Tuesday, February 24, 2009

The trouble with repeat cesareans

So I still get Time magazine. Every so often, there's something really worthwhile to be found in there. Like this article on repeat cesarean sections, and the trouble more and more women are having trying to find a care provider who will agree to attend a vaginal birth after cesarean (VBAC). In the 90's, VBAC was actually encouraged. But the trend has reversed. Fewer doctors are willing to attend VBAC, and some hospitals have right out banned them. Why?

"It's a numbers thing," says Dr. Shelley Binkley, an ob-gyn in private practice in Colorado Springs who stopped offering VBACs in 2003. "You don't get sued for doing a C-section. You get sued for not doing a C-section."

Often, the risk of uterine rupture is cited as a reason to avoid VBAC. However, there are lots of things that can lower that risk, including avoiding induction or pitocin augmentation during labor. And lets not forget that repeat cesareans come with their own set of risks.

With each repeat cesarean, a mother's risk of heavy bleeding, infection and infertility, among other complications, goes up. Perhaps most alarming, repeat C-sections increase a woman's chances of developing life-threatening placental abnormalities that can cause hemorrhaging during childbirth. The rate of placenta accreta--in which the placenta attaches abnormally to the uterine wall--has increased thirtyfold in the past 30 years. "The problem is only beginning to mushroom," says ACOG's Zelop.

Ultimately, the choice should be up to the parents. They should be presented with risks and benefits of both VBAC and repeat cesarean, and able to make an informed decision. Often, this is not happening.

Dr. Stuart Fischbein, an ob-gyn whose Camarillo, Calif., hospital won't allow the procedure, is concerned that women are getting "skewed" information about the risks of a VBAC "that leads them down the path that the doctor or hospital wants them to follow, as opposed to medical information that helps them make the best decision." According to a nationwide survey by Childbirth Connection, a 91-year-old maternal-care advocacy group based in New York City, 57% of C-section veterans who gave birth in 2005 were interested in a VBAC but were denied the option of having one.

Pamela Paul, the author of the article, wrote the backstory to it in the Huffington post. Go read it here.

Even if a repeat cesarean section is necessary, care should be taken not to do it too early. Read here about the risks associated with early c-sections. The bottom line is, if you've had a cesarean section and are faced with a decision about what to do for future births, make sure you're well informed. Discuss the issue at length with your care provider. Find out not only their stance on the subject, but their actual VBAC and c-section rates. And if you do decide to (or need to) go for a repeat c-section, wait as close to your due date as possible, preferably even a trial of labor before to ensure baby is ready to be born.

9 comments:

Science Teacher Mommy said...

And even better, to prevent the problem in the first place, is for providers to everything humanely possible to avoid that FIRST cesarean. In a country where the nationwide Cesarean rate approaches 20% (higher in some areas), we need to redefine the line between EMERGENCY and some supposed sense of CONVENIENCE.

Doreen said...

STM, absolutely agreed. And 20% is actually only the rate of primary cesareans. Overall, it's 31%. Very sad. :o( What really gets me upset about the VBAC issue is that women who did have a primary c/s for a true emergency may go on to have perfectly healthy and normal pregnancies later. And they are almost automatically disqualified from ending those pregnancies in a normal, vaginal birth.

Keith and Nicci said...

In Vegas they have the "no VBAC after C-section" rule and it makes me so mad. I talked to a girl who had an emergency c-section with her first, and really wanted a VBAC here for her second, and after searching for months was only able to find 2 doctors in all of LV who would even consider her request.

tearese said...

I had read all that stuff, and was so glad I had a doctor supportive of my having a VBAC with Joshua! Especially since lots of people here say in this area that is very rare.
But my mom's third pregnancy was a c-section in the early eighties. While the doctors wanted her to have a c-section for her last two pregnancies, she flat out refused, and had a vbac anyway. So I think if the mother is firm enough, and there is really not big reason they have to have another c-section (like if they had a t-incision or something) the mother's choice should determine the birth method.
And yes, my c-section was an emergency.

tearese said...

(To clarify- I lived somewhere else with my two prior pregnancies. I'm saying I'm glad I didn't live here, because my vbac may not have been a possibility!)

Doreen said...

Tearese, believe it or not, there have been cases of court ordered cesareans. Read this. Who are you seeing with this pregnancy? Are you going to be okay for a VBAC, since you've already had one?

Baby Oven said...

What a scary article. After having my emergency c-section I wouldn't wish a c-section on my worst enemy. Lucky for me, my doctor now will allow a vbac as long as I don't have the same issues as last time. Hopefully we don't move for awhile!

Sabrina said...

Just read this article yesterday. I was surprised there was no information about how commonly they are now "elective" and whether or not hospitals/OBs are working to prevent having this major surgery. It's very sad that insurance determines so much of our country's health care.

tearese said...

That article was ridiculous! At least she was able to find another practice.

The doctor here didn't say anything about a c-section. With Josh there were a few complications that almost led to one, but the attending doctor (neither time was the attending dr. my actual doctor) gave me the option of trying other things first.
I hope they are that way here too, as there is always the possibility....