One of the most pernicious problems with a primary (first-time) C-section, is that so many women nowadays are being denied the right to have a subsequent vaginal birth, and are required to have an “elective” repeat C-section. Some doctors refuse to attend them; some hospitals have it as policy that VBACs are not allowed. A large part of this problem is the malpractice insurance provider for either doctor or hospital that has it as part of their policy that they will not cover doctors or hospitals who participate in VBACs. The reason is the possibility of uterine rupture, which though rare is a known risk factor in an attempted VBAC (Overall — 7/1000 in that study — and this probably includes both catastrophic uterine rupture as well as the more benign uterine dehiscence; the breakdown goes as follows: Spontaneous TOL: 7/1544 or 4.5/1000; Prostaglandin E2 gel: 5/172 or 29/1000; Foley catheter: 1/129 or 7.75/1000; induction w/o cerv. ripening: 2/274 or 7.3/1000). The fact that other potential problems that can affect all women and their babies (such as a cord prolapse [2.34/1000, 4/1000, & 1.7/1000 were all figures given in published research; and this study said that obstetrical interventions contribute to 47% of cord prolapses], or placental abruption [9.9/1000, 6.5/1000]) together take place more than the known uterine rupture risk in an attempted VBAC (provided drugs like Pitocin, Cytotec and Cervidil or Prepidil are not used), does not alter the equation at all. It seems to me that the risks to the doctor ought to be the same, but since a previous C-section is a known risk factor for uterine rupture, and because ACOG has made it their guidelines that surgery be “immediately available” to a woman who attempts a VBAC, many hospitals are interpreting this as saying that a full surgical team must be in-hospital the entire time a VBACer is there in labor. Many hospitals, especially small rural ones, do not have this, so many women are being denied their legal rights by having an unwanted surgery forced on them, by an administrative decision made by a body of obstetricians, which is not legally binding. However, if a VBAC goes bad, and the woman decides to sue, you can bet your bottom dollar that the woman’s lawyer will bring up the ACOG guideline as if it were The Eleventh Commandment.
As I wrote in an email to an ICAN group,
So if they don’t induce or augment TOLACs, the rate (which may include dehiscence which is generally not associated with negative perinatal outcomes) is 4.5/1000, which is less than the rate of placental abruption — although women are not required to be at the hospital from 20 weeks onward, just in case their placentas suddenly decide to separate, and PA is definitely associated with higher perinatal morbidity and mortality (partly but not completely due to premature births) than is UR in labor, especially with dehiscence. Obstetric interventions contribute to almost half of all cord prolapses, which may be as high as 4/1000 (almost the rate of UR in TOLACs) but I bet docs aren’t required to be at the hospital before the L&D nurse is allowed to break any woman’s amniotic sac, or otherwise intervene. This study said that these interventions were not associated with higher perinatal morbidity and mortality, presumably because the woman was already at the hospital and quick action was taken. If this can happen for these women, why not VBACers?This also doesn’t begin to touch the future problems women may encounter during pregnancy and birth should they have multiple C-sections, which they will be required to do, if they can’t have VBACs and want more than 2 kids. I guess I should look up rates of placenta accreta/percreta/previa in uteri that are unscarred vs. 1 C-section, 2 C-sections, etc. These not only pose potential hazards for that baby but for the mom as well — and C-sections are more strongly associated with AFE than with vaginal births, too, which has a high maternal and perinatal mortality and morbidity.
Filed under: birth choices, C-section, informed consent, studies & stuff, VBAC | Tagged: amniotic fluid embolism, baby, birth, C-section, caesarean, cesarean, cesarean section, cord prolapse, health, ICAN, international cesarean awareness network, overturning vbac bans, placenta accreta, placenta percreta, placenta previa, pregnancy, pregnant, uterine dehiscence, uterine rupture, vaginal birth after cesarean, VBAC, vbac bans |