Wednesday, April 02, 2008

April is Cesarean Awareness Month

In honor of Cesarean Awareness Month, I wanted to pass along some more articles about VBACs and ERCS.

First is a recent study that found that repeated VBACs become safer and more successful. From the abstract:

OBJECTIVE: To estimate the success rates and risks of an attempted vaginal birth after cesarean delivery (VBAC) according to the number of prior successful VBACs.

METHODS: From a prospective multicenter registry collected at 19 clinical centers from 1999 to 2002, we selected women with one or more prior low transverse cesarean deliveries who attempted a VBAC in the current pregnancy. Outcomes were compared according to the number of prior VBAC attempts subsequent to the last cesarean delivery.

RESULTS: Among 13,532 women meeting eligibility criteria, VBAC success increased with increasing number of prior VBACs: 63.3%, 87.6%, 90.9%, 90.6%, and 91.6% for those with 0, 1, 2, 3, and 4 or more prior VBACs, respectively (P<.001). The rate of uterine rupture decreased after the first successful VBAC and did not increase thereafter: 0.87%, 0.45%, 0.38%, 0.54%, 0.52% (P=.03). The risk of uterine dehiscence and other peripartum complications also declined statistically after the first successful VBAC. No increase in neonatal morbidities was seen with increasing VBAC number thereafter.

CONCLUSION: Women with prior successful VBAC attempts are at low risk for maternal and neonatal complications during subsequent VBAC attempts. An increasing number of prior VBACs is associated with a greater probability of VBAC success, as well as a lower risk of uterine rupture and perinatal complications in the current pregnancy.

Next, another study. Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries
found that cesareans become progressively more dangerous for the mother. Not a big surprise, but this study quantifies some of the risks of multiple cesarean sections, such as placenta accreta. Here's the abstract:

OBJECTIVE: Although repeat cesarean deliveries often are associated with serious morbidity, they account for only a portion of abdominal deliveries and are overlooked when evaluating morbidity. Our objective was to estimate the magnitude of increased maternal morbidity associated with increasing number of cesarean deliveries.

METHODS: Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999–2002).

RESULTS: There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, 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. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively.

CONCLUSION: 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.

More posts about CAM on The Trial of Labor blog.

12 comments:

  1. Thank you for this. Being a 1st time C-section mama (very regretfully), I am nervous about having future children even though I would like many. This has eased my spirits.

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  2. Tie-Dyeing Doula4/3/08, 10:29 AM

    RIXA, VBAC WARRIOR: WHAT CAN I DO? I WANT TO BE ANOTHER VOICE, ADDED TO YOURS, TO CHANGE THIS CRISIS WE ARE IN. I WANT AN ALARM TO BE GOING OFF THAT A NATIONAL ATTACK IS BEING MADE ON NAIVE AND INNOCENT MAMAS AND BABIES. WHERE IS THE LAW ABOUT INHUMANE ACTS AGAINST CHILDREN? WHERE DO WE GO FROM HERE? I WANT MY CAR COVERED IN BUMPER STICKERS (ANY IDEAS ON WHERE TO GET THESE, PLEASE EMAIL ME) I WANT TO SCREAM FROM THE TOP OF THE MOUNTAIN. WHAT CAN I DO TO HELP? DO WE ORGANIZE A "NO INTERVENTION" CAMP OUTSIDE OF THE WHITE HOUSE STEPS, DO WE TRY TO SPEAK ELOQUENTLY TO THE PREGNANT MAMAS? WHAT DO WE DO? I HAVE A POST THAT MAINLY SAYS, (AND YOU CAN READ IT YOURSELF AT SHAWNABABYMOONDOULAS.WORDPRESS.COM-I'M LONELY IN MY BLOGGING WORLD) BUT IT SAYS MAINLY THAT I REALLY HAVE A PROBLEM ALLOWING A MAMA TO JUST JUMP OFF A CLIFF AND I AM TO BE THERE TO PUT THE PEICES TOGETHER BUT INSTEAD, I WANT TO LET HER KNOW "HEY, UP AHEAD IS A CLIFF AND IF YOU CHOOSE TO JUMP, YOU MAY NOT MAKE IT, BUT IF YOU DO, THE PAIN YOU WILL ENDURE IS IMMEASURABLE." THEN SEE WHAT TYPE OF SUPPORT IS NEEDED, AFTER SHE KNOWS THE TRUTH. WHAT CAN WE DO???? PLEASE, LET'S GET TOGETHER AND START SOMETHING, ANYTHING...LET'S BE VOICE AND MAKE IT CLEAR, LET'S BE HEARD, LET'S GET A PLAN AND TAKE BACK OUR RIGHT, LET'S TEACH PEACE!!!!

    April 1, 2008 5:37 PM

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  3. Good post Rixa. Wanted to share... we recently had a mom come in, pregnant with her 6th or 7th child. Somewhere in the mix, she'd had a c-section but had had successful VBACs after that pregnancy. However, she lived in another part of the country at that time. Then they moved up here and she couldn't find a single OB who would support a VBAC, regardless of how successful she'd been previously. With this baby, she went into labor on her own and came to the hospital. She was in very active labor and begged to have a VBAC... they said, "no". (And she was not brave enough to refuse surgery.) So they walked her into the O.R. despite that she was nearly fully dilated, and cut her open. I will never forget the look on her face as she was being prepped. I wanted to SCREAM at everyone in the room to stop. It was so obvious to me how ridiculous the scenario was. They had EVERY person there, for heaven's sake. She was so close to pushing... and considered a grand multip who would likely deliver very quickly. They could have just let her push right there in the O.R. Then they'd be covered in case anything went wrong, they could just do surgery right then and there. But no. Shaking my head in disgust...

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  4. Team Harris,

    What a tragedy for that woman to have to go through a totally unnecessary cesarean, so close to giving birth by herself. It's situations like this that amaze me; how can hospital staff actually justify forcing a woman to go through this? How can they tell her she cannot refuse surgery and feel ethically justified? Argh...

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  5. Team Harris:

    That is just dumb. It is sort of like a the fully dilated breech crowning a bum. I work with Doctors who have done vag breeches in the hosptial just because it would be more trauma to extricate the baby from the Abdominal route. I mean if everybody (anesthesia, OB, scrub, nurses) are present, then the insurance should cover it.

    The Vbac ban is actually about medical malpractice insurance. At least that is my understanding. That the insurance company will not cover malpractice for Doctors who do not have anesthesia readily availible and have the Doctor present. Sounds like you had the 2 qualifying parts availible.

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  6. Hi Rixa!

    Team Harris - hmm, yet another example of why it's best just NOT to leave your house some days . . .

    =( Kimberly

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  7. Team Harris, what do you mean She wasn't brave enough?. what about the midwives the theatre staff, She was in a vulnerable position and didn't have one advocate. I feel more horrified by that than anything else. Great information Rixa, thank you.

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  8. Lisa - she was bullied and she felt very, very vulnerable. She tried to have an open conversation with the docs. They refused and shut her down. I think she felt completely defeated. As for staff... there are no midwives in our small hospital (VERY unfortunate indeed) and the staff felt bullied as well. The staff DID try and speak with the doctors, but they too were shut down. We do have some very outspoken nurses. But the doctors are very, very powerful. When a patient, no matter how strong, is put into that kind of situation, it is very, VERY difficult to come back swinging and defend yourself... especially when you throw active labor into the mix. My heart bleeds for her.

    Believe me, if I could find another line of work that paid this well and afforded me the same schedule, I'd do it in a heartbeat. But I feel somewhat trapped in this profession right now. I make more money than many other full time workers out in the community and I only work roughly 10 shifts per month. I work a schedule that allows me to be home with my children and not utilize daycare. My children are 5 and 6 and I have never had to use daycare and I homeschool them. Difficult to find a way to make this kind of income and get those kind of perks.

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  9. Rixa... I ask myself these questions everyday. For the past couple of years, I have been asking myself how long I can remain in this profession. Part of me wants to run... part of me CAN'T run... and part of me wants to stay and be an advocate for the patients who need hospital help. Right now, I feel trapped. See my response to Lisa.

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  10. Pinky - YES! DUMB! That's the part that killed us... anesthesia and OB were RIGHT THERE, IN HOUSE. She was almost complete. She was considered a grand multip and very likely would have delivered quickly. Plus she had had a successful VBAC already.

    This case was so hot that even though it was late at night, they called in the OB chief and went into a room to discuss the matter... he put his foot down... no way. Not happening. We "just don't do VBACs at this hospital."

    As a nursery nurse, I can SORT of understand his point (ladies, I'm not justifying this!!) But I think he feels stuck... if he okays the VBAC and she ruptures and they can't get the baby out in time, we are not a Level II or a Level III nursery. He takes the fall for that decision.

    I BELIVE IN and ADVOCATE for VBACs. I WANT them. I think that women MUST have that option. However, I understand why so many doctors feel trapped. They are tired of being sued. And unfortunately, that's what happens. The OB chief was looking out for #1... because he has a family to take care of too... and he isn't about to risk his own well being or that of his family because he knows we live in a terribly litigious society. Lawsuits, lawsuits, lawsuits. It's sick the way we throw around lawsuits in this country.

    It's like I have said before... everyone expects a perfect outcome. Unfortunately, that isn't reality. So when it doesn't happen, we just sue. Sick.

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  11. Rixa... sorry, didn't mean to hijack your comments section!! ;-)

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  12. Team Harris, no problem for all of your posts! I still think it's ridiculous that the head OB didn't allow the VBAC even when everyone was in the OR ready to go! I know the reasons why but I just don't *get* it.

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