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 listed 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.
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.
What do you think?
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Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at a hospital, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. Even more have accessed her trainings online. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is the Secretary for the California Association of Midwives and the California Association of Licensed Midwives. Her favorite flavor of ice cream is peanut butter chocolate. And mint chip. And coffee.