Just kicking the can of risk down the road
We cannot afford a casual approach to cesareans. They should be reserved for real medical reasons – or when a birthing parent just prefers one – so that the benefits of having the cesarean outweigh the risks and the birthing person really understands the future implications of this mode of delivery. The truth is, 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. The risk of accreta increases with each prior cesarean.
Many people 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 people, and I’m sure you do too, who were not planning on more children, but got pregnant nonetheless. Unless sterilization is the plan, the chance of an unplanned pregnancy is there. In fact, in the US, 45% of pregnancies are unintended.
By performing routine scheduled repeat cesareans, we do reduce the risk of uterine rupture in the current delivery, but by doing so we simultaneously increase the risks of accreta, previa, maternal death as well as uterine rupture in future pregnancies. As 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 ACOG’s 2010 VBAC Practice Bulletin, and in 2017, ACOG said that any Level 1 facility with an L&D unit should attend VBACs, many of these hospital policies mandating surgical births still stand.
By enforcing these VBAC bans, these hospitals simply ignore national guidelines while they violate the rights of birthing people to make their own medical decisions, and increase the incidence of placenta accreta in their community.
Given that accreta requires a more complex response than uterine rupture, surprise accretas are associated with higher rates of maternal and perinatal complications and deaths. So why not just institute the ideas provided at the 2010 NIH VBAC Conference on how a hospital without 24/7 anesthesia can safely offer VBAC and offer VBAC to those who want it?
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.
The truth is motivated hospitals offer VBAC. They find a way.
When we look at hospital VBAC policies, that is the single common thread among all hospitals that offer VBAC.
Not staffing. Not resources. Not the presence of a NICU or 24/7 OB or anesthesia coverage.
The bottom line is when OB leaders are committed to informed consent, bodily autonomy, and evidence-based medicine, they support the option of VBAC.
Fundamentally, this is why we have to get the facts out to birthing parents and perinatal professionals so we can increase access to VBAC and mitigate the complications caused by multiple repeat cesareans. It is easy to run circles around people who don’t know what the evidence, or even ACOG’s guidelines, really say.
We have to arm ourselves with information to truly make a difference in VBAC access. Is that the whole solution? No. But it’s the foundation to the movement and the first step towards creating real, measurable change.
What do you think?
Leave a comment.
What do you think? Leave a comment.
As an internationally recognized consumer advocate and Founder of VBAC Facts®, Jen helps perinatal professionals, and cesarean parents, achieve clarity on vaginal birth after cesarean (VBAC) through her educational courses for parents, online membership for professionals, continuing education trainings, and consulting services. She speaks at conferences across the US, presents Grand Rounds at hospitals, advises on midwifery laws and rules that limit VBAC access, educates legislators and policy makers, and serves as an expert witness and consultant in legal proceedings. She envisions a time when every pregnant person seeking VBAC has access to unbiased information, respectful providers, and community support, so they can plan the birth of their choosing in the setting they desire.