Category Archives: Cesarean section

Q&A: What are the risks of cesareans?

no right answers right-right 238370_640Q: “I know the risk of uterine rupture is 1-2% during a VBAC, but do you have any statistics for the risks of a repeat cesarean?”

A: The risk of uterine rupture after one prior low transverse cesarean is 0.4% – 1% depending on whether the VBAC labor is spontaneous, augmented or induced (Landon, 2004). Spontaneous means labor begins naturally. Induced means the woman is not in labor and is given a drug to try to start labor. Augmentation means labor has already begun and drugs are used to make the labor progress more quickly.

Cesareans carry increased risks of infection, hysterectomy, hemorrhage, blood transfusion, blood clots, adhesions (which are implicated in bowel obstructions, infertility, and long term chronic pain), surgical injuries, maternal mortality, as well as placenta accreta and placenta previa in subsequent pregnancies.

Both VBAC and repeat cesarean have real risks and benefits. Two women can look at the same data and make different decisions thus there are no Right or Wrong answers here. Best of luck making The Right Decision For You.

There are many resources out there on VBAC and repeat cesarean. Here are a few of my favorites:

Understanding Obstetrical Risk

James, K. (n.d.). Understanding obstetrical risk: The language of risk. Retrieved from kimjames.net: http://www.kimjames.net/Data/Sites/3/understandingobstetricalrisk2.pdf

James, K. (n.d.). Understanding obstetrical risk: What is a reasonable risk to take? Retrieved from kimjames.net: http://www.kimjames.net/Data/Sites/3/understandingobstetricalrisk.pdf

Decision Making Tools

Association of Ontario Midwives. (n.d.). Vaginal Birth After Caesarean: Making an Informed. Retrieved from Association of Ontario Midwives: http://www.aom.on.ca/files/Health_Care_Professionals/VBAC/VBAC.pdf

BC Women’s Cesarean Task Force. (2010). Power to Push VBAC and Planned Repeat Cesarean Birth Booklet. Retrieved from http://issuu.com/powertopush/docs/power_to_push_-_vbac_info_booklet

National Institutes of Health. (2010, June). Final Statement. Retrieved from NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights: http://consensus.nih.gov/2010/vbacstatement.htm

Shorten, A. (2011, Sep 27). A Woman’s Guide to VBAC: Weighing the Pros and Cons. Retrieved from Giving Birth with Confidence: http://www.givingbirthwithconfidence.org/p/bl/et/blogid=16&blogaid=933

Learn More…

California Healthcare Foundation. (2014, Nov). A Tale of Two Births: High- and Low-Performing Hospitals on Maternity Measures in California. Retrieved from California Healthcare Foundation: http://www.chcf.org/publications/2014/11/tale-two-births

Declercq, E. R. (2014, Oct 6). Birth by the numbers: The update. Retrieved from Brith By the Numbers: http://www.birthbythenumbers.org/?p=1722

Kamel, J. (2015, April 2). Too Bad We Can’t Just “Ban” Accreta – The Downstream Consequences of VBAC Bans Retrieved from Science & Sensibility: http://www.scienceandsensibility.org/placenta-accreta-vbac-ban/

Kmom. (2013, August 26). Placenta Accreta, Part One: What Is Accreta? Retrieved from The Well-Rounded Mama: http://wellroundedmama.blogspot.com/2013/08/placenta-accreta-part-one-what-is.html

What are your favorite VBAC and repeat cesarean resources? Leave them in the comment section.

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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. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMoa040405

Q&A: Single vs. dual layer suturing

pregnant-belly---hands---manQ: Is there any evidence to support double layer suturing over single layer?

A: Conclusive evidence on single vs dual suture does not exist. Also note that ACOG does not say one form of closure is better than another in their VBAC guidelines.

Bujold (2012) stated, “Although there is a growing body of evidence that the technique for uterine closure can be crucial for uterine scar healing, strong evidence regarding optimal techniques is scarce and there currently exist no national or international guidelines on which obstetricians-gynecologists and surgeons can rely.”

Bujold provides a good review of the literature, so you can use his bibliography to find specific studies if you would like but please don’t just read the abstract. Read the full text of the study and note factors like induction/ augmentation rates, as that increases the incidence of uterine rupture, and the number of women included in the study, as small samples sizes can result in very high or low reported rates.

While Bujold lists the research done to date, he prefaces his summary with the quote above which basically says, we don’t know enough. We need more large studies. This is important for mothers and providers to understand.

I see so much language used that seems to indicate absolute certainty on which method is best. This results in a lot of confusion and even providers who won’t attend VBAC in a mom with a single layer suture. This is very unusual, but those policies are based on a misunderstanding of the literature.

There are many, many variables that could impact rupture such as suture technique, suture material, number of sutures, size of needle, locked vs unlocked, induction/augmentation, etc. There are many theories about how which variables can be combined to create the strongest scar. None of these theories have been sufficiently tested.

Meta studies, when the findings of smaller studies are combined, are weak because they don’t control for all these variables and as Bujold said, there are no closure guidelines on which OBGYNs can rely. This means that the cesareans performed in Alabama could be different than those in Brazil or Portugal. We have to keep this variance in mind when looking at meta-studies, or really any study, on suture closure.

It’s important to remember when looking at any study on VBAC that you need at least a few thousand women in order to accurately measure the event of uterine rupture that occurs about 0.5% of the time. At ideal study on suture closure would preferably include 5,000 single layer women and a similar number of dual layer women. Then we could measure rupture by the various factors identified above. I have not seen one large, well designed study that controls for any of these relevant factors.

I’ve heard women say that they would request a certain type of closure. I personally would rather have my surgeon use the closure style they were trained in and performed thousands of times.

What type of closure do you have? If you planned a VBAC, did your provider ask if your scar was closed with single or dual layer suture?

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American College of Obstetricians and Gynecologists. (2010). Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Obstetrics and Gynecology , 116 (2), 450-463, http://dhmh.maryland.gov/midwives/Documents/ACOG%20VBAC.pdf

Bujold, E. (2012, August). The Optimal Uterine Closure Technique During Cesarean. North American Journal of Medical Sciences, 4(8), 362-363. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3421916/

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

surgery-surgical-instrumentsI 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.

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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/

Woman has 4th cesarean, 8 hour surgery, and requires 33 gallons of blood

Update: This powerhouse of a woman has since started the non-profit organization “Hope for Accreta Foundation.”


What a miracle this woman survived!  This was her fifth baby and fourth cesarean.

She had a complication known as placenta percreta which is when “the placenta attaches itself and grows through the uterus, sometimes extending to nearby organs, such as the bladder” (March of Dimes 2012).  The risk of having placenta accreta, increta, or percreta during a fourth cesarean or a VBA3C (vaginal birth after three cesareans) is 2.13% (1 in 47) (Silver 2006).

Image credit: Wikipedia

Image credit: Wikipedia

Most women planning a VBA1C (vaginal birth after one cesarean) are aware of the risks of uterine rupture.  However, women planning their first vaginal birth or VBA1C need the WHOLE picture so they can really work to prevent an unnecessary cesarean.  They need to understand the risks and benefits of VBAC versus repeat cesarean for mom and baby now as well as how current choices impact mom’s future health, fertility, delivery options, and complications that present in subsequent births.

A huge part of this – I believe – is hiring a vaginal birth/VBAC supportive care provider because once a woman has that first cesarean, her options narrow, and they do so even more drastically after that second cesarean.  As her options narrow, her risks increase and unlike uterine rupture which you can circumvent through a repeat cesarean, the risk of accreta, percreta, and increta are not as easily mitigated.

By avoiding one complication, we are increasing our risk for another serious complication in future pregnancies.  For women who plan for large families, this should be on your radar and every practitioner should be discussing intended family size with their patients so that it can be taken into consideration.

Read more about placenta abnormalities, the risks of multiple cesarean sections, the marketing of risk, and how reversing VBAC bans would make birth safer for everyone.

And please donate blood. These women need it.

Woman survives crisis delivery with 33 gallons of donated blood

Posted on April 11, 2012 at 9:46 PM

SAN ANTONIO — University Hospital is sharing an incredible story of survival. A San Antonio woman was saved during a crisis baby delivery. But it took more than 33 gallons of blood.

Two-month-old Addison Walker came into the world in an unusual way. Her mother, Gina, had a rare pregnancy condition called placenta percreta. The placenta invaded through the uterine wall into the bladder, causing massive bleeding during a delivery operation.

Doctors at University Hospital recalled the February eight-hour operation.

“Unfortunately, Ms. Walker had blood loss that superseded anything that we could have prepared for,” said Dr. Jason Parker, U.T. Health Science Center OB/GYN.

Walker lost more than ten times the amount of blood surgeons anticipated. She needed more than 33 gallons. That’s 540 units to keep her alive.

“After I watched cooler after cooler after cooler with my wife’s name on it full of blood going up and down the hallways, yeah, I did get worried,” recalled Gina’s husband Dustin. Read more.

A couple comments left on Facebook:

University is a Level 1 trauma center.  It is the trauma center in San Antonio.  Only other hospital that takes the worst of the worst is SAMMC [San Antonio Military Medical Center] which is the military hospital.  University takes all the gunshots, stabbings, multiple injury accidents, etc…. And these come in multiple times a day.  If any hospital has 100+ units on hand it would be that hospital.  Even if it didn’t, it is literally a couple hundred yards from a half dozen other hospitals that could dip into their supply.

It’s approx $1060 per unit of blood from the blood bank, not including the one time cost of all the testing, which is about $400-500. (These costs depend on the facility, but are a ball park.) Think about what the cost of the blood alone was…

I laboured just fine with my attempted VBA3C but the labour pains at the end were intense and I needed some meds of sorts so I went off to the hospital only to be bullied into the surgery room. All stats were excellent with me and my baby (and noted by the doctors in surgery that my little girl was down the birth canal and had I only been given something to help with pain, I would have pushed her out just fine). Because of that unnecessarian I had to endure a 6 hour reconstructive surgery to fix the mistakes of all the other batched c-sections and to repair the fistula left by the 4th C. But in the meantime I got the pleasure of toting around a catheter for the 5 months in between surgeries. That’s on top of the other procedures, tests and pain I had to go through. All of this could have been avoided had the doctors not allowed me that very first c-section and all the others that were not required. I kick myself in the butt for not educating myself right from the beginning, but how was I to know the doctors wouldn’t be educated either!

I desire to go on to have more children, but am terrified for things like this article speaks of.

Chipping away at the “too posh to push” myth

glamourous-womanSome new research questions the idea that women who are “too posh to push” are responsible for America’s rising cesarean rate. The work of University of Arizona sociologist Louise Roth has been featured in an University of Arizona UA News article dated April 13, 2012.

Watch for Roth’s research which will be “published in the May issue of the sociology journal Social Problems, published by the Society for the Study of Social Problems.”

I’ve highlighted a few passages for those who like to skim.

By Jeff Harrison, University Communications, April 13, 2012

UA sociologist Louise Roth says the increasing number of cesarean deliveries negatively impacts the health of women and their children and health-care costs.

University of Arizona sociologist Louise Roth wonders why women, at least according to news reports, are increasingly opting to give birth by cesarean section, rather than via natural delivery. Stories have focused on better-educated and more well-to-do women having the surgical procedure, a phenomenon dubbed “too posh to push.”

Roth, an associate professor of sociology who is interested in the effects of malpractice and, more generally, on the impact of the organizational environment on maternity care, looked at the data surrounding the issue and found herself totally stumped.

“I’d been reading a lot in the news about how women were choosing to have cesareans, and what I discovered was that women you would expect would have more cesareans – if that story were true – were not the women who were more likely to have them,” Roth said.

“In fact, the women who were most likely to have cesareans were low-education, Black and Hispanic women, which was not what I expected based on the ‘too-posh-to-push’ story. That was the impetus of this paper. I started playing with the data and found this finding that seemed counter-intuitive to me, and so I decided to investigate further.”

The results of her study will be published in the May issue of the sociology journal Social Problems, published by the Society for the Study of Social Problems.

Roth said the disparities in the rates of cesareans are an important issue because the procedure is tied to maternal deaths and the cost of health care. One key issue is understanding the “pervasive racial-ethnic and socioeconomic disparities in maternity care (and) health care more generally, yet there has been little scrutiny of how overuse of cesarean deliveries might be linked to these disparities.

Roth poured through a year’s worth of data, approximately 4 million recorded births in 2006, the most recent year available. Black, Native American, Hispanic and women from lower socio-economic backgrounds were less likely to have needed cesareans or more likely to have medically unnecessary cesareans.

Either scenario has potentially negative outcomes for both the mother and child. While maternal deaths are statistically low, they still are a concern to public health officials – and deaths from c-sections are four times higher than from vaginal births. Likewise, infants born earlier than 36 weeks, whether naturally or via c-section, are at higher risk for respiratory ailments.

What then is driving the increase in surgeries? Roth asked several researchers, including one who studies cesareans, if this trend was because women want them.

“I think the answer is ‘no.’ Women can have different preferences, but those who have the most ability to exercise those preferences seem to exercise them in the direction of avoiding cesareans rather than choosing them,” she said.

What’s more, lack of prenatal care does not seem to be a factor, and Roth noted that women who get more prenatal care are more likely to have cesareans.

There are other confounding issues. Some studies suggest women in a higher socio-economic status are more likely to get cesareans because they are getting more care than would otherwise be warranted. Other literature report that minority women are more likely to get cesareans.

“I have a statistical model where I account for all of those clinical indications. And when we look at the cases where the clinical indications don’t appear to be there, who is more likely to end up with a cesarean delivery?”

“One thing I find is that if you just look at education alone, with rising education, there are more cesareans, which would suggest that it is the more affluent women who are being overtreated,” Roth said.

“But that is because they are older and maternal age is correlated with cesarean delivery. Once you take that into account, you see that education is actually associated with a much lower probability of having a cesarean.”

A woman who is the same age but has less education is actually more likely to have a cesarean delivery, she said.

“There is that confounding effect that if you look at education alone, without accounting for all those other factors, you might think the ‘too-posh-to-push’ story might be correct. But once you look at everything together, you see that it is not. In fact, it’s the opposite. The ‘posh’ women are more likely to avoid the cesarean.

From a public policy standpoint, Roth said the rising number of cesarean deliveries significantly contributes to the high cost of health care, as well as increasing the risks for women in subsequent pregnancies. Insurance companies and Medicade plans pay more for cesarean deliveries. Hospitals are able to charge more for them.

One goal of her research is dispelling the myth that cesarean deliveries have increased are because women are choosing to have them.

“The most recent data, the last two years suggest that the increase is close to a third, so it is very high, and higher than would be clinically recommended. There also are things that suggest that practice patterns are the cause of this, not the choices that women make,” Roth said.

“In a larger way, there hasn’t been that much attention paid on the beginning of life and the unnecessary costs that are incurred at the beginning of life through these practice patterns.

“There is some discussion of end-of-life care, but not that much on maternity care and how the maternity care system could be made more cost-effective and lead to public health improvements. These things have implications, especially in subsequent pregnancies.”

Contact Info
Louise Roth
UA Department of Sociology
520-621-3531
lroth@email.arizona.edu

Placenta problems in VBAMC/ after multiple repeat cesareans

I thought that I would take the data from the Silver (2006) that I’ve previously discussed and share it in a different way that would be helpful to women with multiple prior cesareans.  (You might find it worthwhile to read this article specifically, where you can view the data below in graphs, as well as other articles on placental abnormalities first.)  Remember that accreta is when the placenta abnormality deeply attaches into the uterus requiring surgical removal.  There is a 7% maternal mortality rate with accreta as well as a high rate of hemorrhage and hysterectomy.   One of the factors that determines your risk of accreta or previa is your number of prior cesareans.

Whether a mom has a repeat cesarean or a VBA1C, her risk of accreta (including increta and percreta) and previa in that pregnancy are:

risk of accreta: 0.31% (1 in 323)
risk of previa: 1.3% (1 in 77)
risk of accreta if previa is present: 11% (1 in 9)

Whether a mom plans a third cesarean or a VBA2C, her risk of accreta and previa in that pregnancy are:<

risk of accreta: 0.57% (1 in 175)
risk of previa: 1.14% (1 in 88)
risk of accreta if previa is present: 40% (1 in 2.5)

If a mom plans a fourth cesarean or a VBA3C, the risk during that pregnancy increases to:

risk of accreta: 2.13% (1 in 47)
risk of previa: 2.27% (1 in 44)
risk of accreta if previa is present: 61% (1 in 1.6)

The jump in risk from two prior cesareans to three prior cesareans is pretty huge…

If mom plans a fifth cesarean or a VBA4C, the risk during that pregnancy increases to:

risk of accreta: 2.33% (1 in 43)
risk of previa: 2.3% (1 in 43)
risk of accreta if previa is present: 67% (1 in 1.5)

If mom plans a sixth cesarean or a VBA5c, the risk during that pregnancy increases to:

risk of accreta: 6.74% (1 in 15)
risk of previa: 3.4% (1 in 29)
risk of accreta if previa is present: 67% (1 in 1.5)

Here are some stats to consider:

Silver (2006) found the following rates of accreta (including increta and percreta), during the first, second, third, fourth, fifth, and sixth cesareans: 0.24%, 0.31%, 0.57%, 2.13%, 2.33%, 6.74%.  (View a graph of this data.)

In other words, your risk of placenta accreta increases from first to sixth cesarean delivery:
1 in 417,
1 in 323,
1 in 175,
1 in 47,
1 in 43,
1 in 15.

Read more about accreta.

The studies that have been conducted (that I’m aware of) on uterine rupture in VBAMC are kind of small (including hundreds, not thousands of women).  So I don’t think we have an accurate idea of VBA3C rupture risk.  This site is a great resource.

Update:  When I posted a link to this article on Facebook, a mom left this comment:

Thank you for posting. My friend had 2 previous c-sections, and with her 3rd pregnancy had the bad luck of having both placenta accreta and placenta previa (both risks of repeat c-section). Her pregnancy was awful..lots of bleeding, hospitalizations, steriods and other drugs to help hold onto the pregnancy and bedrest at 20 weeks. They couldn’t do cerclage because of the placenta previa). In the end she had a healthy baby, but a 5 hour c-section surgery where she lost a lot of blood and needed a blood transfusion of 6 units of blood. She had to have a hysterectomy and also they removed part of her bladder because her placenta had embedded so far it was attached to her bladder! She was pissed that her doctor never warned her of the risks of repeat c-sections. She is 39 years old.

[and]

yes, you can share my comment. again, my friend ultimately is ok bec she was planning on having her tubes tied after this 3rd unplanned pregnancy — but she was upset initially bec her OB never shared with her any of these risks of repeat c-section…and she said “had I known, I would have really pushed for a vbac with #2”

These are the complication rates that Silver 2006 found in 30,000
women during multiple cesareans.The rates quoted were what he found during the third CS but, I think
the accreta and previa rates illustrate the risks that are present
during a third pregnancy after two prior CS.In other words, whether a mom has a third CS or a VBA2C, her risk of
accreta and previa in that third pregnancy are:

risk of accreta: 0.57% (1 in 175)
risk of previa: 1.14% (1 in 88)
risk of accreta *if* previa is present: 40% (1 in 2.5)

If she has a third CS and becomes pregnant again, the risk during that
fourth pregnancy increases to:

risk of accreta: 2.13% (1 in 47)
risk of previa: 2.27% (1 in 44)
risk of accreta *if* previa is present: 61% (1 in 1.6)

Compare that to the risks in a first pregnancy:

risk of accreta: 0.24% (1 in 417)
risk of previa: 6.4% (1 in 16) [yes, that figure is correct, previa was the reason for many of these women’s primary CS]
risk of accreta *if* previa is present: 3% (1 in 33)

That means the risk of accreta increases 887% from the first pregnancy – a huge jump.

So, if it was me, getting that ultrasound and knowing I didn’t have these complications would give me huge peace of mind.

Just kicking the can of risk down the road

This is why cesareans should not be casual or performed for the convenience of anyone.  They should be reserved for real medical reasons so that the benefits of having the cesarean outweigh the risks.  And there are real risks to cesareans, but since the ones list below are future risks, they may seem less real.  Per a November 2011 study published in the Journal of Maternal-Fetal and Neonatal Medicine:

If primary and secondary cesarean rates continue to rise as they have in recent years, by 2020 the cesarean delivery rate will be 56.2%, and there will be an additional 6236 placenta previas, 4504 placenta accretas, and 130 maternal deaths annually. The rise in these complications will lag behind the rise in cesareans by approximately 6 years.

Placenta previa and accreta are nothing to mess around with.  Accreta in particular has a very high maternal mortality rate and many mothers end up having cesarean hysterectomies.   I write more about accreta here.

Many women do not think these complications are applicable to them as they don’t plan on more children after their two cesareans.  But I know many women, and I’m sure you do too, who were not planning on more children, but got pregnant nonetheless.  Unless you or your partner get sterilized or practice abstinence (what fun!), the chance of you getting pregnant is there.

By performing routine scheduled repeat cesareans, we do reduce the risk of uterine rupture in the current pregnancy, but we are also increasing the risks of accreta, previa, maternal death as well as uterine rupture in future pregnancies.  In addition, another large study found

[t]he risks of placenta accreta, cystotomy [surgical incision of the urinary bladder], bowel injury, ureteral [ureters are muscular ducts that propel urine from the kidneys to the urinary bladder] injury, and ileus [disruption of the normal propulsive gastrointestinal motor activity], the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries.

And this is especially relevant in rural hospitals which institute VBAC bans because they don’t offer 24/7 anesthesia.  Even though the “immediately available” clause was removed in the latest (2010) ACOG VBAC Practice Bulletin, many of these bans still stand.

However, in order to rapidly respond to the potentially sudden diagnosis of accreta, previa, or abruption, the hospital will have to enact many of the same ideas provided at the 2010 NIH VBAC Conference on how a hospital without 24/7 anesthesia can safely offer VBAC and respond to uterine rupture.  So why not just institute those ideas from the get-go and offer VBAC to those who want it?  (I know, I know: medico-legal reasons, which the NIH also addressed, but that is another post.)  From VBAC Ban Rationale is Irrational:

 As David J. Birnbach, M.D., M.P.H (2010), who presented on the impact of anesthesiologists on the incidence of VBAC [at the 2010 NIH VBAC Conference] asserted:

Lack of immediate available of anesthesia may not always be a key factor in outcome [during a uterine rupture], especially in cases where the obstetrician is not present. Many cases of uterine rupture can be stabilized while the anesthesiologists becomes available, and examples have been suggested of ways to reduce the risk associated with such a crisis. These include antepartum [prenatal] consultation of VBAC patients with the anesthesia departments, development of cesarean delivery under local anesthesia protocols, finding methods of improving communication on labor and delivery suites, practice “fire-drills,” and development of protocols matching resources to risk.

I urge you to watch Dr. Birnbach’s presentation along with all the presentations from the 2010 NIH VBAC conference.

Read more about the how the risk of serious complications increase with each cesarean surgery.

Below is Silver’s (2006) study abstract:

J Matern Fetal Neonatal Med. 2011 Nov;24(11):1341-6. Epub 2011 Mar 7.

The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality.

Solheim KN, Esakoff TF, Little SE, Cheng YW, Sparks TN, Caughey AB. Source Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA. Abstract

OBJECTIVE: The overall annual incidence rate of caesarean delivery in the United States has been steadily rising since 1996, reaching 32.9% in 2009. Primary cesareans often lead to repeat cesareans, which may lead to placenta previa and placenta accreta. This study’s goal was to forecast the effect of rising primary and secondary cesarean rates on annual incidence of placenta previa, placenta accreta, and maternal mortality.

METHODS: A decision-analytic model was built using TreeAge Pro software to estimate the future annual incidence of placenta previa, placenta accreta, and maternal mortality using data on national birthing order trends and cesarean and vaginal birth after cesarean rates. Baseline assumptions were derived from the literature, including the likelihood of previa and accreta among women with multiple previous cesarean deliveries.

RESULTS: If primary and secondary cesarean rates continue to rise as they have in recent years, by 2020 the cesarean delivery rate will be 56.2%, and there will be an additional 6236 placenta previas, 4504 placenta accretas, and 130 maternal deaths annually. The rise in these complications will lag behind the rise in cesareans by approximately 6 years.

CONCLUSIONS: If cesarean rates continue to increase, the annual incidence of placenta previa, placenta accreta, and maternal death will also rise substantially.

http://www.ncbi.nlm.nih.gov/pubmed/21381881

Study: Two-Thirds of OB-GYN Clinical Guidelines Have No Basis in Science

PushNews from The Big Push for Midwives Campaign
CONTACT: Katherine Prown, (414) 550-8025, katie@pushformidwives.org
FOR IMMEDIATE RELEASE: August 15, 2011
Study: Two-Thirds of OB-GYN Clinical Guidelines Have No Basis in Science
Majority of ACOG Recommendations for Patient Care Found to Be Based on Opinion and Inconsistent Evidence
WASHINGTON, D.C. (August 15, 2011)—A study published this month in Obstetrics & Gynecology, the journal of the American College of Obstetricians and Gynecologists, found that barely one-third of the organization’s clinical guidelines for OB/GYN practice meet the Level A standard of “good and consistent scientific evidence.” The authors of the study found instead that the majority of ACOG recommendations for patient care rank at Levels B and C, based on research that relies on “limited or inconsistent evidence” and on “expert opinion,” both of which are known to be inadequate predictors of safety or efficacy.

“The fact that so few of the guidelines that govern routine OB/GYN care in this country are supported by solid scientific evidence—and worse, are far more likely to be based on anecdote and opinion—is a sobering reminder that our maternity care system is in urgent need of reform,” said Katherine Prown, PhD, Campaign Manager of The Big Push for Midwives. “As the authors of the study remind us, guidelines are only as good as the evidence that supports them.”

ACOG Practice Bulletin No. 22 on the management of fetal macrosomia—infants weighing roughly 8 ½ lbs or more at birth—illustrates the possible risks to mothers and babies of relying on unscientific clinical guidelines. The only Level A evidence-based recommendation on the delivery of large-sized babies the Bulletin makes is to caution providers that the methods for detection are imprecise and unreliable. Yet at the same time, the Bulletin makes a Level C opinion-based recommendation that, despite the lack of a reliable diagnosis, women with “suspected” large babies should be offered potentially unnecessary cesarean sections as a precaution, putting mothers at risk of surgical complications and babies at risk of being born too early.

“It’s no wonder that the cesarean rate is going through the roof and women are seeking alternatives to hospital-based OB/GYN care in unprecedented numbers,” said Susan M. Jenkins, Legal Counsel of The Big Push for Midwives. “ACOG’s very own recommendations give its members permission to follow opinion-based practice guidelines that have far more to do with avoiding litigation than with adhering to scientific, evidence-based principles about what’s best for mothers and babies.”

The Big Push for Midwives Campaign represents tens of thousands of grassroots advocates in the United States who support expanding access to Certified Professional Midwives and out-of-hospital maternity care. The mission of The Big Push for Midwives is to educate state and national policymakers and the general public about the reduced costs and improved outcomes associated with out-of-hospital maternity care and to advocate for expanding access to the services of Certified Professional Midwives, who are specially trained to provide it.

Media inquiries: Katherine Prown (414) 550-8025, katie@pushformidwives.org

Shows the rates of placenta accreta in up to six cesareans (Silver 2006).

Risk of serious complications increase with each cesarean surgery

Yesterday I shared a Canadian article, and last year a letter from two OBs opposing a hospital VBAC ban, which discuss the risks of cesarean sections including placenta accreta and hysterectomy.

Definitions

Today I want to share a study that measured the increasing risks that come with multiple cesareans, but before I do so, lets do a quick review of definitions.

Placenta accreta (March of Dimes 2005):

In a normal pregnancy, the placenta attaches itself to the uterine wall, away from the cervix.

  • Placenta accreta is a placenta that attaches itself too deeply and too firmly into the wall of the uterus.
  • Placenta increta is a placenta that attaches itself even more deeply into the uterine wall.
  • Placenta percreta is a placenta that attaches itself through the uterus, sometimes extending to nearby organs, such as the bladder.

Hysterectomy (Women’s Health 2009):

A hysterectomy (his-tur-EK-tuh-mee) is a surgery to remove a woman’s uterus or womb. The uterus is where a baby grows when a woman is pregnant. The whole uterus or just part of it may be removed. After a hysterectomy, you no longer have menstrual periods and cannot become pregnant.

Placenta previa (PubMedHealth 2011):

Placenta previa is a complication of pregnancy in which the placenta grows in the lowest part of the womb (uterus) and covers all or part of the opening to the cervix.

There are different forms of placenta previa:

  • Marginal: The placenta is next to cervix but does not cover the opening.
  • Partial: The placenta covers part of the cervical opening.
  • Complete: The placenta covers all of the cervical opening.

Increasing risks with multiple cesareans: Focusing on accreta

Today’s study is Maternal morbidity associated with multiple repeat cesarean deliveries (Silver 2006) which included over 30,000 women undergoing up to six cesareans over four years.  (Download the full text PDF.)  Silver measured the complication rates per cesarean number.  And their findings are important to every mom pregnant after a cesarean.  Keep in mind that all the cesareans included in the Silver (2006) study were schedule and performed without medical indication except for the first cesarean.  All the complications noted were a direct result of the surgery, not of any other medical complication.

Silver (2006) found:

The risks of placenta accreta, cystotomy [surgical incision of the urinary bladder], bowel injury, ureteral [ureters are muscular ducts that propel urine from the kidneys to the urinary bladder] injury, and ileus [disruption of the normal propulsive gastrointestinal motor activity], the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries.

Accreta was defined as the “placenta being adherent to the uterine wall without easy separation [and] included placenta accreta, increta, and percreta.”

Below are some slides from the VBAC Class I developed and teach illustrating the  rates of placenta accreta, previa, previa with accreta, and hysterectomy by number of cesareans (Silver 2006).   The number below the cesarean number indicate how many women were included in that category.

Remember as you look these over, the risk of uterine rupture in a spontaneous labor after one prior low horizontal (“bikini-cut”) cesarean is 0.4% (Landon 2004).  Risk of uterine rupture during one’s second cesarean is 0.9% (Landon 2006).

Shows the rates of placenta accreta in up to six cesareans (Silver 2006).

 Shows the rate of placenta previa by cesarean number (Silver 2006).

Accreta, previa, and cesarean hysterectomies

I was especially interested to see the relationship between previa and accreta.  Silver (2006) found that if you have previa, you are very likely to have accreta and that risk increases with each cesarean.  For example, if a woman has one cesarean and is diagnosed with previa in her next pregnancy, her risk of having accreta is 11%.  That risk jumps to 40% in the third pregnancy, 61% in the fourth pregnancy and 67% for the fifth and sixth pregnancy.

Shows the rate of placenta previa with accreta per Silver 2006.

Complications associated with accreta

Accreta is nothing to mess around with as it has a very high rate of maternal mortality (up to 7%) and morbidity including hemorrhage and hysterectomy.  Fang (2006) asserted, “abnormal adherent placentation [is] the primary indication leading to emergent peripartum hysterectomy…. As the number of prior cesarean deliveries rises, the risk of cesarean hysterectomy increases dramatically.”   In other words, all these primary cesareans and repeat cesareans are causing placentas to abnormally implant in subsequent pregnancies.  As a result, many women who have placenta accreta end up having hysterectomies as that is the best way to control the hemorrhaging that results from accreta.

Rate of hysterectomy by cesarean number (Silver 2006).

Women who had accreta also experienced the following complications:

  • 15.4% (1 in 6.5): surgical injury to bladder
  • 2.1%  (1 in 48): surgical injury to the ureters which are the tubes that connect the kidneys to the bladder and is the “most serious complication of gynecologic surgery
  • 2.1%  (1 in 48 ): blockage of an artery in the lungs (pulmonary embolism)
  • 14% (1 in 7):  mom was put on a mechanical ventilator because she couldn’t breathe effectively
  • 26.6% (1 in 3.8): mom requires advanced monitoring and care so she is admitted to the intensive care unit
  • 5.6% (1 in 17.8): mom requires another operation
  • 3.5% (1 in 28.6): endometritis, “an inflammation or irritation of the lining of the uterus”

Because the risks of cesarean are so great, Silver (2006) concluded with the following statement,

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.

Alternatives to cesarean hysterectomy

Non-hysterectomy options were discussed in a February 2006 Healthline article by Alison Stuebe, Department of Maternal-Fetal Medicine, Brigham and Women’s Hospital, Boston, MA:

In the majority of cases, hysterectomy is the most effective way to manage the potentially fatal consequences of placenta accreta. Unfortunately, however, most cases of placenta accreta are not discovered until the last minute. And, because a hysterectomy results in infertility, some women may want to consider more conservative options.

Conservative or alternate techniques for treating placenta accreta include:

  • curettage (scraping) of the uterus;
  • surgical repair of the part of the uterus where the placenta was attached;
  • clamping the blood vessels that nourish the pelvis (to control the bleeding); and
  • using x-ray guidance to inject gelatin sponge particles or spring coils into the blood vessels that nourish the uterus (this procedure usually is not feasible in emergency situations.) This procedure requires help from interventional radiologists, doctors who specialize in advanced treatments for bleeding.

Reported success rates of these procedures vary widely. In one recent study, 31 cases of placenta accreta were managed without hysterectomy; there were no reports of infertility or maternal death.

Using ultrasound and MRI to diagnose accreta

All the statistics I have shared above are from hospital based studies where women have access to operating rooms, surgeons, and blood products.  I suspect that the likelihood of a mother dying from hemorrhage due to placenta accreta is significantly higher in an OOH (out-of-hospital) birth.  This is why I think it is completely reasonable to have an ultrasound or MRI to try to diagnose accreta when planning a OOH birth.

Although second and third trimester bleeding can be a symptom for previa, I was surprised to read on the University of Maryland Medical Center’s website, “About 7% to 30% of women with placenta previa do not experience vaginal bleeding as a symptom before delivery.”   Thus one cannot rely on bleeding during pregnancy as a reliable symptom for previa which is why ruling it out via ultrasound appears to be a effective plan. (No citation was given, so if anyone has information to affirm or refute this stat, please leave a comment.)

There appears to be some controversy about the ability to accurately diagnose accreta during pregnancy.  According to a 2011 Medscape article byDr. Robert Resnik, “the diagnosis [of placenta accreta] can be made with accuracy, by very specific ultrasound findings, about 80% of the time, and can be confirmed with MRI findings.”

However, in a 2010 article published in the Journal Watch Women’s Health, Andrew M. Kaunitz, MD states, “If ultrasound findings [while looking for accreta] are not definitive, MRI evaluation is appropriate.  Unfortunately, the diagnostic precision of these two imaging modalities for placenta accreta can be suboptimal.”

I also highly recommend you read Dwyer (2008) which provides an excellent overview and compared the accuracy of the two methods:

Sonography correctly identified the presence of placenta accreta in 14 of 15 patients (93% sensitivity) and the absence of placenta accreta in 12 of 17 patients (71% specificity). Magnetic resonance imaging correctly identified the presence of placenta accreta in 12 of 15 patients (80% sensitivity) and the absence of placenta accreta in 11 of 17 patients (65% specificity). In 7 of 32 cases, sonography and MRI had discordant diagnoses: sonography was correct in 5 cases, and MRI was correct in 2.

Because of this high rate of maternal mortality and morbidity, some doctors suggest if accreta is diagnosed via ultrasound and/or magnetic resonance imaging (MRI) during pregnancy, a cesarean hysterectomy should to performed as early as 34 – 35 weeks.  (Read Does Antenatal Diagnosis of Placenta Accreta Improve Maternal Outcomes?, The maternal outcome in placenta accreta: the significance of antenatal diagnosis and non-separation of placenta at delivery and Placenta accreta: A dreaded and increasing complication for more information on early delivery via cesarean section.)

What difference does it make if you know you have accreta before delivery?

Because accreta has a high maternal mortality and morbidity rate, a hospital plans for a birth with accreta (usually a cesarean if diagnosed before labor) very differently than a birth (cesarean or vaginal) without known accreta.

One night during my endless random reading, I stumbled across the Royal College of Obstetricians and Gynaecologists’ (the UK’s ACOG) clinical guidelines for placenta praevia, placenta praevia accreta and vasa praevia.  (Note that the Brits do spell previa/praevia differently than Americans.)  This document included a detailed description of how they recommend a hospital plan for a cesarean birth due to placenta accreta:

The six elements considered to be reflective of good care were:
1. consultant obstetrician planned and directly supervising delivery
2. consultant anaesthetist planned and directly supervising anaesthetic at delivery
3. blood and blood products available
4. multidisciplinary involvement in pre-op planning
5. discussion and consent includes possible interventions (such as hysterectomy, leaving the placenta in place, cell salvage and intervention radiology)
6. local availability of a level 2 critical care bed.

Taking this extensive preparation into account, I suspect that women fare better when accreta is diagnosed before delivery.

Evidence to suggest previa less likely to “move” in VBAC/VBAMC moms

RCOG’s clinical guidelines also included evidence that of women who were diagnosed with previa early in their pregnancy, women with a prior cesarean where less likely than an unscarred mom to have their placenta “move” enough to permit a vaginal delivery at term (50% vs. 11%).  Since the study in question included over 700 women with previa, this is a large enough study to give us good evidence.

Women with a previous caesarean section require a higher index of suspicion as there are two problems to exclude: placenta praevia and placenta accreta.  If the placenta lies anteriorly and reaches the cervical os at 20 weeks, a follow-up scan can help identify if it is implanted into the caesarean section scar.

Placental ‘apparent’ migration, owing to the development of the lower uterine segment, occurs during the second and third trimesters,52–54 but is less likely to occur if the placenta is posterior55 or if there has been a previous caesarean section.35  In one study, only five of 55 women with a placenta reaching or overlapping the cervical os at 18–23 weeks of gestation (diagnosed by TVS) had placenta praevia at birth and in all cases the edge of the placenta had overlapped 15 mm over the os at 20 weeks of gestation.56  A previous caesarean section influences this: a large retrospective review of 714 women with placenta praevia found that even with a partial ‘praevia’ at 20–23 weeks (i.e. the edge of the placenta reached the internal cervical os), the chance of persistence of the placenta praevia requiring abdominal delivery was 50% in women with a previous caesarean section compared with 11% in those with no uterine scar.53

Conversely, although significant migration to allow vaginal delivery is unlikely if the placenta substantially overlaps the internal os (by over 23 mm at 11–14 weeks of gestation in one study,54 by over 25 mm at 20–23 weeks of gestation in another52 and by over 20 mm at 26 weeks of gestation in a third study57), such migration is still possible and therefore follow-up scanning should be arranged.

I looked up source 53 and it’s Dashe (2002) which shared:  “The outcome of the study was persistent placenta previa resulting in cesarean delivery.  This diagnosis was based on clinical assessment and ultrasound at time of delivery.”  You can read Dashe in its entirety by clicking on this link and then looking for the “Article as PDF” link on the right hand side.

Considering your future fertility

Many women who don’t plan on having more children do not think these complications are applicable.  But I know many women, and I’m sure you do too, who were not planning on more children, but got pregnant nonetheless.  This is consistent with the CDC’s findings that 49% of pregnancies are unintentional.  Unless you or your partner get sterilized or practice abstinence (what fun!), the chance of you getting pregnant, and experiencing these downstream risks, are there.  It’s important when evaluating your current birth options to consider how that decision will impact the risks of your future pregnancies as well as your future delivery options.

Last updated 9/13/12.

Hospital’s Oxytocin Protocol Change Sharply Reduces Emergency C-Section Deliveries

This article published June 19, 2009 demonstrates one hospital’s experience when they changed their oxytocin (Pitocin) protocol.

I’ve included the entire article below and have emphasized what I consider to be the most interesting parts.

Hospital’s Oxytocin Protocol Change Sharply Reduces Emergency C-Section Deliveries
By Betsy Bates
Elsevier Global Medical News
Conferences in Depth

CHICAGO (EGMN) – The modification of the oxytocin infusion protocol at a large university-affiliated community hospital nearly halved the number of emergency cesarean deliveries over a 3-year period, reported Dr. Gary Ventolini.

As oxytocin utilization declined from 93.3% to 78.9%, emergency cesarean deliveries decreased from 10.9% to 5.7%, Dr. Ventolini said at the annual meeting of the American College of Obstetricians and Gynecologists.

Other birth outcomes improved as well at an 848-bed community hospital that serves as the primary teaching hospital of the Boonshoft School of Medicine at Wright State University in Dayton, Ohio.

These included significant declines in emergency vacuum and forceps deliveries and a sharp reduction in neonatal ICU team mobilization for signs of fetal distress (P = .0001 in year 3 compared with year 1).

“More and more data are showing us that we are using too much oxytocin too often,” Dr. Ventolini, professor and chair of obstetrics and gynecology at the university, said in an interview.

“Our pivotal change was to modify the oxytocin infusion from 2 by 2 units every 20 minutes to 1 by 1 unit every 30 minutes. And we see the results,” he said.

Outcomes of 14,184 births from 2005, 2006, and 2007 were retrospectively analyzed to determine any impact of the change in an oxytocin protocol implemented in 2005. Patient characteristics were similar in all three calendar years.

The most profound changes were in emergency deliveries, including caesarean deliveries, vacuum deliveries (which dropped from 9.1% to 8.5%), and forceps deliveries (which fell from 4% to 2.3%).

The overall cesarean section rate remained unchanged, as did the rates of cord prolapse, preeclampsia, and abruption.

Dr. Ventolini cited a recent article in the American Journal of Obstetrics and Gynecology that suggests guidelines for oxytocin use, including avoidance of dose increases at intervals shorter than 30 minutes in most situations (Am. J. Obstet. Gynecol. 2009;200:35.e1-.e6).

Dr. Ventolini and his associates reported no financial conflicts of interest relevant to the study.

Subject Codes:
womans_health;
Elsevier Global Medical News
http://www.imng.com

June 19, 2009   10:04 AM EDT

VBAC & Cesarean Rates of California Hospitals, 2007

This information is so important for any woman seeking VBAC.  It’s not enough that your hospital “allows” VBAC.  In order to see how supportive that hospital is of vaginal birth, you need to know what their VBAC rate is in addition to their primary CS rate.  Be sure to read, “Why if your hospital ‘allows’ VBAC isn’t enough” for more information as well as I’m pregnant and want a VBAC, what do I do?.

From 2006 to 2007, the total cesarean rate increased from 27.9% to 28.8% and the primary cesarean rate grew from 16.6% to 17.1 whereas the overall VBAC rate decreased from 8.9% to 8.1%.

You can also read excerpts from a January 2008 press release from the California Office of Statewide Health Planning and Development (OSHPD) where they categorize cesarean section and primary cesarean section as “POSSIBLE OVER UTILIZATION” and VBAC as “POSSIBLE UNDER UTILIZATION” here.  On that same page, OSHPD further describes how they categorized cesareans vs. VBACs:

  • Cesarean Delivery Rate
    Number of Cesarean Section Deliveries per 100 Deliveries (excludes abnormal presentation, preterm birth, fetal death, multiple gestations, and breech procedure). Cesarean delivery may be overused in some facilities, so lower rates may represent better care.
  • Cesarean Delivery Rate – Primary
    Number of Cesarean Deliveries per 100 deliveries among women who have not previously had a Cesarean section (excludes abnormal presentation, preterm, fetal death, multiple gestation, and breech procedures). Cesarean delivery may be overused in some facilities, so lower rates may represent better care.
  • Vaginal Birth After Cesarean (VBAC) Rate
    Number of vaginal births per 100 women with a previous Cesarean delivery. VBAC may be underused in some facilities, so higher rates may represent better care, though this rate includes some women who were probably not good candidates for vaginal birth.
  • Vaginal Birth After Cesarean (VBAC) Rate, Uncomplicated
    Number of vaginal births per 100 women with a previous Cesarean delivery (excludes abnormal presentation, preterm birth, fetal death, multiple gestation, and breech procedures). VBAC may be underused in some facilities, so higher rates may represent better care.

Below, I will use the VBAC Rate which includes all VBACs performed at that hospital.

Top 5 California Hospitals: VBACs Performed 2007

  1. Santa Clara Valley Medical Center – 289
  2. Alta Bates Summit Medical Center – Alta Bates Campus – 227
  3. California Hospital Medical Center – Los Angeles – 160
  4. Kaiser Fnd Hosp – South Sacramento – 133
  5. Sutter Memorial Hospital – 123

Top 5 California Hospitals: VBAC Rate 2007

  1. San Francisco General Hospital – 33.0% (53 VBACs)
  2. Kaiser Fnd Hosp – Redwood City – 32.1% (42 VBACs)
  3. Kaiser Fnd Hosp – South Sacramento – 31.7% (133 VBACs)
  4. Santa Clara Valley Medical Center  – 31.3% (289 VBACs)
  5. Seton Medical Center – 28.8% (20 VBACs)

Top 5 Hospitals: Primary Cesareans Performed 2007

  1. Sharp Mary Birch Hospital For Women – 1338 (22.2%)
  2. Cedars Sinai Medical Center – 1,231 (21.0%)
  3. Citrus Valley Medical Center – Qv Campus – 1,173 (30.7%)
  4. St. Francis Medical Center – 1,054 (21.8%)
  5. Pomona Valley Hospital Medical Center – 1,003 (17.7%)

Top 5 Hospitals: Overall Cesareans Performed 2007

  1. Sharp Mary Birch Hospital For Women – 2,469 (33.4%)
  2. Pomona Valley Hospital Medical Center – 2,318 (34.0%)
  3. Citrus Valley Medical Center – Qv Campus – 2,178 (46.4%)
  4. St. Francis Medical Center – 2,114 (37.1%)
  5. Cedars Sinai Medical Center – 1,968 (27.9%)

Top 6 Hospitals: Overall Cesarean Rate 2007

  1. Stanford Hospital – 89.1% (4 CS)
  2. Los Angeles Community Hospital-62.2% (341 CS)
  3. East Valley Hospital Medical Center – 58.3% (204 CS)
  4. Community And Mission Hsp Of Hntg Park – Slauson – 51.8% (735 CS)
  5. El Centro Regional Medical Center – 48.2% (641 CS)
  6. Pacifica Hospital Of The Valley – 48.0% (453 CS)

Inland Empire Hospitals – VBAC vs. Primary CS Rates

  1. Loma Linda University Medical Center – 15.8% vs. 16.2%
  2. Kaiser Fnd Hosp – Riverside – 15.7% vs. 16.2%
  3. Kaiser Fnd Hosp – Fontana – 13.5% vs. 12.4%
  4. Riverside County Regional Medical Center – 7.3% vs. 9.9%
  5. St. Bernardine Medical Center – 5.9% vs. 10.8%
  6. Pomona Valley Hospital Medical Center – 4.2% vs.  17.7%
  7. St. Mary Regional Medical Center – 2.2% vs. 9.1%
  8. Hi-Desert Medical Center – 1.4% vs. 23.6%
  9. Redlands Community Hospital – 1.4% vs. 15.3%
  10. Parkview Community Hospital Medical Center – 1.3% vs. 20.2%
  11. Corona Regional Medical Center – Main – 1.0% vs. 16.4%
  12. Community Hospital Of San Bernardino – 0.8% vs. 28.6%
  13. Montclair Hospital Medical Center – 0.6% vs. 27.2%
  14. San Antonio Community Hospital – 0.5% vs. 25.3%
  15. Hemet Valley Medical Center – 0.4% vs. 31.4%
  16. Riverside Community Hospital – 0.2% vs. 19.0%
  17. Mountains Community Hospital – 0.0% vs. 16.4%
  18. Eisenhower Memorial Hospital – No births reported
    Chino Valley Medical Center – No births reported
    Kindred Hospital Ontario – No births reported

Hospitals with VBAC Bans?  All these hospitals had 5 or fewer VBACs in 2007.  I wonder if it is because they have banned them.  There are 257 hospitals that reported births and the 109 listed below represents 42.4% of them (up from 39% in 2006).  I guess they should read this and this.

  1. Anaheim General Hospital
  2. Banner Lassen Medical Center
  3. Barstow Community Hospital
  4. Barton Memorial Hospital
  5. Bellflower Medical Center
  6. Beverly Hospital
  7. Central Valley General Hospital
  8. Coalinga Regional Medical Center
  9. Coastal Communities Hospital
  10. Colusa Regional Medical Center
  11. Community Hospital Monterey Peninsula
  12. Community Hospital Of San Bernardino
  13. Corona Regional Medical Center – Main
  14. Delano Regional Medical Center
  15. Desert Valley Hospital
  16. Doctors Hospital Of Manteca
  17. East Los Angeles Doctors Hospital
  18. East Valley Hospital Medical Center
  19. Eden Medical Center
  20. El Centro Regional Medical Center
  21. Fairchild Medical Center
  22. Feather River Hospital
  23. Foothill Presbyterian Hospital-Johnston Memorial
  24. French Hospital Medical Center
  25. George L Mee Memorial Hospital
  26. Goleta Valley Cottage Hospital
  27. Greater El Monte Community Hospital
  28. Hazel Hawkins Memorial Hospital
  29. Hemet Valley Medical Center
  30. Henry Mayo Newhall Memorial Hospital
  31. Hi-Desert Medical Center
  32. John F Kennedy Memorial Hospital
  33. La Palma Intercommunity Hospital
  34. Little Company Of Mary – San Pedro Hospital
  35. Lodi Memorial Hospital
  36. Lompoc Healthcare District
  37. Los Angeles Community Hospital
  38. Los Angeles Metropolitan Med Ctr
  39. Mammoth Hospital
  40. Marshall Medical Center (1-Rh)
  41. Los Angeles Co Martin Luther King Jr/Drew Med Ctr
  42. Mayers Memorial Hospital
  43. Memorial Hospital Los Banos
  44. Memorial Hospital Medical Center – Modesto
  45. Memorial Hospital Of Gardena
  46. Mendocino Coast District Hospital
  47. Mercy Medical Center
  48. Mercy Medical Center Mt. Shasta
  49. Modoc Medical Center
  50. Montclair Hospital Medical Center
  51. Monterey Park Hospital
  52. Moreno Valley Community Hospital
  53. Mountains Community Hospital
  54. North Bay Medical Center
  55. Northern Inyo Hospital
  56. Oak Valley District Hospital (2-Rh)
  57. Oroville Hospital
  58. Pacific Alliance Medical Center, Inc.
  59. Pacific Hospital Of Long Beach
  60. Pacifica Hospital Of The Valley
  61. Palo Verde Hospital
  62. Paradise Valley Hospital
  63. Parkview Community Hospital Medical Center
  64. Petaluma Valley Hospital
  65. Pioneers Memorial Hospital
  66. Plumas District Hospital
  67. Pomerado Hospital
  68. Providence Holy Cross Medical Center
  69. Redbud Community Hospital
  70. Redlands Community Hospital
  71. Regional Medical Of San Jose
  72. Ridgecrest Regional Hospital
  73. Riverside Community Hospital
  74. Salinas Valley Memorial Hospital
  75. San Antonio Community Hospital
  76. San Dimas Community Hospital
  77. San Gorgonio Memorial Hospital
  78. San Ramon Regional Medical Center
  79. Santa Barbara Cottage Hospital
  80. Santa Monica – Ucla Medical Center
  81. Sierra Kings District Hospital
  82. Sierra Nevada Memorial Hospital
  83. Sierra View District Hospital
  84. Simi Valley Hospital And Health Care Svcs-Sycamore
  85. Sonoma Valley Hospital
  86. Sonora Regional Medical Center – Greenley
  87. St. Elizabeth Community Hospital
  88. St. Helena Hospital
  89. St. John’s Pleasant Valley Hospital
  90. St. John’s Regional Medical Center
  91. St. Joseph Hospital – Eureka
  92. St. Louise Regional Hospital
  93. St. Rose Hospital
  94. Stanford Hospital
  95. Sutter Amador Hospital
  96. Sutter Auburn Faith Hospital
  97. Sutter Coast Hospital
  98. Sutter Davis Hospital
  99. Sutter Medical Center Of Santa Rosa
  100. Sutter Tracy Community Hospital
  101. Tahoe Forest Hospital
  102. Tulare District Hospital
  103. Twin Cities Community Hospital
  104. Valley Memorial Hospital – Livermore
  105. Verdugo Hills Hospital
  106. Victor Valley Community Hospital
  107. Western Medical Center Hospital – Anaheim
  108. Whittier Hospital Medical Center
  109. Woodland Memorial Hospital

Utilization Rates* for Selected Medical Procedures in California Hospitals, 2007
Office of Statewide Health Planning and Development, Hospital Patient Data**
  (Here is the info as a Adobe Acrobat PDF for easy printing.)

      

  Hospital Total CS # Total CS % Primary CS # Primary CS % VBAC Uncomp # VBAC Uncomp % VBAC # VBAC %
  Statewide 140,559 28.8 70,889 17.1 6,289 8.3 7,034 8.1
Alameda ALAMEDA CO MED CTR – HIGHLAND CAMPUS 253 20.2 126 11.3 50 27.7 55 27.3
Alameda ALAMEDA HOSPITAL . . . . . . . .
Alameda ALTA BATES SUMMIT MED CTR-ALTA BATES CAMPUS 1634 22.5 814 13.2 209 20.4 227 19.2
Alameda ALTA BATES SUMMIT MED CTR-SUMMIT CAMPUS-HAWTHORNE . . . . . . . .
Alameda CHILDRENS HOSPITAL AND RESEARCH CTR AT OAKLAND . . . . . . . .
Alameda EDEN MEDICAL CENTER 231 25.2 122 15.3 0 0.0 1 0.7
Alameda KAISER FND HOSP – FREMONT . . . . . . . .
Alameda KAISER FND HOSP – HAYWARD 689 24.1 415 17.0 83 23.3 90 22.8
Alameda KAISER FND HOSP – OAKLAND CAMPUS 607 25.0 352 17.0 52 17.2 59 17.4
Alameda KINDRED HOSPITAL – SAN FRANCISCO BAY AREA . . . . . . . .
Alameda SAN LEANDRO HOSPITAL . . . . . . . .
Alameda ST. ROSE HOSPITAL 247 26.9 129 15.6 2 1.6 2 1.4
Alameda VALLEY MEMORIAL HOSPITAL – LIVERMORE 442 30.5 241 20.0 3 1.5 4 1.7
Alameda WASHINGTON HOSPITAL – FREMONT 702 24.8 351 14.8 27 7.2 34 8.2
Amador SUTTER AMADOR HOSPITAL 65 25.6 33 14.3 1 3.0 2 4.3
Butte BIGGS GRIDLEY MEMORIAL HOSPITAL . . . . . . . .
Butte ENLOE MEDICAL CENTER- ESPLANADE CAMPUS 339 24.7 183 14.9 7 4.3 7 3.9
Butte FEATHER RIVER HOSPITAL 182 25.4 98 15.0 1 1.2 2 1.9
Butte OROVILLE HOSPITAL 143 30.1 65 15.2 3 3.6 4 3.9
Calaveras MARK TWAIN ST. JOSEPH’S HOSPITAL . . . . . . . .
Colusa COLUSA REGIONAL MEDICAL CENTER 72 38.0 39 23.8 0 0.0 0 0.0
Contra Costa CONTRA COSTA REGIONAL MEDICAL CENTER 423 22.0 220 12.8 80 27.9 87 26.7
Contra Costa DOCTORS MEDICAL CENTER – SAN PABLO . . . . . . . .
Contra Costa JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS . . . . . . . .
Contra Costa JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS 624 22.7 276 12.6 56 14.2 58 13.0
Contra Costa KAISER FND HOSP – RICHMOND CAMPUS . . . . . . . .
Contra Costa KAISER FND HOSP – WALNUT CREEK 994 23.4 569 15.8 79 15.8 81 13.9
Contra Costa KAISER FOUND HSP-ANTIOCH 28 20.7 17 13.6 0 0.0 0 0.0
Contra Costa SAN RAMON REGIONAL MEDICAL CENTER 261 34.8 148 25.0 0 0.0 0 0.0
Contra Costa SUTTER DELTA MEDICAL CENTER 207 23.5 97 12.6 12 9.8 12 8.4
Del Norte SUTTER COAST HOSPITAL 62 20.4 32 11.0 0 0.0 0 0.0
El Dorado BARTON MEMORIAL HOSPITAL 140 29.8 73 18.0 1 1.5 2 2.7
El Dorado MARSHALL  MEDICAL CENTER (1-RH) 163 29.2 88 17.9 4 5.0 5 5.8
Fresno COALINGA REGIONAL MEDICAL CENTER 0 0.0 0 0.0 . 0.0 0 0.0
Fresno COMMUNITY MEDICAL CENTER – CLOVIS 975 32.9 470 19.4 34 6.3 38 6.4
Fresno COMMUNITY REGIONAL MEDICAL CENTER-FRESNO 1563 29.0 645 13.8 72 7.2 95 7.8
Fresno FRESNO HEART AND SURGICAL HOSPITAL . . . . . . . .
Fresno FRESNO SURGICAL HOSPITAL . . . . . . . .
Fresno KAISER FND HOSP – FRESNO 289 23.9 147 14.4 43 23.1 44 20.7
Fresno KINGSBURG MEDICAL CENTER . . . . . . . .
Fresno SAN JOAQUIN VALLEY REHABILITATION HOSPITAL . . . . . . . .
Fresno SIERRA KINGS DISTRICT HOSPITAL 498 36.5 229 19.9 0 0.0 0 0.0
Fresno ST. AGNES MEDICAL CENTER 1207 34.3 649 21.4 24 4.1 28 4.2
Fresno UNIVERSITY MEDICAL CENTER . . . . . . . .
Glenn GLENN MEDICAL CENTER . . . . . . . .
Humboldt JEROLD PHELPS COMMUNITY HOSPITAL . . . . . . . .
Humboldt MAD RIVER COMMUNITY HOSPITAL 118 23.1 75 16.4 13 23.0 14 22.8
Humboldt REDWOOD MEMORIAL HOSPITAL 62 22.4 22 9.1 6 12.8 6 12.8
Humboldt ST. JOSEPH HOSPITAL – EUREKA 180 31.6 97 19.4 0 0.0 0 0.0
Imperial EL CENTRO REGIONAL MEDICAL CENTER 641 48.2 340 32.4 3 1.0 3 0.9
Imperial PIONEERS MEMORIAL HOSPITAL 386 28.6 162 13.7 1 0.4 1 0.4
Inyo NORTHERN INYO HOSPITAL 55 31.6 26 17.3 0 0.0 0 0.0
Inyo SOUTHERN INYO HOSPITAL . . . . . . . .
Kern BAKERSFIELD HEART HOSPITAL . . . . . . . .
Kern BAKERSFIELD MEMORIAL HOSPITAL- 34TH STREET 501 24.1 178 9.7 29 8.1 32 8.1
Kern DELANO REGIONAL MEDICAL CENTER 215 26.2 71 10.0 1 0.7 1 0.6
Kern GOOD SAMARITAN HOSPITAL-BAKERSFIELD . . . . . . . .
Kern KERN MEDICAL CENTER 820 24.5 281 9.8 99 15.3 113 14.9
Kern KERN VALLEY HEALTHCARE DISTRICT . . . . . . . .
Kern MERCY HOSPITAL – BAKERSFIELD 754 23.2 374 13.3 80 17.1 89 16.6
Kern RIDGECREST REGIONAL HOSPITAL 180 39.3 88 22.8 3 3.1 3 2.8
Kern SAN JOAQUIN COMMUNITY HOSPITAL 497 21.9 188 9.1 29 8.5 29 8.1
Kern TEHACHAPI HOSPITAL . . . . . . . .
Kings CENTRAL VALLEY GENERAL HOSPITAL 690 37.3 309 20.0 0 0.0 1 0.2
Kings CORCORAN DISTRICT HOSPITAL . . . . . . . .
Kings HANFORD COMMUNITY MEDICAL CENTER 299 34.4 146 19.5 5 3.1 7 3.8
Lake REDBUD COMMUNITY HOSPITAL 35 23.1 9 6.7 2 6.9 2 6.9
Lake SUTTER LAKESIDE HOSPITAL 98 31.4 56 20.5 7 14.2 7 12.4
Lassen BANNER LASSEN MEDICAL CENTER 58 28.4 25 14.0 2 5.6 2 5.5
Los Angeles ALHAMBRA HOSPITAL . . . . . . . .
Los Angeles ANTELOPE VALLEY HOSPITAL 1565 31.1 750 17.2 14 1.7 19 2.1
Los Angeles BARLOW RESPIRATORY HOSPITAL . . . . . . . .
Los Angeles BELLFLOWER MEDICAL CENTER 597 39.6 322 25.2 0 0.0 1 0.3
Los Angeles BEVERLY HOSPITAL 478 36.4 226 20.3 0 0.0 0 0.0
Los Angeles BROTMAN MEDICAL CENTER . . . . . . . .
Los Angeles CALIFORNIA HOSPITAL MEDICAL CENTER – LOS ANGELES 1045 28.7 532 16.9 133 20.4 160 20.8
Los Angeles CATALINA ISLAND MEDICAL CENTER . . . . . . . .
Los Angeles CEDARS SINAI MEDICAL CENTER 1968 27.9 1231 21.0 100 12.3 112 12.3
Los Angeles CENTINELA FREEMAN REG MED CTR-MARINA CAMPUS . . . . . . . .
Los Angeles CENTINELA HOSPITAL MEDICAL CENTER 848 33.3 395 18.5 28 5.8 30 5.3
Los Angeles CENTURY CITY DOCTORS HOSPITAL . . . . . . . .
Los Angeles CHILDREN’S HOSPITAL OF LOS ANGELES . . . . . . . .
Los Angeles CITRUS VALLEY MEDICAL CENTER – IC CAMPUS . . . . . . . .
Los Angeles CITRUS VALLEY MEDICAL CENTER – QV CAMPUS 2178 46.4 1173 30.7 10 1.0 14 1.2
Los Angeles CITY OF ANGELS MEDICAL CENTER-DOWNTOWN CAMPUS . . . . . . . .
Los Angeles CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL . . . . . . . .
Los Angeles COAST PLAZA DOCTORS HOSPITAL . . . . . . . .
Los Angeles COMMUNITY AND MISSION HSP OF HNTG PK – SLAUSON 735 51.8 384 35.2 9 2.5 9 2.3
Los Angeles COMMUNITY HOSPITAL OF LONG BEACH . . . . . . . .
Los Angeles DOCTORS HOSPITAL OF WEST COVINA, INC . . . . . . . .
Los Angeles DOWNEY REGIONAL MEDICAL CENTER 344 22.6 149 11.4 27 12.1 30 11.5
Los Angeles EARL AND LORRAINE MILLER CHILDRENS HOSPITAL 1391 29.2 643 16.4 104 12.2 121 11.7
Los Angeles EAST LOS ANGELES DOCTORS HOSPITAL 318 46.4 142 26.6 1 0.6 1 0.5
Los Angeles EAST VALLEY HOSPITAL MEDICAL CENTER 204 58.3 113 42.3 0 0.0 0 0.0
Los Angeles ENCINO-TARZANA REGIONAL MED CTR-ENCINO . . . . . . . .
Los Angeles ENCINO-TARZANA REGIONAL MED CTR-TARZANA 611 29.8 326 20.1 16 5.5 17 5.3
Los Angeles FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL 278 40.6 147 27.3 1 0.8 1 0.7
Los Angeles GARFIELD MEDICAL CENTER 1226 37.0 607 23.3 13 2.1 14 1.9
Los Angeles GLENDALE ADVENTIST MEDICAL CENTER – WILSON TERRACE 760 34.6 427 23.4 23 6.4 26 6.2
Los Angeles GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER 487 30.5 224 17.0 14 5.1 14 4.5
Los Angeles GOOD SAMARITAN HOSPITAL-LOS ANGELES 1306 26.7 641 15.6 44 6.2 52 6.5
Los Angeles GREATER EL MONTE COMMUNITY HOSPITAL 171 30.9 57 12.5 0 0.0 1 0.8
Los Angeles HENRY MAYO NEWHALL MEMORIAL HOSPITAL 370 28.5 173 16.4 1 0.5 2 0.9
Los Angeles HOLLYWOOD COMMUNITY HOSPITAL OF HOLLYWOOD . . . . . . . .
Los Angeles HOLLYWOOD PRESBYTERIAN MEDICAL CENTER 1512 38.3 843 25.1 50 6.9 56 6.8
Los Angeles HUNTINGTON MEMORIAL HOSPITAL 1024 31.9 572 21.9 18 3.9 20 3.7
Los Angeles KAISER FND HOSP – BALDWIN PARK 676 22.8 329 13.3 82 19.3 89 18.7
Los Angeles KAISER FND HOSP – BELLFLOWER 703 23.5 380 14.9 110 25.4 118 23.4
Los Angeles KAISER FND HOSP – HARBOR CITY 455 25.9 239 16.4 47 18.0 49 17.2
Los Angeles KAISER FND HOSP – PANORAMA CITY 409 29.4 245 20.9 31 15.9 38 15.5
Los Angeles KAISER FND HOSP – SUNSET 673 32.1 437 24.8 41 15.0 44 14.2
Los Angeles KAISER FND HOSP – WEST LA 317 23.0 181 15.2 29 17.7 32 16.5
Los Angeles KAISER FND HOSP – WOODLAND HILLS 390 22.6 202 14.2 51 21.6 59 21.7
Los Angeles KINDRED HOSPITAL – LA MIRADA . . . . . . . .
Los Angeles KINDRED HOSPITAL – LOS ANGELES . . . . . . . .
Los Angeles LAC/RANCHO LOS AMIGOS NATIONAL REHAB CENTER . . . . . . . .
Los Angeles LAKEWOOD REGIONAL MEDICAL CENTER . . . . . . . .
Los Angeles LANCASTER COMMUNITY HOSPITAL . . . . . . . .
Los Angeles LITTLE COMPANY OF MARY – SAN PEDRO HOSPITAL 185 25.4 75 11.6 1 0.9 1 0.8
Los Angeles LITTLE COMPANY OF MARY HOSPITAL 713 28.6 441 20.6 5 1.8 6 2.0
Los Angeles LONG BEACH MEMORIAL MEDICAL CENTER . . . . . . . .
Los Angeles LOS ANGELES CO HARBOR-UCLA MEDICAL CENTER 274 28.9 158 19.1 26 18.3 29 18.0
Los Angeles LOS ANGELES CO USC MEDICAL CENTER 394 31.2 191 18.8 44 17.9 54 17.7
Los Angeles LOS ANGELES COMMUNITY HOSPITAL 341 62.2 206 48.4 2 1.4 2 1.4
Los Angeles LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER 245 28.2 97 14.3 52 25.7 57 24.0
Los Angeles LOS ANGELES METROPOLITAN MEDICAL CENTER 340 35.2 158 19.5 1 0.5 1 0.5
Los Angeles MARTIN LUTHER KING JR.-HARBOR HOSPITAL 40 31.8 20 19.0 2 9.2 4 16.9
Los Angeles MEMORIAL HOSPITAL OF GARDENA 571 41.2 275 24.3 0 0.0 0 0.0
Los Angeles METHODIST HOSPITAL OF SOUTHERN CALIFORNIA 568 26.5 307 16.9 19 6.8 24 7.2
Los Angeles MIRACLE MILE MEDICAL CENTER . . . . . . . .
Los Angeles MISSION COMMUNITY HOSPITAL – PANORAMA CAMPUS . . . . . . . .
Los Angeles MONTEREY PARK HOSPITAL 656 42.7 331 26.2 0 0.0 0 0.0
Los Angeles MOTION PICTURE AND TELEVISION HOSPITAL . . . . . . . .
Los Angeles NORTHRIDGE HOSPITAL MEDICAL CENTER 881 34.9 424 20.7 9 1.9 11 2.1
Los Angeles NORWALK COMMUNITY HOSPITAL . . . . . . . .
Los Angeles OLYMPIA MEDICAL CENTER . . . . . . . .
Los Angeles PACIFIC ALLIANCE MEDICAL CENTER, INC. 726 37.5 366 22.3 5 1.4 5 1.3
Los Angeles PACIFIC HOSPITAL OF LONG BEACH 377 33.1 105 11.4 1 0.4 1 0.3
Los Angeles PACIFICA HOSPITAL OF THE VALLEY 453 48.0 248 32.8 1 0.5 1 0.4
Los Angeles POMONA VALLEY HOSPITAL MEDICAL CENTER 2318 34.0 1003 17.7 55 4.0 64 4.2
Los Angeles PRESBYTERIAN INTERCOMMUNITY HOSPITAL 954 29.2 474 17.5 51 9.6 63 10.4
Los Angeles PROMISE HOSPITAL OF EAST LOS ANGELES-EAST L.A. CAMPUS . . . . . . . .
Los Angeles PROVIDENCE HOLY CROSS MEDICAL CENTER 825 34.6 461 22.1 1 0.3 1 0.2
Los Angeles PROVIDENCE SAINT JOSEPH MEDICAL CENTER 869 29.6 500 19.6 9 2.4 9 2.0
Los Angeles SAN DIMAS COMMUNITY HOSPITAL 188 25.3 85 13.8 1 1.0 1 0.9
Los Angeles SAN GABRIEL VALLEY MEDICAL CENTER 723 32.1 360 19.8 11 3.0 13 3.0
Los Angeles SANTA MONICA – UCLA MEDICAL CENTER & ORTHOPAEDIC HOSPIT 490 34.6 278 25.0 3 1.4 3 1.3
Los Angeles SHERMAN OAKS HOSPITAL . . . . . . . .
Los Angeles SHRINERS HOSPITAL FOR  CHILDREN – L.A. . . . . . . . .
Los Angeles ST. FRANCIS MEDICAL CENTER 2114 37.1 1054 21.8 94 8.0 111 8.2
Los Angeles ST. JOHN’S HEALTH CENTER 510 25.1 339 19.6 9 5.3 9 4.6
Los Angeles ST. MARY MEDICAL CENTER 751 28.9 393 17.1 29 7.4 31 7.2
Los Angeles ST. VINCENT MEDICAL CENTER . . . . . . . .
Los Angeles TEMPLE COMMUNITY HOSPITAL . . . . . . . .
Los Angeles TORRANCE MEMORIAL MEDICAL CENTER 1248 34.7 634 22.5 15 2.4 15 2.1
Los Angeles TRI-CITY REGIONAL MEDICAL CENTER . . . . . . . .
Los Angeles UCLA MEDICAL CENTER 415 23.9 242 16.5 60 25.9 61 23.4
Los Angeles USC KENNETH NORRIS, JR. CANCER HOSPITAL . . . . . . . .
Los Angeles USC UNIVERSITY HOSPITAL . . . . . . . .
Los Angeles VALLEY PRESBYTERIAN HOSPITAL 1887 39.6 932 23.7 26 2.6 29 2.5
Los Angeles VERDUGO HILLS HOSPITAL 305 33.8 184 25.2 0 0.0 0 0.0
Los Angeles VISTA HOSPITAL OF SAN GABRIEL VALLEY . . . . . . . .
Los Angeles VISTA HOSPITAL OF SOUTH BAY . . . . . . . .
Los Angeles WEST HILLS HOSPITAL AND MEDICAL CENTER 424 34.3 230 23.7 6 3.1 6 2.9
Los Angeles WHITE MEMORIAL MEDICAL CENTER 821 34.4 427 21.5 70 14.9 84 14.4
Los Angeles WHITTIER HOSPITAL MEDICAL CENTER 606 31.8 288 17.8 2 0.6 2 0.6
Madera CHILDREN’S HOSPITAL CENTRAL CALIFORNIA . . . . . . . .
Madera MADERA COMMUNITY HOSPITAL 464 28.3 211 14.7 20 7.3 22 6.9
Marin KAISER FND HOSP – SAN RAFAEL . . . . . . . .
Marin KENTFIELD REHABILITATION HOSPITAL . . . . . . . .
Marin MARIN GENERAL HOSPITAL 360 21.4 189 13.4 51 23.5 56 20.9
Marin NOVATO COMMUNITY HOSPITAL . . . . . . . .
Mariposa JOHN C FREMONT HEALTHCARE DISTRICT . . . . . . . .
Mendocino FRANK R HOWARD MEMORIAL HOSPITAL . . . . . . . .
Mendocino MENDOCINO COAST DISTRICT HOSPITAL 34 22.9 21 15.1 0 0.0 0 0.0
Mendocino UKIAH VALLEY MEDICAL CENTER/HOSPITAL DRIVE 172 23.1 94 14.1 19 19.5 19 17.7
Merced MEMORIAL HOSPITAL LOS BANOS 160 25.7 50 9.4 1 0.9 1 0.8
Merced MERCY MEDICAL CENTER MERCED-COMMUNITY CAMPUS 609 26.2 249 12.2 14 3.7 17 3.9
Modoc MODOC MEDICAL CENTER 0 0.0 0 0.0 0 0.0 0 0.0
Modoc SURPRISE VALLEY COMMUNITY HOSPITAL . . . . . . . .
Mono MAMMOTH HOSPITAL 38 31.6 17 17.4 0 0.0 0 0.0
Monterey COMMUNITY HOSPITAL MONTEREY PENINSULA 345 27.2 190 17.6 2 1.3 2 1.2
Monterey GEORGE L MEE MEMORIAL HOSPITAL 174 31.0 73 15.1 1 1.0 2 1.7
Monterey NATIVIDAD MEDICAL CENTER 592 29.6 223 12.9 5 1.3 7 1.6
Monterey SALINAS VALLEY MEMORIAL HOSPITAL 679 30.6 311 16.5 1 0.3 2 0.5
Napa N M HOLDERMAN MEMORIAL HOSPITAL (VET’S HOME OF CAL . . . . . . . .
Napa QUEEN OF THE VALLEY HOSPITAL – NAPA 191 21.6 88 11.3 15 12.6 19 14.4
Napa ST. HELENA HOSPITAL 81 29.3 40 17.5 0 0.0 0 0.0
Nevada SIERRA NEVADA MEMORIAL HOSPITAL 107 25.9 62 16.5 2 4.2 2 3.7
Nevada TAHOE FOREST HOSPITAL 91 18.9 51 11.7 0 0.0 1 2.1
Orange ANAHEIM GENERAL HOSPITAL 159 31.0 69 15.7 1 1.1 1 1.0
Orange ANAHEIM MEMORIAL MEDICAL CENTER 418 24.3 200 13.5 6 2.7 9 3.6
Orange CHAPMAN MEDICAL CENTER . . . . . . . .
Orange CHILDREN’S HOSPITAL AT MISSION . . . . . . . .
Orange CHILDREN’S HOSPITAL OF ORANGE COUNTY . . . . . . . .
Orange COASTAL COMMUNITIES HOSPITAL 876 41.9 438 25.8 1 0.2 1 0.2
Orange COLLEGE HOSPITAL COSTA MESA . . . . . . . .
Orange FOUNTAIN VALLEY RGNL HOSP AND MED CTR – EUCLID 896 25.2 506 16.6 34 8.1 36 7.4
Orange GARDEN GROVE HOSPITAL AND MEDICAL CENTER 855 32.8 379 17.5 19 3.8 21 3.7
Orange HOAG MEMORIAL HOSPITAL PRESBYTERIAN 1595 30.2 896 21.0 26 3.7 27 3.4
Orange HUNTINGTON BEACH HOSPITAL . . . . . . . .
Orange IRVINE REGIONAL HOSPITAL AND MEDICAL CENTER 554 29.3 278 18.5 19 6.5 19 6.2
Orange KAISER FND HOSP – ANAHEIM 709 22.1 378 14.0 93 22.1 102 21.1
Orange KINDRED HOSPITAL BREA . . . . . . . .
Orange KINDRED HOSPITAL WESTMINSTER . . . . . . . .
Orange LA PALMA INTERCOMMUNITY HOSPITAL 67 22.3 33 12.3 0 0.0 0 0.0
Orange LOS ALAMITOS MEDICAL CENTER 456 25.9 192 13.0 5 1.9 7 2.4
Orange MISSION HOSPITAL REGIONAL MEDICAL CENTER 793 28.1 421 17.7 18 4.7 23 5.2
Orange ORANGE COAST MEMORIAL MEDICAL CENTER 379 25.6 176 14.4 7 3.4 9 4.0
Orange PLACENTIA LINDA HOSPITAL . . . . . . . .
Orange SADDLEBACK MEMORIAL MEDICAL CENTER 626 23.9 299 14.3 60 15.9 67 15.3
Orange SADDLEBACK MEMORIAL MEDICAL CENTER – SAN CLEMENTE . . . . . . . .
Orange SOUTH COAST MEDICAL CENTER 189 28.4 101 18.6 10 10.3 10 9.8
Orange ST. JOSEPH HOSPITAL – ORANGE 1469 32.2 735 19.7 54 6.9 60 6.8
Orange ST. JUDE MEDICAL CENTER 523 26.3 295 17.8 30 11.8 32 11.1
Orange TUSTIN HOSPITAL MEDICAL CENTER . . . . . . . .
Orange UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER 255 26.1 132 15.7 34 21.6 43 19.3
Orange WESTERN MEDICAL CENTER – SANTA ANA 992 34.4 437 18.4 11 1.9 12 1.8
Orange WESTERN MEDICAL CENTER HOSPITAL – ANAHEIM 721 28.4 240 11.2 3 0.6 5 1.0
Placer KAISER FND HOSP – SACRAMENTO/ROSEVILLE-EUREKA . . . . . . . .
Placer SUTTER AUBURN FAITH HOSPITAL 121 26.2 62 14.9 0 0.0 0 0.0
Placer SUTTER ROSEVILLE MEDICAL CENTER 655 24.1 295 12.9 41 10.2 42 9.8
Plumas EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS . . . . . . . .
Plumas PLUMAS DISTRICT HOSPITAL 22 24.3 11 13.6 0 0.0 0 0.0
Plumas SENECA HEALTHCARE DISTRICT . . . . . . . .
Riverside CORONA REGIONAL MEDICAL CENTER-MAIN 527 28.7 265 16.4 3 1.1 3 1.0
Riverside DESERT REGIONAL MEDICAL CENTER 1027 33.2 500 19.2 25 4.5 28 4.5
Riverside EISENHOWER MEMORIAL HOSPITAL 0 0.0 0 0.0 0 0.0 0 0.0
Riverside HEMET VALLEY MEDICAL CENTER 578 44.6 361 31.4 1 0.5 1 0.4
Riverside JOHN F KENNEDY MEMORIAL HOSPITAL 953 34.3 427 17.9 4 0.7 5 0.8
Riverside KAISER FND HOSP – RIVERSIDE 909 25.8 488 16.2 79 15.7 87 15.7
Riverside MENIFEE VALLEY MEDICAL CENTER . . . . . . . .
Riverside MORENO VALLEY COMMUNITY HOSPITAL 372 25.9 139 11.0 0 0.0 0 0.0
Riverside PALO VERDE HOSPITAL 41 41.8 30 32.6 1 8.2 1 5.8
Riverside PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER 603 36.8 274 20.2 4 1.2 5 1.3
Riverside RIVERSIDE COMMUNITY HOSPITAL 948 32.0 492 19.0 1 0.2 1 0.2
Riverside RIVERSIDE COUNTY REGIONAL MEDICAL CENTER 674 25.4 226 9.9 36 7.3 41 7.3
Riverside SAN GORGONIO MEMORIAL HOSPITAL 128 33.1 52 15.5 0 0.0 0 0.0
Riverside SOUTHWEST HEALTHCARE SYSTEM-MURRIETA 854 25.6 394 13.7 13 2.7 14 2.7
Riverside VISTA HOSPITAL OF RIVERSIDE . . . . . . . .
Sacramento KAISER FND HOSP – SACRAMENTO/ROSEVILLE-MORSE 868 24.5 474 15.7 89 18.5 101 17.8
Sacramento KAISER FND HOSP – SOUTH SACRAMENTO 532 15.8 270 9.2 116 30.8 133 31.7
Sacramento KINDRED HOSPITAL – SACRAMENTO . . . . . . . .
Sacramento MERCY GENERAL HOSPITAL 644 28.3 354 17.4 35 10.6 38 10.3
Sacramento MERCY HOSPITAL – FOLSOM 257 23.1 105 11.7 10 6.3 10 6.0
Sacramento MERCY SAN JUAN HOSPITAL 674 25.1 360 15.0 52 14.1 58 13.1
Sacramento METHODIST HOSPITAL OF SACRAMENTO 266 24.6 144 15.3 21 14.7 22 12.8
Sacramento SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF. . . . . . . . .
Sacramento SUTTER GENERAL HOSPITAL . . . . . . . .
Sacramento SUTTER MEMORIAL HOSPITAL 1305 27.2 640 15.8 111 14.3 123 13.4
Sacramento UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER 539 25.1 307 16.6 88 27.4 96 25.5
San Benito HAZEL HAWKINS MEMORIAL HOSPITAL 166 33.0 80 18.2 1 1.1 2 2.1
San Bernardino ARROWHEAD REGIONAL MEDICAL CENTER 965 28.9 415 14.3 51 8.4 54 7.9
San Bernardino BARSTOW COMMUNITY HOSPITAL 88 31.1 37 14.7 3 5.4 4 6.8
San Bernardino BEAR VALLEY COMMUNITY HOSPITAL . . . . . . . .
San Bernardino CHINO VALLEY MEDICAL CENTER 0 0.0 0 0.0 0 0.0 0 0.0
San Bernardino COLORADO RIVER MEDICAL CENTER . . . . . . . .
San Bernardino COMMUNITY HOSPITAL OF SAN BERNARDINO 1109 45.2 584 28.6 3 0.6 5 0.8
San Bernardino DESERT VALLEY HOSPITAL 116 32.3 46 15.3 1 1.4 1 1.3
San Bernardino HI-DESERT MEDICAL CENTER 151 36.7 89 23.6 1 1.6 1 1.4
San Bernardino KAISER FND HOSP – FONTANA 942 22.9 440 12.4 82 14.0 90 13.5
San Bernardino KINDRED HOSPITAL ONTARIO 0 0.0 0 0.0 0 0.0 0 0.0
San Bernardino LOMA LINDA UNIVERSITY MEDICAL CENTER 595 28.2 289 16.2 61 16.4 75 15.8
San Bernardino MONTCLAIR HOSPITAL MEDICAL CENTER 335 40.6 196 27.2 1 0.7 1 0.6
San Bernardino MOUNTAINS COMMUNITY HOSPITAL 32 28.0 17 16.4 0 0.0 0 0.0
San Bernardino RANCHO SPECIALTY HOSPITAL . . . . . . . .
San Bernardino REDLANDS COMMUNITY HOSPITAL 538 25.7 285 15.3 1 0.4 4 1.4
San Bernardino SAN ANTONIO COMMUNITY HOSPITAL 756 36.2 431 25.3 2 0.6 2 0.5
San Bernardino ST. BERNARDINE MEDICAL CENTER 363 21.8 165 10.8 14 6.5 15 5.9
San Bernardino ST. MARY REGIONAL MEDICAL CENTER 459 19.6 198 9.1 7 2.6 7 2.2
San Bernardino VICTOR VALLEY COMMUNITY HOSPITAL 479 33.9 160 13.9 3 0.9 4 1.1
San Diego ALVARADO HOSPITAL . . . . . . . .
San Diego FALLBROOK HOSPITAL DISTRICT 147 33.8 79 21.7 6 8.1 6 7.2
San Diego GROSSMONT HOSPITAL 965 30.6 530 19.7 77 15.0 83 14.3
San Diego KAISER FND HOSP – SAN DIEGO 1061 26.8 621 18.4 81 15.6 90 15.2
San Diego KINDRED HOSPITAL – SAN DIEGO . . . . . . . .
San Diego PALOMAR MEDICAL CENTER 1104 29.4 531 16.9 88 13.2 90 12.6
San Diego PARADISE VALLEY HOSPITAL 357 25.6 163 13.7 1 0.5 2 0.9
San Diego POMERADO HOSPITAL 326 30.7 152 17.7 1 0.6 1 0.5
San Diego PROMISE HOSPITAL OF SAN DIEGO . . . . . . . .
San Diego RADY CHILDREN’S HOSPITAL – SAN DIEGO . . . . . . . .
San Diego SAN DIEGO HOSPICE AND PALLIATIVE CARE-ACUTE CARE CTR . . . . . . . .
San Diego SCRIPPS GREEN HOSPITAL . . . . . . . .
San Diego SCRIPPS MEMORIAL HOSPITAL – ENCINITAS 330 21.7 152 12.0 41 18.8 44 19.0
San Diego SCRIPPS MEMORIAL HOSPITAL – LA JOLLA 1255 30.7 715 22.2 66 11.2 69 10.6
San Diego SCRIPPS MERCY HOSPITAL 517 24.2 300 16.0 77 26.2 83 25.6
San Diego SCRIPPS MERCY HOSPITAL – CHULA VISTA 629 35.3 393 24.4 11 4.4 12 4.4
San Diego SHARP CHULA VISTA MEDICAL CENTER 1021 33.8 405 16.7 7 1.1 7 1.0
San Diego SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER . . . . . . . .
San Diego SHARP MARY BIRCH HOSPITAL FOR WOMEN 2469 33.4 1338 22.2 104 8.4 122 8.4
San Diego SHARP MEMORIAL HOSPITAL . . . . . . . .
San Diego TRI-CITY MEDICAL CENTER 933 28.1 523 18.0 60 12.6 67 12.2
San Diego UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER 712 30.5 447 22.1 35 11.8 45 12.0
San Francisco CALIFORNIA PACIFIC MED CTR-PACIFIC CAMPUS 1197 19.5 711 13.6 64 12.2 74 11.7
San Francisco CHINESE HOSPITAL . . . . . . . .
San Francisco KAISER FND HOSP – GEARY S F 638 25.0 401 18.7 47 17.0 53 16.9
San Francisco LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER . . . . . . . .
San Francisco SAN FRANCISCO GENERAL HOSPITAL 202 18.3 110 11.1 47 33.6 53 33.0
San Francisco ST. FRANCIS MEMORIAL HOSPITAL . . . . . . . .
San Francisco ST. LUKE’S HOSPITAL 195 18.7 108 11.4 9 9.3 9 8.1
San Francisco ST. MARY’S MEDICAL CENTER, SAN FRANCISCO . . . . . . . .
San Francisco UCSF MEDICAL CENTER 335 19.2 216 14.2 48 29.5 53 25.8
San Joaquin DAMERON HOSPITAL 575 27.2 300 16.2 12 4.2 20 5.5
San Joaquin DOCTORS HOSPITAL OF MANTECA 164 24.7 65 11.1 0 0.0 2 1.8
San Joaquin KAISER FND HOSP-MANTECA . . . . . . . .
San Joaquin LODI MEMORIAL HOSPITAL 414 36.9 220 22.9 0 0.0 1 0.5
San Joaquin SAN JOAQUIN GENERAL HOSPITAL 630 28.1 241 12.5 18 4.4 22 4.8
San Joaquin ST. JOSEPH’S MEDICAL CENTER OF STOCKTON 583 27.9 276 14.9 11 3.4 11 3.0
San Joaquin SUTTER TRACY COMMUNITY HOSPITAL 204 29.2 97 16.5 1 0.9 1 0.8
San Luis Obispo ARROYO GRANDE COMMUNITY HOSPITAL . . . . . . . .
San Luis Obispo FRENCH HOSPITAL MEDICAL CENTER 158 20.2 99 13.6 1 1.7 1 1.5
San Luis Obispo SIERRA VISTA REGIONAL MEDICAL CENTER 346 31.1 161 18.6 38 17.2 40 16.0
San Luis Obispo TWIN CITIES COMMUNITY HOSPITAL 154 25.8 79 14.7 4 5.0 5 5.3
San Mateo KAISER FND HOSP – REDWOOD CITY 197 14.6 114 9.6 40 32.9 42 32.1
San Mateo KAISER FND HOSP – SOUTH SAN FRANCISCO . . . . . . . .
San Mateo MENLO PARK SURGICAL HOSPITAL . . . . . . . .
San Mateo PENINSULA MEDICAL CENTER 398 21.3 221 13.9 12 6.5 13 5.5
San Mateo SAN MATEO MEDICAL CENTER . . . . . . . .
San Mateo SEQUOIA HOSPITAL 365 25.8 190 17.1 24 12.6 24 11.2
San Mateo SETON MEDICAL CENTER 144 22.8 100 17.4 19 30.0 20 28.8
Santa Barbara GOLETA VALLEY COTTAGE HOSPITAL 66 23.0 31 12.5 0 0.0 0 0.0
Santa Barbara LOMPOC HEALTHCARE DISTRICT 105 27.0 57 16.0 0 0.0 1 1.9
Santa Barbara MARIAN MEDICAL CENTER 885 34.3 370 17.2 4 0.8 6 1.0
Santa Barbara SANTA BARBARA COTTAGE HOSPITAL 580 26.5 269 14.5 3 1.0 4 1.1
Santa Barbara SANTA YNEZ VALLEY COTTAGE HOSPITAL . . . . . . . .
Santa Clara COMMUNITY HOSPITAL OF LOS GATOS 189 24.4 97 15.5 14 13.4 14 12.8
Santa Clara EL CAMINO HOSPITAL 1167 26.2 649 17.6 10 1.9 10 1.7
Santa Clara GOOD SAMARITAN HOSPITAL-SAN JOSE 1065 30.7 634 22.4 17 3.9 22 4.4
Santa Clara KAISER FND HOSP – SAN JOSE 484 20.4 268 13.1 59 21.5 64 21.4
Santa Clara KAISER FND HOSP – SANTA CLARA 432 21.5 275 15.9 58 27.1 64 25.8
Santa Clara KAISER FND HOSP – SANTA CLARA 432 21.5 275 15.9 58 27.1 64 25.8
Santa Clara LUCILE SALTER PACKARD CHILDREN’S HOSP. AT STANFORD 983 20.6 488 12.1 108 18.3 116 15.8
Santa Clara O’CONNOR HOSPITAL – SAN JOSE 983 27.7 500 16.7 11 2.2 11 2.0
Santa Clara REGIONAL MEDICAL OF SAN JOSE 189 28.3 87 15.9 3 2.9 4 3.4
Santa Clara SANTA CLARA VALLEY MEDICAL CENTER 945 20.0 418 10.2 265 33.2 289 31.3
Santa Clara ST. LOUISE REGIONAL HOSPITAL 122 26.0 59 14.0 1 1.6 2 2.8
Santa Clara STANFORD HOSPITAL 4 89.1 4 85.9 0 0.0 0 0.0
Santa Cruz DOMINICAN HOSPITAL-SANTA CRUZ/SOQUEL 232 22.5 101 12.0 39 23.0 42 21.0
Santa Cruz SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ 183 19.6 112 13.7 20 22.4 20 20.6
Santa Cruz WATSONVILLE COMMUNITY HOSPITAL 388 27.6 172 14.2 16 6.9 19 7.2
Shasta MAYERS MEMORIAL HOSPITAL 22 22.7 10 11.3 0 0.0 0 0.0
Shasta MERCY MEDICAL CENTER 472 27.1 220 14.2 2 0.8 2 0.7
Shasta NORTHERN CALIFORNIA REHABILITATION HOSPITAL . . . . . . . .
Shasta PATIENTS’ HOSPITAL OF REDDING . . . . . . . .
Shasta SHASTA REGIONAL MEDICAL CENTER . . . . . . . .
Siskiyou FAIRCHILD MEDICAL CENTER 77 39.2 47 27.2 2 6.2 2 5.5
Siskiyou MERCY MEDICAL CENTER MT. SHASTA 39 26.6 19 14.4 1 4.7 1 4.3
Solano KAISER FND HOSP – REHABILITATION CENTER VALLEJO 567 25.0 309 15.8 45 14.8 49 15.0
Solano NORTH BAY MEDICAL CENTER 370 27.7 174 14.7 2 1.0 3 1.3
Solano NORTH BAY VACAVALLEY HOSPITAL . . . . . . . .
Solano SUTTER SOLANO MEDICAL CENTER 228 26.1 115 15.1 23 16.8 25 16.1
Sonoma HEALDSBURG DISTRICT HOSPITAL . . . . . . . .
Sonoma KAISER FND HOSP – SANTA ROSA 381 22.0 203 13.7 32 15.3 39 16.8
Sonoma PALM DRIVE HOSPITAL . . . . . . . .
Sonoma PETALUMA VALLEY HOSPITAL 124 24.1 62 13.5 1 1.6 1 1.4
Sonoma SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY 279 24.7 110 12.2 43 20.2 48 20.3
Sonoma SONOMA VALLEY HOSPITAL 43 22.8 19 11.3 0 0.0 0 0.0
Sonoma SUTTER MEDICAL CENTER OF SANTA ROSA-CHANATE CAMPUS 273 17.8 144 10.0 0 0.0 1 0.7
Stanislaus DOCTORS MEDICAL CENTER 1308 33.3 585 17.6 50 6.4 50 5.8
Stanislaus EMANUEL MEDICAL CENTER, INC 558 21.0 223 9.6 16 4.5 16 4.4
Stanislaus MEMORIAL HOSPITAL MEDICAL CENTER – MODESTO 551 29.2 285 17.3 1 0.4 3 1.0
Stanislaus OAK VALLEY DISTRICT HOSPITAL (2-RH) 70 26.2 33 13.7 0 0.0 1 2.6
Stanislaus STANISLAUS SURGICAL HOSPITAL . . . . . . . .
Sutter FREMONT MEDICAL CENTER 515 27.0 217 13.1 30 9.0 35 9.5
Tehama ST. ELIZABETH COMMUNITY HOSPITAL 152 25.4 76 13.8 0 0.0 0 0.0
Trinity TRINITY HOSPITAL . . . . . . . .
Tulare KAWEAH DELTA DISTRICT HOSPITAL 1175 34.3 559 19.3 22 3.4 25 3.3
Tulare SIERRA VIEW DISTRICT HOSPITAL 546 29.8 285 17.2 1 0.4 1 0.4
Tulare TULARE DISTRICT HOSPITAL 419 40.8 202 23.3 1 0.5 1 0.4