have risks sugar-coated or minimized by a midwife or birth advocate who may not understand the facts or whose zealous desire for everyone to VBAC clouds their judgement (19-20).

If you would like to get the opinions of actual VBAC supportive medical professionals who support a woman’s right to informed consent, there are several obstetricians and midwives who you can talk to on the VBAC Facts Community.

Take home message

Cesareans are not benign and the more you have, the more risky your future pregnancies become regardless of your preferred mode of delivery.

Almost half of the pregnancies in America are unintentional.

If hospitals can attend to cesarean-related complications, they can attend to VBAC-related complications.

_________________________________________________

1. Declercq, E. R., & Sakala, C. (2006). Listening to Mothers II: Reports of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection. Retrieved from Childbirth Connection: http://www.childbirthconnection.org/article.asp?ck=10068

2. Osterman, M. J., Martin, J. A., Mathews, T. J., & Hamilton, B. E. (2011, July 27). Expanded Data From the New Birth Certificate, 2008. Retrieved from CDC: National Vital Statistics Reports: http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_07.pdf

3. Coassolo, K. M., Stamilio, D. M., Pare, E., Peipert, J. F., Stevens, E., Nelson, D., et al. (2005). Safety and Efficacy of Vaginal Birth After Cesarean Attempts at or Beyond 40 Weeks Gestation. Obstetrics & Gynecology, 106, 700-6.

4. Huang, W. H., Nakashima, D. K., Rumney, P. J., Keegan, K. A., & Chan, K. (2002). Interdelivery Interval and the Success of Vaginal Birth After Cesarean Delivery. Obstetrics & Gynecology, 99, 41-44.

5. Landon, M. B., Hauth, J. C., & Leveno, K. J. (2004). Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery. The New England Journal of Medicine, 351, 2581-2589.

6. Landon, M. B., Spong, C. Y., & Tom, E. (2006). Risk of Uterine Rupture With a Trial of Labor in Women with Multiple and Single Prior Cesarean Delivery. Obstetrics & Gynecology, 108, 12-20.

7. Macones, G. A., Cahill, A., Pare, E., Stamilio, D. M., Ratcliffe, S., Stevens, E., et al. (2005). Obstetric outcomes in women with two prior cesarean deliveries: Is vaginal birth after cesarean delivery a viable option? American Journal of Obstetrics and Gynecology, 192, 1223-9.

8. Silver, R. M., Landon, M. B., Rouse, D. J., & Leveno, K. J. (2006). Maternal Morbidity Associated with Multiple Repeat Cesarean Deliveries. Obstetrics & Gynecology, 107, 1226-32.

9. Kamel, J. (2012, Mar 30). Placenta problems in VBAMC/ after multiple repeat cesareans. Retrieved from VBAC Facts: http://vbacfacts.com/2012/03/30/placenta-problems-in-vbamc-after-multiple-repeat-cesareans/

10. Zwart, J. J., Richters, J. M., Ory, F., de Vries, J., Bloemenkamp, K., & van Roosmalen, J. (2009, July). Uterine rupture in the Netherlands: a nationwide population-based cohort study. BJOG: An International Journal of Obstetrics and Gynaecology, 116(8), pp. 1069-1080. Retrieved January 15, 2012, from http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2009.02136.x/full

11. National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. (2012, Apr 4). Unintended Pregnancy Prevention. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/index.htm

12. Kamel, J. (2012, Mar 27). Just kicking the can of risk down the road. Retrieved from VBAC Facts: http://vbacfacts.com/2012/03/27/just-kicking-the-can-of-risk-down-the-road/

13. Kamel, J. (2010, July 22). VBAC ban rationale is irrational. Retrieved from VBAC Facts: http://vbacfacts.com/2010/07/22/vbac-ban-rationale-is-irrational/

14.  Landro, L. (2012, Dec 10). Steep Rise Of Complications In Childbirth Spurs Action. Retrieved from Wall Street Journal: http://online.wsj.com/article/SB10001424127887324339204578171531475181260.html?mod=rss_Health

15. Mercer BM, Gilbert S, Landon MB. et al. Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Obstet Gynecol. 2008 Feb;111(2):285-291. Retrieved from: http://journals.lww.com/greenjournal/Fulltext/2008/02000/Labor_Outcomes_With_Increasing_Number_of_Prior.6.aspx

16. NIH Consensus Development Conference. (2010). Vaginal Birth After Cesarean: New Insights. Bethesda, Maryland. Retrieved from http://consensus.nih.gov/2010/vbac.htm

17. Kamel, J. (2012, Apr 11). The best compilation of VBAC research to date. Retrieved from VBAC Facts: http://vbacfacts.com/2012/04/11/best-compilation-of-vbac-research-to-date/

18. Kamel, J. (2012, Dec 7). Some people think I’m anti-this/ pro-that: My advocacy style. Retrieved from VBAC Facts: http://vbacfacts.com/2012/12/07/some-people-think-im-anti-thispro-that-my-advocacy-style/

19. Kamel, J. (n.d.). Birth myths. Retrieved from VBAC Facts: http://vbacfacts.com/category/vbac/birth-myths

20. Kamel, J. (n.d.). Scare tactics. Retrieved from VBAC Facts: http://vbacfacts.com/category/vbac/scare-tactics/

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27 comments to Why cesareans are a big deal to you, your wife, and your daughter

  • Zinnia

    Thank you for these posts. The downstream complications were very important in my decision to try for (and have) a VBAC with our 2nd baby. It’s nice to see this info compiled in one place. I don’t know if a 3rd baby is in our future, but I do know that it would definitely not be if I’d had a RCS. I’m not willing to voluntarily have that many abdominal surgeries, particularly when women I know have had to have adhesions, etc. removed after “just” two Cs.

  • Thanks for putting this together! Great research, as always. I was just talking to someone today about this very subject and saying that the thing that bothers me the most in uninformed consent for surgical births is the impact on future pregnancies. That’s not the kind of thing you take lightly or fail to tell women.

  • Audre

    Thanks, Jen for another great article! I always refer people who are looking for VBAC info to your site. You have the most comprehensive, non-biased, research-based information out there! I was never told about any complications to future pregnancies that a csection could cause. I had to find out for myself. None of my doctors ever mentioned it, they just told me I was “not a candidate” for a VBAC (as having had a csection with my first son, I had never had a vaginal birth). This is most definitely something they should discuss with patients. I went on to finally have a VBA2C at home with a midwife with my third baby, my daughter.

  • jennifer mcculler

    I have had five c-sections! I have always wanted to go vbac but everytime we were scared into having another c-section. I do not recommend c-sections. The first one we had to have because it was a emergency. But the others were from the doctors scaring my husband and I into them plus they were saying they don’t do vbac’s because they were not equipped for them. Thank you for this article. It is nice to be informed.

  • Sarah

    I think this is a great article. But some women do prefer c sections over vaginal birth – like myself.
    I think at the end of the day if you’ve had both; a c section and a vaginal birth that you should be able to choose what you want for the next birth without being forced or scared into an option you don’t want to do.

    • Jen Kamel

      Sarah,

      I absolutely agree with you!

      Jen

    • Helen

      I totally disagree that anyone other than a self funded patient should have a choice in whether or not to opt for a vaginal or c-section birth. The costs invilved in the latter are four times as much as a vaginal birth and this is unfairly borne by public funds or other medical scheme members. I honestly believe elective c-sections should not be allowed and that doctors and patient who collude to pretend that a c-section is medically necessary when it is not should be prosecuted for insurance fraud just like it would be if you colluded with a builder over a false house insurance claim. This to me is worse than people who refuse to stop smoking whilst being treated for lung dusease or alcoholics who keep drinking whikst undergoing liver treatment. The evidence is right there that women are chosing to harm themselves, their babies and bring upon themselves more and more long term health problems. It ia not done in our interests but because more money can be claimed from funds.

      • Marlene

        Amen! I feel exactly the same way! Unfortunately, I’m afraid our reasoning would lead to exactly the opposite, with court ordered C/S all over the place! Money talks,Doctors shout,reason only whispers in your ear.Common sense is not common any more!

  • Ivana M

    Thank your for all these great articles!! This is exactly why I will push for a vba2c, I know how dangerous c-sections are.

  • chanell

    Just want to add that ppl can Dr anyplace.. but deliver vbac at a larger hospital. I dr in a smaller town. Its a great hospital but they are not equipped for any emg problems that cant happen with them.. So very early on my DR asked me if I wanted to try for a VBAC, and if so he could still be my DR but I would have to pick a larger hospital to deliver at.. and he wouldnt be able to deliver my baby.. I myself choose to have a 2nd c-section. 1) because I pushed for 3 hours and baby never came out..They could touch her head.. but nope she wasnt moving. :( but with my second I got HELLP syndrome so I had to have an emg c-section at a larger hospital anyways..

    Ill also add.. my cousin Drs at a larger MPLS hospital.. and she had a c-section with her first child.. then 4 years later got preg again.. She went on to have 3 vbacs.. all noraml full term healthy deliveries.. :) her dr said that they suggest you wait for 2-3 years before tryin for a vbac.. so she would prob do fine.

    • Hannah

      Seems to me if a hospital isn’t equipped to handle a vbac then they aren’t equipped to handle any kind of birth.

  • Richele Rutledge

    I had a c-section with my first child due to the fact that she was in a sunny side up position and her forehead was straight down causing her to get stuck. I felt like a failure. When I had my second child,knowing I had felt like a failure with my first delivery, my doctor encouraged me to have a VBAC. I successfully delivered with a VB with my 2nd and my 3rd children. Now the hospital where my children were born doesn’t allow VBAC due to the possible complications that could arise. I’m glad I was given the chance to have a VBAC and would go somewhere else for a VBAC if I would ever have another child.

  • [...] Why cesareans are a big deal to you, your wife, and your daughter « VBAC Facts. [...]

  • Lourdes

    Great article. I am a mom of 5. I had 3 normal deliveries (#1 “successful” induction with 24 hour labor, #2 spontaneous 10 hour labor, #3 spontaneous 3 hour labor in a birthing center) followed by a c-section for #4 that was the result of a failed induction, followed by a VBAC for #5. Baby #1 was induced because the OB insisted it was time, even though all I had was Braxton-Hicks. Baby #2 was with a good CNM who avoided unnecessary interventions. Baby #3 was at a great birthing center. I had fully expected to have an easy birth for baby #4, but a change of insurance meant I couldn’t go to the birthing center or the CNM I’d had before. The new CNM insisted the baby would be huge like 12 pounds (she was 8.5 lbs) and I must get it out before it was “too late”. She scared me into being induced and an emergency complication arose (cord prolapse at 3 cm dilation after 12 excruciating hours). Those four kids were close in age, born between 1992 and 1999 and about 2-3 years apart each. After the c-section I did not get pregnant successfully again for nearly 13 years of trying (1 early miscarriage in 2006, 1 late miscarriage in 2010 and no other pregnancies-I thought I was unable to have a baby ever again). Finally in 2012 I got pregnant with #5, but had bleeding during the pregnancy. I went into labor 8 weeks early. I had a midwife (had been planning to attempt a Home Birth VBAC because I feared the doctors and hospitals) and she helped me get a doctor willing to do a TOL, and I safely delivered my 5 lb 14 oz preemie by VBAC at the hospital. I am so thankful for that doctor- the one on call at the hospital was insisting on a repeat c-section but the one my midwife called for me felt that I was a good candidate for VBAC. I am grateful I had a successful VBAC so I didn’t have a painful incision to add to my worries while my baby was in the hospital for 37 days. I saw other moms of preemies in the NICU who had had c-sections and I could feel their pain as they shuffled through the NICU holding their bellies.

  • [...] Why does having a vaginal birth, or a VBAC matter to women?  Why cesareans are a big deal to you, your wife, and your daughter « VBAC Facts. [...]

  • Hans P. Schmitz

    Great to heart all about the statistic for VBAC. In my view these Stats are greatly influenced by fear. Doctors and (sad to say) Midwifes are often afraid to have a VBAC. That leads them to not doing it, which then leads to Statistics. My wife had 9 x a VBAC, most of them as Homebirth. The “Danger” we encountered was mostly in the heads of the Doctors. We my be a bit old-fashion, but we proofed that it can be done!

  • [...] “Why Cesareans are a BIG DEAL to you, your wife, and your daughter” from VBACFacts.com [...]

  • Christy

    I agree.
    I had an emergency c-section (due to low heart rate, turned out my baby had a severe heart defect) and the with my 2nd child I was given the choice, but my Doctor did advise me of the high risk associated with a VBAC, so we opted to go c-section again…. A year later I was having bleeding problems and ended up having a Complete hysterectomy (3rd abdomen surgery!) Since then I have had bladder issues and tender abdomen that nothing can be done except another abdomen surgery…..I wish I had been given a more positive outlook on VBAC maybe I wouldn’t have had the hysterectomy.

  • Kaylene

    I had an emergency c- section with my first child. His heart rate dropped after they gave me some pitocin. I delivered child #2 and child #3 vbac. The dr. never even brought up a c- section. I guess I did not know that I was not the norm with this. I do know that I enjoyed the recovery from the last two much more than the first one. I would never recommend a planned c-section. Why take that risk, but that is just me.

  • Melissa

    I will be sharing this with a few pages! Thank you! I had two vaginal births and my 3rd was an emergency cesarean due to his heart rate dropping & a sharp pain in me with each push, ended up the cord was wrapped around his neck twice and the sharp pain was it almost pulling from me so it saved us both. I would opt for vaginal any day if I could, even with no pain meds, the pain and healing was hard on me, but worth it to have my handsome boy who will be a year in Feb :-) I hope dr’s and hospitals get update and stop beig so silly!

  • […] bullets above are copied and pasted from a study published here, which was also quoted here.  I don’t know what half of those words mean, but I’d like to avoid things like blood […]

  • Rachel

    Thank you so much for this great website! I had two natural vaginal births before having a c-section with my third due to complete placenta previa. We were surprised to find out we are expecting our fourth in June, so you are so right that planned and actual family size are two different things! I want to try for a VBAC, and my doctor is very supportive, but I have felt nervous. After reading this, I have realized that as long as my pregnancy remains normal the risks of a VBAC are actually lower than those of a repeat c-section. Thanks for helping me to be informed!

  • Brilliant comment from Hannah who wrote: “Seems to me if a hospital isn’t equipped to handle a vbac then they aren’t equipped to handle any kind of birth.”
    I will never forget talking with my Doctor back in the late 90’s. (He was my Gyn. but we used to talk business all the time because I was also an accountant) He assured me that anyone I sent to him with my flyer in hand for a VBAC, he would do everything he could for them to “have their VBAC” however if the mother was not one of mine, then, “Come on Teresa, I am a business man — they are going to have a C-section.” He then went on to tell me, “You do know that the risk of uterine rupture for a VBAC is 1 1/2 to 2%. You should really encourage your moms to have another C.”
    When I asked him what the risk was for complications for a second C-section, his reply was “Oh, 17 -18%. But let’s face it — I am a business man.” Really?

  • Hi, I’ve been following the talk about c-sections for years, and have failed to find anyone talking seriously about the way the baby is affected. When “rescued” from a labour “gone wrong” he is already getting organised for independent life. Not so from an elective caesar. He is expected to transition from a 24hour, total support system as an aquatic creature to an air breathing, semi-independent person with no preparation time. I think we must ask ourselves just what long term effects such a traumatic entry to the world has. When I was young, even babies born in 2hours or less were treated for shock– as were their mothers.Michel Odent in his Primal Health essays talks of the importance -to the baby-of the birth experience.
    Somehow, we must again respect the fact that nature, evolution, God–your choice, provided the best way for birth, and it is our duty to re-establish it’s wisdom.
    Jean Sutton

  • […] 1. Mengapa bedah caesar adalah masalah besar bagi Anda, istri Anda, dan anak Anda yang ditulis di VBACFacts.com, oleh Jen Kamel. Silahkan buka link berikut : http://vbacfacts.com/2012/12/09/why-cesareans-are-a-big-deal-to-you-your-wife-and-your-daughter/ […]