Wednesday, April 01, 2009

Cesarean section and VBAC, yet again

I seem to be on a cesarean section and VBAC kick lately, but there are just so many things to discuss and so many new articles and studies coming out. And with close to 1 in 3 births occurring via c-section in the U.S., these topics are certainly relevant to anyone who is of childbearing age!

First, continuing our discussion of the ethics of refusing to perform elective c-sections, I came across this comment from an Australian physician who argues that that doing an ECS to stave "save the vagina" or "prevent urinary incontinence" is not a valid reason. She argues that an ECS is like a healthy weight woman requesting gastric bypass surgery to prevent future obesity. From the article Caesarean beliefs "misguided" from the Sydney Morning Herald:

WOMEN who choose to have an elective caesarean in the belief that it will prevent incontinence and genital prolapse are "misguided" and may be putting their health, and that of their baby, at unnecessary risk.

That is the view of Jenny King, a urogynaecologist at Westmead Hospital, who questions the right of women to choose surgical births to avoid pelvic floor problems.

Evidence is mounting that repeat caesareans cause harm and there are doubts that they provide the protection they were thought to provide, she said.

Dr King will present the findings of a review of about 9000 births at Westmead Hospital in 2004 at the annual scientific meeting of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists in Auckland on Sunday.

She projected that surgical birth could prevent 35 per cent of urinary incontinence in women under 50, but the method of delivery made minimal difference to pelvic dysfunction later in life.

"Incontinence is an emotional issue, but I looked at the data and you have got more chance of losing a baby from the complications of a caesarean section than getting incontinence problems," she said.

"If a young woman of healthy weight asked a gastric surgeon for lap-band surgery to prevent the possibility of becoming obese later in life, surely no one would agree to that.

"So why does a pregnant woman have the right to surgery she doesn't need?"

Women who have a caesarean are at much greater risk of a ruptured uterus, hysterectomy or infection. And their babies are more likely to be born premature, have serious breathing problems or need intensive care.

Next, an article in the Arizona Republic discussing how C-sections are linked to future birth risks. The article focuses on one worrisome trend due to the rapid rise of c-sections: placenta accreta. Once something that was an obstetrical rarity (1 in 30,000 in the 1950s when the c-section rate was in the low single digits), accreta now is as high as 1 in 2,500 to 1 in 500. The article also stresses the relative safety of VBAC, emphasizing that as many as 90% of women with a previous c-section are candidates for a VBAC.

Studies and textbooks suggest that the risk of developing an accreta is as high as 4 percent in women who have had two previous Cesareans; that jumps to 60 percent with three C-sections, their physicians said.

And while Valley hospitals can't say exactly how many women they are seeing with the complication, those that traditionally deliver the most babies say it's a trend they're watching.

Earlier this year, St. Joseph's saw three women with the condition in one week, Chambliss said.

"In the 1950s, the incidence was something like 1 in 30,000 women," Mills said, adding that newer studies, conducted within the last decade, suggest that the rate has climbed to as high as 1 in 2,500 or even 1 in 500.

"So there is definitely an increase in occurrence," he said. "And in women with C-sections, that's where we've really seen an explosion."

I've posted about this before, but I wanted to remind readers of this recent study about Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries. Not surprisingly, it found that cesareans become progressively more dangerous for the mother. I bolded the parts relating to placenta accreta. It seems the 60% statistic from the previous article comes from women with two previous c-sections who also have placenta previa. 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.
Thanks to Unnecessarean and Birth Faith for the links!


  1. It is great to see someone talking about this issue and not keeping it hidden. A friend of mine in Toronto has developed an incontinent underwear for women using microfiber.

    I thought you may be interested in taking a look and maybe doing an article on her. The website is at


  2. I just wanted to say that I REALLY enjoy reading your blog. I'm actually well on my way to reading your thesis too (although that will take me a bit longer).

    I feel very passionate about these subjects as well, so it is very great that you're writing about them (and that you know/research what you're talking about).

    ~ Rachel Clear

  3. Great links! Looks like we get some of the same Google alerts, too. Just had my HBAC baby on Monday, March 30 (previous cesarean was for breech). We're doing great, and I'm so glad I wasn't in the hospital, even though there were no complications with the birth. Keep up the great blog work!

  4. Oh, good analogy with the gastric bypass. I'm going to have to remember these.

  5. you'll have to read this article too!

  6. ~Melissa

    I stumbled upon your blog and I love this article about elective cesarean sections. I am an L&D nurse in a large urban hospital in the northeast and I keep hearing this ridiculous "choice" argument being thrown around by some of the obstetricians I work with. Now don't get me wrong, I support patient's rights, women's rights, autonomy, and informed consent but you are absolutely right about the gastric bypass comparison. And it is not a matter of autonomy, it is a matter of safety for both mom and baby not only for "this" cesarean but every other cesarean she may have to have or be forced to have. I have also heard the argument that if a woman knows she only wants one or two kids then it should be okay to let her choose an elective primary cesarean. The truth is that there is acutally research out there supporting how bad women are at predicting how many kids they are going to have (haha, it's true :) There was a very interesting research article published in ACOG's Green Journal in August 2008 entitled "The accuracy of predicting parity as a prerequisite for cesarean delivery on maternal request". CONCLUSION: At the time of first pregnancy, many women underestimate their final parity. This raises questions about making an estimate of parity a consideration for offering cesarean delivery on maternal request.


  7. Thanks Melissa for adding your comments--I'll have to look up that study.

  8. I think elective c-sections are crazy and think VBAC's can be a great thing.

    The only reason why I can think any woman would want to have an unnecessary c-section is because she can't bear the thought of even possibly loosing her child. If her doctor has told her there are risks for something going wrong for the child, she's probably more likely to err on the side of caution then take even a slight risk that her child could not make it.

    As for the increased risks, I know they're out there. I keep hearing about them, but out of many many many c-section women I've met online, I've heard hardly any serious problems from the c-sections. The biggest problem I've seen has been with the woman's post-c-section emotional state and dealing with the fact that she ended up with an un-natural childbirth.

    As a 4x c-section mom, I hope and pray never to be one of those statistics!


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