The back story to the Times article

Pamela Paul, author of the Times article The Trouble With Repeat Cesareans, wrote another article in The Huffington Post: Childbirth Without Choice. This piece gives the back story of the Times article, including her own fight to have a VBAC in a supposedly "pro-VBAC" hospital.

She writes:

I wrote an article in this week's issue of Time magazine called "The Trouble With Repeat Cesareans" on the subject of women's diminishing patient's rights. I won't repeat the story here, since you can link to it here, but will give some of the back story for those who want more:

This was a story I've been wanting to write for a long time. The short version is, doctors and hospitals are no longer allowing many women to have a vaginal birth after cesarean (or VBAC, pronounced "vee-back") because the "medicolegal" costs are too high. Or, as one ob-gyn put it when I asked why she and other doctors no longer allow VBACs, ""It's a numbers thing. It is financially unsustainable for doctors, hospitals and insurers to engage in a practice when the cost of doing business way exceeds the payback. You don't get sued for doing a C-section; you get sued for not doing a C-section."

Read the rest of the article here.

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Time article on VBAC and Forced Repeat Cesareans

I am excited to announce that Time magazine just released an article about VBAC and forced repeat cesareans, called The Trouble With Repeat Cesareans. It will hit newsstands tomorrow morning. I was privileged to play a (very small) part in helping the International Cesarean Awareness Network (ICAN) phone hospitals all across the US to determine whether or not VBACs were allowed in their facilities.

With a few exceptions, ICAN has contacted every American hospital that has a maternity ward. As you'll see in the article, 28% of U.S. hospitals have an outright ban on VBACs, and another 21% have a "de facto" ban: while VBACs are technically allowed at the hospital, no doctor will attend them. To find out the VBAC policies in your local hospitals, visit ICAN's VBAC policy database (it might not be up and running until tomorrow).

I feel that access to VBAC is one of the most pressing maternity care issues in this country, along with the disturbingly high cesarean rate (31.1% as of 2006). Please advertise this article widely, making sure to link to the original article on Time's website. The more traffic it gets, the longer it will remain online.

From the article:

For many pregnant women in America, it is easier today to walk into a hospital and request major abdominal surgery than it is to give birth as nature intended. Jessica Barton knows this all too well. At 33, the curriculum developer in Santa Barbara, Calif., is expecting her second child in June. But since her first child ended up being delivered by cesarean section, she can't find an obstetrician in her county who will let her even try to push this go-round. And she could locate only one doctor in nearby Ventura County who allows the option of vaginal birth after cesarean (VBAC). But what if he's not on call the day she goes into labor? That's why, in order to give birth the old-fashioned way, Barton is planning to go to UCLA Medical Center in Los Angeles. "One of my biggest worries is the 100-mile drive to the hospital," she says. "It can take from 2 to 3 1/2 hours. I know it will be uncomfortable, and I worry about waiting too long and giving birth in the car."

Much ado has been made recently of women who choose to have cesareans, but little attention has been paid to the vast number of moms who are forced to have them. More than 9 out of 10 births following a C-section are now surgical deliveries, proving that "once a cesarean, always a cesarean"--an axiom thought to be outmoded in the 1990s--is alive and kicking. Indeed, the International Cesarean Awareness Network (ICAN), a grass-roots group, recently called 2,850 hospitals that have labor and delivery wards and found that 28% of them don't allow VBACs, up from 10% in its previous survey, in 2004. ICAN's latest findings note that another 21% of hospitals have what it calls "de facto bans," i.e., the hospitals have no official policies against VBAC, but no obstetricians will perform them.

Read the rest of the article here.

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Cesarean section and uterine rupture

Two recent studies--one still in press--that I find quite fascinating relating to uterine rupture. I have the full text of the first one, and hope to access the second one* as soon as it is officially published. As always, email me if you'd like to take a look at the full text.

A few comments/questions/observations:

• I hope that the evidence from the first study won't be used to risk out women who never went into labor before their cesarean section. Instead, I hope it will simply be used to give extra confidence and reassurance to women who did experience labor before they had a cesarean.
• In the second study, note the correlation between oxytocics (i.e., Pitocin) and uterine rupture in both scarred and unscarred uteri. 21 of the 41 uterine true ruptures occurred in connection with oxytocics--9 among women with previous cesarean sections and 12 among women with unscarred uteri. This, of course, doesn't mean that using Pitocin = uterine rupture, but certainly it suggests the need for prudence and caution when administering Pitocin during labor--not just among women having a VBAC, but also among women with no previous cesarean section.
  

1) Laboring before a primary C/S reduces the risk of uterine rupture in a subsequent intended VBAC
C.S. Algert et al. "Labor before a primary cesarean delivery: reduced risk of uterine rupture in a subsequent trial of labor for vaginal birth after cesarean." Obstet Gynecol. 2008 Nov;112(5):1061-6.

OBJECTIVE: To estimate the effect of the onset of labor before a primary cesarean delivery on the risk of uterine rupture if vaginal birth after cesarean (VBAC) is attempted in the next pregnancy.
METHODS: Longitudinally linked birth records were used to follow women from a primary cesarean delivery to a trial of labor at term for their next birth. The effects of characteristics of both the trial of labor and primary cesarean deliveries on the risk of uterine rupture were examined.
RESULTS: Of 10,160 women who had a trial of labor, 39 (0.38%) had a uterine rupture. Women who were induced or augmented for their trial of labor had a greater relative risk (RR) of uterine rupture (crude RR 4.24, 95% confidence interval [CI] 2.23-8.07). Women whose primary cesarean delivery was planned or followed induction of labor also had an increased risk of uterine rupture (crude RR 2.61, 95% CI 1.24-5.49), and this risk remained after adjustment for other factors. Women with a history of either spontaneous labor or vaginal birth had one uterine rupture for every 460 deliveries; women without this history who required induction or augmentation to proceed with a VBAC attempt had one uterine rupture for every 95 deliveries.
CONCLUSION: Labor before the primary cesarean delivery can decrease the risk of uterine rupture in a subsequent trial of labor. A history of primary cesarean delivery preceded by spontaneous labor is favorable for VBAC.
LEVEL OF EVIDENCE: II.

2) Half of all true uterine ruptures are not associated with prior cesarean section
Porreco RP, Clark SL, Belfort MA, Dildy GA, Meyers JA. The changing specter of uterine rupture. Am J Obstet Gynecol. 2009 Jan 9. [Epub ahead of print] Presbyterian/St. Luke's Medical Center, Denver, CO.

OBJECTIVE: The objective of the study was to review all patient records discharged with codes for uterine rupture in 2006 in Hospital Corporation of America hospitals. STUDY DESIGN: All patient charts were distributed to a committee of perinatologists and general obstetricians. Case report forms were analyzed for variables of interest to determine validity of coding and quality of care.
RESULTS: Of 69 cases identified, only 41 were true ruptures. Twenty patients had previous cesareans, and in 9 of these patients, concurrent use of oxytocics was documented. Among the 21 patients without previous cesareans, 7 had previous uterine surgery, and oxytocics were documented in 12 of the remaining 14 patients. Standard of care violations were identified in 10 of 41 true rupture cases.
CONCLUSION: Epidemiological data on uterine rupture based on hospital discharge codes without concurrent chart review may be invalid. Patients with previous cesareans represent only half of true uterine ruptures in contemporary practice.

* thanks to Jill for this one!

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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.

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