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

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.

_________________________________________________

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

brothers-baby-siblings

AAFP National VBAC Guidelines

Update: In May 2014, the AAFP released new guidelines.

This is a great piece for deciding between VBAC and repeat cesarean.  Those who wish to VBAC, but have husbands, family, and/or friends who don’t understand why, might find this document very useful.

I have found that people who are anti-VBAC really seem impressed by what doctors and medical organizations have to say, so I’m thinking they will find this document compelling.

Plus, VBAC has this reputation of being “risky” and repeat cesareans are thought of as the “conservative approach,” and this document challenges both lines of thinking.

Why not write a sweet little note like, “I know you are concerned about me choosing the VBAC, so I thought you would find this interesting,” and mail them a copy.  That way, they can read it, think it over, and you can chat about it later.

No one wants to see a loved one hurt or die, and since most believe that a repeat cesarean is the most conservative approach, they tend to lean in that direction.  However, once they understand that real, but small, risks are present with VBAC and repeat cesarean, and that the risks of VBAC go down with each VBAC whereas the risks of cesareans go up with each surgery, hopefully they will respect your decision.

I recommend bringing this document with you when you go to interview OBs about VBAC.  They might be unfamiliar with the data, and they too might be persuaded by a document written by a medical organization.  If your OB is anti-VBAC, this might be a good document to mail them once you have found a truly supportive OB or midwife.

I’ve included the entire text below because when I searched on Google for VBAC vs. Repeat Cesarean, it wasn’t on the first page of results, so I’d like to bring more attention to it.

Please note, they refer to VBAC as TOLAC (Trial of Labor After Cesarean.)

You can view and print the document in PDF format here: Trial of Labor After Cesarean: A Shared Patient-Physician Decision Tool.

******************************************************************

In March 2005, the American Academy of
Family Physicians published an evidence based
clinical practice guideline on TOLAC
(Trial of Labor After Cesarean; formerly called
Trial of Labor Versus Elective Repeat Cesarean
Section for the Woman With a Previous
Cesarean Section).
The AAFP guideline
recommends offering a trial of labor to women
who have had one previous cesarean delivery
with a low transverse incision. The guideline
also recommends that physicians and other
maternity care professionals explore the risks
and benefits associated with a trial of labor with
each woman who is a candidate for TOLAC.
The following shared patient-physician decision
tool can be used to initiate the conversation
about the potential risks and benefits of TOLAC.
It is important to note that this piece is not
a patient education handout. It is not meant
to be used as a standalone tool. Physicians
should go through each section with the
TOLAC candidate and explain how each factor
may (or may not) affect her. After answering
any questions the patient may have, the
physician can give the annotated handout to
the patient so she and her partner can review
it as they consider their options.
To read the AAFP’s TOLAC Guideline, visit
http://www.aafp.org/tolac.

Patient name: ____________________________________________________
Physician: _______________________________________________________
________________________________________________________________
________________________________________________________________

Trial of Labor After Cesarean:
Deciding What’s Right for You
and Your Baby

Women who have had a baby by cesarean section (C-section)
may have a choice about how to have their next
baby. They may choose to have another C-section. This
is called an “elective repeat cesarean delivery” (ERCD for
short). Or they may decide to try having the baby vaginally.
This is called a “trial of labor after cesarean” (TOLAC). When
a woman tries a trial of labor and is able to deliver vaginally,
this is called a “vaginal birth after cesarean” (VBAC).

If you’re reading this handout, it’s because your doctor
has decided that you have a choice between a planned
C-section and a trial of labor. To help you understand the
risks and benefits of each, you doctor will go through
this handout with you. He or she will explain how the
factors below apply to you. Be sure to ask your doctor any
questions you have. It’s important that you understand all
of the issues before you make a decision.

If I try labor, how likely am I to have my baby vaginally?
Because every situation is different, no one can tell if you
will be able to give birth vaginally. However, you should
know that about 76 out of 100 women who try a trial of
labor deliver their babies vaginally.

What happens to women who try labor but can’t
deliver vaginally?
Some women who try a trial of labor are not able to deliver
vaginally and end up having an unplanned C-section. You
should know that most of the babies born by unplanned
C-section are healthy and do not have long-term problems
from the C-section.

Is it is safer trying labor or having a planned C-section?
You already know that having a baby—whether vaginally or
by C-section—has some risks. The risks are generally small
whether you choose a trial of labor or planned C-section.
Studies have shown that there is no difference between
the two when it comes to the woman’s risk of death or
hysterectomy. There are, however, a few other risks to
consider. These are explained below.

Infection. Of women who choose a trial of labor,
7 out of 100 will get an infection. By comparison,
9 or 10 out of 100 women who choose planned
C-section will get an infection. This means that women
who choose C-section have a slightly higher risk of
infection (2% to 3% higher) than women who choose a trial
of labor.

Uterine rupture. A C-section leaves a scar on the
uterus. During a trial of labor, the scar can break open.
Usually this doesn’t affect you or the baby. In rare cases,
however, it can pose serious risks to you or your baby.
This is called symptomatic uterine rupture and it occurs
in 2.7 out of 1,000 women, or about ¼ of 1%, who try a
trial of labor.

Infant death. Sometimes—but not always—uterine rupture
results in the death of the baby. The chance of
this is about 15 in 100,000, or about 1/100th of 1%, in
women who try a trial of labor. There is no good data
about the risk of infant death for women who choose
elective repeat C-section.

What factors affect my chances of delivering
vaginally?
Doctors have studied thousands of women who have
attempted a trial of labor. They found that the following
factors affect a woman’s chance of delivering vaginally.
Your doctor will tell you how these factors apply to you.
You might want to ask your doctor to put a checkmark
next to the factors that may affect you and to cross out
the ones that probably won’t.

Factors that increase the likelihood of a
vaginal birth after C-section (VBAC)

• Being younger than 40 years old. If you’re under 40,
you are 2½ times more likely to have a VBAC.
My age: _________
Other notes: ________________________________
__________________________________________
__________________________________________
__________________________________________

• Having a vaginal birth before. If you’ve ever had a
baby vaginally, you’re more likely to be able to deliver
that way again.
I had a baby vaginally, but it was before I had a
C-section. You are 1½ to 2 times more likely to
deliver vaginally again.
I had a baby vaginally after I had a baby by
C-section. You are 3 to 8 times more likely to
have a VBAC.
Notes about your previous delivery or deliveries:
__________________________________________
__________________________________________
__________________________________________
Other notes: ________________________________
__________________________________________
__________________________________________
__________________________________________

• Having favorable cervical factors during labor. This
means that your cervix is dilated (open) and effaced
(thinned out) enough to deliver vaginally. If you’re well
dilated and effaced, you are 1½ to 5 times more likely
to have a VBAC. If you’ve had a vaginal birth before,
your cervix may open and thin out more quickly than if
you haven’t. If you haven’t had a vaginal birth, it’s hard
to tell how well dilated and effaced your cervix will
become during labor.
I have had a previous vaginal birth.
Other notes: ________________________________
__________________________________________
__________________________________________

• If the reason you needed a C-section before isn’t
a factor this time. You might have needed a
C-section because of infection, difficult labor, breech
presentation, or concerns about the baby’s size or
heart rate. If you don’t have the same problem this
time, you are 2 times more likely to have a VBAC.
Reason for my previous C-section: ______________
__________________________________________
__________________________________________
__________________________________________
Other notes: ________________________________
__________________________________________
__________________________________________
__________________________________________
Factors that decrease the likelihood
of a VBAC

• Having had more than one C-section. If you have had
two or more C-sections, you’re 60% less likely to have
a VBAC.
Number of C-sections I’ve had: _________
Other notes: ________________________________
__________________________________________
__________________________________________
__________________________________________

 

• Going into labor after 40 weeks. After this time, you
are 20% to 30% less likely to have a VBAC.
My baby’s current gestational age: ________
My previous child(ren)’s gestational age(s) at birth:
__________________________________________
__________________________________________
__________________________________________
Other notes: ________________________________
__________________________________________
__________________________________________
__________________________________________

RISK OF SYMPTOMATIC UTERINE
RUPTURE IN ALL WOMEN
For all women . . . . . . . . . . . . . . Less than 1 birth per 1,000
For women who have
not had a C-section . . . . . . . . . Less than 1 birth per 1,000
For women who have an
elective repeat C-section . . . . About 1 birth per 1,000
For women who have a trial
of labor after C-section . . . . . . 2 to 4 births per 1,000
(800) 274-2237 • www.aafp.org

• Trying to deliver a baby that is 8 pounds, 13 ounces
(4,000 grams) or larger. If your baby weighs this much
(or more), you are 40% less likely to have a VBAC.
My baby’s current estimated weight: ____________
My previous child(ren)’s weight(s) at birth: _______
Other notes: ________________________________
__________________________________________

• Using medicines to induce or augment labor. If you
need medicine to start or help your labor, you are 50%
less likely to have a VBAC.
Notes: _____________________________________
__________________________________________

What if I have other concerns?
In addition to thinking about your health and that of your
baby, you’re probably dealing with emotional issues
and practical concerns about the birth. Some common
concerns are listed below. When you read through this
list, you may want to put a checkmark next to the issues
you really care about and cross out those that aren’t
as important to you. Talk with your doctor about your
concerns. These issues haven’t been studied like the ones
above, but your doctor may be able to give you some
insight into how they might affect you.

Recovery time. If you deliver vaginally, you’ll probably
spend less time in the hospital and be back on your
feet more quickly. Some women think this is important
because they’ll be caring for the new baby and their older
children too.

Involvement in the delivery. For some women, having a
baby vaginally is more emotionally satisfying than having
a C-section. You get to hold your baby sooner, which
may help with bonding and even with breastfeeding. Your
partner may feel more involved in a vaginal birth too.

Future childbearing. Doctors typically don’t want women
to have more than two or three C-sections. So, you’re more
likely to be able to have more children if you have a vaginal
birth instead of another C-section.

Planned versus unplanned delivery date. Because
it’s better to go into labor on your own when you’re
planning a trial of labor, you probably won’t be able to
be induced. Not knowing when you will go into labor can
be stressful. It can also be a problem if you can’t arrange
for someone to watch your other child or children at a
moment’s notice. For these reasons, some women prefer
to plan on a C-section.

Pain during labor and delivery. If you had an especially
difficult and painful labor before, you may fear going
through it again. For this reason, some women prefer to
have another C-section and avoid labor. It’s important to
remember, though, that there are ways to manage the pain
if you decide on a trial of labor.

How do I make this choice?
You and your partner should work with your doctor to
decide whether the benefits of a trial of labor outweigh
the risks.

If you decide to try labor, you and your doctor will talk
about what to do if it looks like your labor is running into
complications. It’s best to have a plan before you begin your
labor so that you don’t have to make decisions during labor.
References

1. Wall E, Roberts R, Deutchman M, Hueston W, Atwood LA, Ireland B.
Trial of labor after cesarean (TOLAC), formerly trial of labor versus
elective repeat cesarean section for the woman with a previous
cesarean section. Leawood, Kan.: American Academy of Family
Physicians; March 2005.
2. Guise J-M, McDonagh M, Hashima J, Kraemer DF, Eden KB,
Berlin M, et al. Vaginal Birth After Cesarean (VBAC). Evidence
Report/Technology Assessment No. 71. Rockville, Md.: Agency for
Healthcare Research and Quality; March 2003. AHRQ Publication
No. 03-E018.
3. Gardeil F, Daly S, Turner MJ. Uterine rupture in pregnancy reviewed.
Eur J Obstet Gynecol Reprod Biol 1994;56:107-10.
4. Miller DA, Goodwin TM, Gherman RB, Paul RH. Intrapartum rupture
of the unscarred uterus. Obstet Gynecol 1997;89:671-3.
5. Kieser KE, Baskett TF. A 10-year population based study of uterine
rupture. Obstet Gynecol 2002;100:749-53.

The cost of getting your medical records

When considering your post-cesarean birth options, it’s good to know what type of uterine incision you have.  The only way to verify this is by getting a copy of your operative report from the hospital where you had your cesarean.  I recommend bringing copies of your operative report when interviewing care providers as most will want to confirm your uterine incision type.

Sometimes women have a different incision on their skin than their uterus, so just because you have a low transverse (“bikini cut”) incision on your skin, doesn’t necessarily mean you have the same incision on your uterus.   Low transverse incisions are the most commonly used method in America and come with the lowest uterine rupture rare.

You may also want to get a copy of your medical records from your care provider to complete the picture of your prior pregnancy/pregnancies.

Read more here: Medical Records Copying Charges by State

Last updated October 9, 2012

A RN’s Perspective on the 2 NJ CS Deaths & Her Own Birth Experience

As I’m sure you can imagine there was much discussion on the ICAN list of the two moms who died within days of each other after their cesareans at Underwood, a New Jersey hospital.

I’m sharing the following post, with permission.

********************************************

I am a registered nurse, and have no intention of ever working within a hospital setting again. It really is all about the business and not about the patient. The human life we are caring for. In NJ, where I reside, there is a nursing shortage. In addition to a nursing shortage, there are very poor unregulated nurse patient ratios, making quality care hard to provide when the nurse is spread thin. I don’t know what the mother baby ratio was at Underwood, but I do believe that with the appropriate monitoring, these cases if truly resulting in hemorrhage and a clot perhaps may have been prevented. But there are a lot of questions that need to be asked.

At what point in their stay did the episodes occur?

Where was the clot? Was it a pulmonary embolism? Clot went to the lungs. A myocardial infarction? Clot went to the heart. A stroke? Clot went to the brain. Was her PT/PTT time measured before or after the surgery? Bleeding time. What were her platelets? Clotting component. These measure clotting predictability. Was she wearing compression boots on her legs and if so, for how long. This is to prevent clot formation, which is very often where clots form s/p surgeries due to venous stasis, and platelet formation at the incision site. How often was the nursing staff in the room? How often were her vitals measured? Did she complain of any DVT pain? Leg pain, heat, swelling of the leg at the location of the clot? There is clot busting medication available IV for emergency situations. But if no one was in her room for hours upon hours, no one would have seen the signs. I know from my 4 c/s that nurses don’t frequent the room as often as they should
and they don’t respond quickly to your calls on the call bell.

Hemorrhage. Where did it originate? Was her CBC monitored? Was her vitals monitored? If so, how often? What was her PT/PTT pre-operatively & postoperatively? Was something nicked? Was it vaginally? Did they attempt a blood transfusion? Did they attempt to stop the cause of the bleed?
There are so many unanswered questions here.

My horror story,

[After my cesarean] they medicated me and took my baby back to the nursery. They told me they would bring him back at 1am to breastfeed. They did not. I awoke at 6am when they did my vitals, which was done by a tech, at the beginning of each 12 hour shift. Q 12 hour vitals are not enough to detect a potential postoperative problem. They never brought my baby back. I asked for him, and was told, soon. I called again at 7am and they were in the middle of a shift change. I called again at 7:45am and was told the babies were being seen by the docs and he would be brought to me after. 8:30am I called down and was told that he was being seen by the doc. 9 am, the doc came into my room, no baby. No nurse. It had not even been 24 hours since his c/s birth. I was still medicated, still could not feel my legs, I was in compression boots, still had the foley catheter, still had the IV. The doc sat at the foot of my bed and proceeded to tell me that my baby had stopped breathing, needed resuscitation. There were other details but all I could hear was my baby stopped breathing. He WAS fine when he was with me. He left me there, by myself. I called down to the nurse, that I needed her NOW. No one came for the 15 minutes that I was on the phone with my mother and my husband telling them what had happened and to come down. I had to call the nurses station again, this time, demanding that a nurse come and release me from everything or I would do it myself.  For God Sake my baby nearly died. One came, and an hour later I was being wheeled down to see my baby… nothing urgent to them. Not enough staff to meet the needs of the patients. My son is wonderful, thank GOD, he is 16 months old! But if I could not get nursing support, and I was calling for it, who is to say that this was not part of the problems in these Underwood cases?

Tiffani, RN

http://icanofcapeatlantic.blogspot.com/