Category Archives: Repeat Cesarean

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

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.

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
Tuolumne SONORA REGIONAL MEDICAL CENTER – GREENLEY 158 32.9 79 19.1 0 0.0 0 0.0
Tuolumne TUOLUMNE GENERAL MEDICAL FACILITY . . . . . . . .
Ventura COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA 820 30.4 363 16.3 8 1.7 8 1.5
Ventura LOS ROBLES HOSPITAL & MEDICAL CENTER 598 31.4 326 21.3 20 7.0 24 7.0
Ventura OJAI VALLEY COMMUNITY HOSPITAL . . . . . . . .
Ventura SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE 146 27.2 80 17.2 1 1.5 1 1.4
Ventura ST. JOHN’S PLEASANT VALLEY HOSPITAL 79 17.1 43 10.2 1 2.7 1 2.5
Ventura ST. JOHN’S REGIONAL MEDICAL CENTER 372 24.1 193 13.9 2 1.1 2 0.9
Ventura THOUSAND OAKS SURGICAL HOSPITAL . . . . . . . .
Ventura VENTURA COUNTY MEDICAL CENTER 735 26.5 284 11.7 10 2.1 12 2.2
Yolo SUTTER DAVIS HOSPITAL 181 14.8 83 7.4 0 0.0 1 0.9
Yolo WOODLAND MEMORIAL HOSPITAL 153 24.4 71 12.7 2 2.4 2 2.1
Yuba RIDEOUT MEMORIAL HOSPITAL . . . . . . . .

* Agency for Healthcare Research and Quality, Inpatient Quality Indicators, Version 3.1. All indicators are age-adjusted and laparoscopic cholecystectomy is also sex-adjusted.

**Patient Discharge Data 2007

OSHPD

Note: Blank cells indicate that no procedures were performed; VBAC = Vaginal Birth After Cesarean; CS = Cesarean Section.
(go here for rate explanation  )

VBAC vs. Repeat Cesarean by the American Academy of Family Physicians

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.

Cesarean Risks: Adhesions

This is a comprehensive article on adhesions which is a fancy word for scar tissue.  I think the most relevant points of this whole discussion are:

  1. Adhesions “develop in 93% of people who have undergone pelvic surgery” and “they are especially common after cesarean sections.”
  2. You get more adhesions with each cesarean.
  3. Adhesions can cause:
    • Pelvic or Abdominal Pain
    • Bowel Obstruction
    • Infertility
  4. Adhesions impact future cesareans by making the surgery longer which can put your baby at risk in an emergency situation (emphasis mine):
    • “If you have had a cesarean section and are pregnant or planning to have another child, these adhesions could complicate matters. If you are having another c-section, your health care provider will have to separate and cut through all of your adhesions before she can begin the c-section. For women who have had more than three cesareans, this could take ten minutes to an hour or more. In an emergency, this could place your baby at risk.
  5. Adhesions “shouldn’t pose a problem” for VBAC:
    • “If you elect to have a vaginal birth after a cesarean , or VBAC, adhesions shouldn’t pose much of a problem, unless you have had multiple cesarean sections. Typically, women who have only had one cesarean section can deliver vaginally without any difficulties. There is a chance that the scar tissue covering the incision in your uterus could rupture. This can be very dangerous, as it can cause massive bleeding or cut off your baby’s oxygen supply. However, the risk of uterine rupture during a VBAC is very low, typically occurring in less than 1 out of every 1,000 births.”

To read the whole article, go here: C-Sections and Adhesions

Cesarean Risks: Overview

We all know the primary risk of VBAC – uterine rupture.  And when your typical VBACing mom meets with an OB, she must sign a “VBAC consent form” acknowledging that she understands this risk.  However, I find it ironic that women signing up for a repeat cesarean are not required by their OB to sign a “Repeat Cesarean Section consent form” as a matter of course during prenatal exams since there are risks associated with cesarean section.   But since this does not happen, and most OBs breeze over the risks if they even bother to mention them, expectant moms are lead to believe that VBACs are risky and cesareans are not.

What most moms signing up for cesareans don’t know, is that this decision not only introduces risks that can impact them or their baby immediately, but this decision also impacts their future fertility as well as future cesarean deliveries and babies.  And some of these complications increase with each surgery.  As they say, “Clearly, all the risks of primary cesarean delivery are only increased for repeat cesareans, and increase even more with third, fourth, and higher-order cesarean deliveries.”

This is a great article detailing the risks of cesareans, but I’ll just list the risks below.  If you wish to read more in detail, you can go here: Risks Associated With Cesarean Delivery

Short-term Risks of Cesarean Delivery

  • Maternal Death (yeap, that is the first one they list)
  • Thromboembolism – which is define as “blockage of a blood vessel by a clot that can travel in the bloodstream to the heart, lungs or brain and cause serious damage.”  If the clot goes to your brain, that’s a stroke.  It goes to your heart, that is a heart attack.  If the clot goes to your lungs, that’s a pulmonary embolism.  None of these things are good.
  • Hemorrhage – “The risk of hemorrhage requiring blood transfusion increases substantially with increasing number of prior cesarean deliveries.”
  • Infection – “most common complications of cesarean delivery” affecting 85% of women who labored prior and 4-5% of women with intact membranes.  “Wound infections may occur in 2.5% to 16% of cesareans.”
  • Incidental Surgical Injuries – typically the bladder, bowel or ureters which, if not corrected soon, can cause other complications such as sepsis (major, serious infection), renal (kidney) failure, or fistula formation. 
  • Extended hospitalization– some people view their stay at the hospital as a vacation, me, I like my vacations pain free and with better food, but to each their own!
  • Emergency Hysterectomy – This unfortunately happened to this woman.  “. . . those who did have a hysterectomy were 13 times more likely to have been delivered by cesarean section.”
  • Pain – This little word is so powerful.  Pain is such an easy thing to overlook or to say, yeah, that’s obvious, but when you are trying to care for a newborn, or a newborn and an older child, the risk of pain is huge.  And pain for some women can go on for months.  It took me 18 months for my scar to not be oddly numb, yet sensitive. From the article, emphasis mine:
    • “A study of 242 primiparous women reported that all those who underwent cesarean deliveries (both planned and unplanned) required narcotic pain medications compared with 11% of those who delivered vaginally.Having to relieve pain with narcotic pain medications can have a significant impact on initial bonding between the mother and the newborn and on breastfeeding success rates, as well as maternal functioning postpartum; in addition, the risk for postpartum depression may be greater.”
  • Poor Birth Experience – “more likely to report dissatisfaction with their birth experience compared with those who delivered vaginally . . . less early contact with their newborns . . . significantly longer time before their first contact with their baby . . . more likely to cite a poorer score for their initial contact with their baby.”

Long-term Risks of Cesarean Delivery

  • Readmission to the Hospital – ” . . . postpartum readmission to the hospital was significantly greater for those who delivered by cesarean delivery.”
  • Pain – ” . . . more likely to report pain to be a problem in the first 2 months after delivery.”  A survey of 1500 women who had cesareans in the past 24 months said, “incisional pain was a major problem 25% of the time, and a major or minor problem 83% of the time” and at 6 months postpartum, 7% of CS moms reported incisional pain compared with 2% of vaginal birth moms who reported perineal pain.
  • Adhesion Formation – “. . . is common and significantly contributes to the risk of complications at future deliveries . . . reported increased risk of ectopic pregnancy among women with prior cesarean deliveries.”
  • Infertility/Subfertility – “. . . more likely to be unable to conceive a pregnancy for more than 1 year”

Risks for the Newborn of Cesarean Delivery

  • Neonatal death (they listed this first)
  • Respiratory difficulties – “. . . probably result from a failure of the mechanisms to resorb fetal lung fluid that are typically triggered during vaginal birth . . .3 times more common after elective cesarean delivery than after vaginal delivery”
  • Asthma – “. . . those delivered either by planned or unplanned cesarean were approximately 30% more likely than those delivered vaginally to have been admitted to the hospital for asthma during childhood”
  • Iatrogenic Prematurity – This means that the baby was premature because the cesarean occurred before the baby was ready to be born.  This typically happens with scheduled cesareans.
  • Trauma – Meaning the baby is accidentally cut by the surgeon
  • Failure to breastfeed

Risks of Cesarean Delivery to Future Pregnancies

  • Uterine Rupture – For more stats on this go here.
    • A population-based study of more than 255,000 women in Switzerland found that the incidence of uterine rupture for a woman with no previous cesarean delivery was 0.007%. That incidence rose to 0.192% for a woman with a prior cesarean delivery who planned a repeat cesarean delivery, and rose even higher to 0.397% for women who planned a trial of labor after a prior cesarean delivery. 
  • Abnormal Placentation – This means that your placenta either implants over the opening of the cervix (placenta previa) which means you have to have another cesarean or that your placenta grows through the uterine wall (placenta accreata) which can mean the placenta needs to be manually or surgically removed and puts you at a greater risk of post-partum hemorrhage.
    • . . . women with at least 1 prior cesarean delivery had approximately 3 times the risk of having a placenta previa at the time of delivery compared with women with no prior cesarean deliveries, and this risk increased substantially with increasing numbers of prior cesarean deliveries — reaching nearly 45 times the risk for women with 4 or more prior cesarean deliveries.
  • Hysterectomy – “As the number of prior cesarean deliveries rises, the risk of cesarean hysterectomy increases dramatically.”

As I’ve said before:

VBACs have risks.

Cesareans have risks.

Please understand all the information before making a decision.

Learn more here: Elective Cesarean Surgery Versus Planned Vaginal Birth: What Are the Consequences?