Well It’s About Time!

If you’re a faithful reader of this blog and/or a fellow birth junkie, the following article will not come as a big surprise — Cesarean Sections Linked to Future Birth Risks. It warns of the dangers of placenta accreta or percreta in future pregnancies (accreta is when the placenta implants too deeply into the uterine wall; percreta is when the placenta actually grows through the uterine wall and attaches to other organs). The only surprising factor to me was that it was an article in a non-birth publication which strongly warned of the danger of C-sections. All too often, the standard argument in most mainstream articles (and by that, I mean non-birth-oriented publications) is a “balanced” picture of C-sections versus vaginal birth, with the pros and cons of both sides being presented as basically equal. There are pros and cons to both sides, but that doesn’t mean that they are balanced or roughly equal. If a mom or baby truly needs a C-section, then obviously, the balance tips dramatically in the favor of a C-section; but if the surgery is not medically necessary, then vaginal birth obviously is favored for both mom and baby.

The first mom mentioned had placenta percreta (in which the placenta grows through the uterine wall, and in her case invaded her bladder), forcing the doctors to end her pregnancy 4 months early. Her baby is still struggling to survive, and she lost her uterus. She wanted four children. She says after her first baby was born by C-section, she expected “lots of C-sections” in order to have the size of family she wanted — I guess she was told “once a C-section, always a C-section,” because it doesn’t sound like she even thought of attempted VBAC. Not that it ultimately mattered in her case, since her first post-op pregnancy cost her her uterus, but placenta accreta and percreta increase exponentially with every additional surgery, so for many women, it may be their 2nd, 3rd, or 4th unnecessary C-section which costs them their ability to bear children, and possibly the life of their baby, and even potentially threatens their own life.

The article also quotes the rate of placenta accreta as being 1/30,000 in the 1950s, but current studies show a rate of 1/2500-500! Yikes!

I’ve seen some “VBAC Consent Forms” which pretty much magnify the risks of VBAC, particularly uterine rupture, which can be devastating or even deadly for the baby. But the risk is small, especially in labors that are allowed to begin or continue naturally; and if the care providers are monitoring the mother and baby, they can usually get early warning that something is wrong (like the mother feeling the pain of her uterus splitting, or the baby’s heartbeat showing signs of distress), so the absolute risk of death or severe morbidity to the baby is low. Often the consent forms tell the mother that if she has a VBAC, her baby is the one that will be put at risk, whereas if she chooses a C-section, then she’ll be the one that has more risks (from the actual surgery, which has a higher rate of blood loss necessitating transfusion, risk of hysterectomy, infection, etc.). Put that way, most women will feel selfish for wanting a vaginal birth, so sign up for a repeat C-section. However, this article points out that even one C-section increases the risk of future placenta accreta/percreta, and each repeat C-section increases the risk exponentially, so mothers may be choosing a repeat C-section to keep their current baby from the 1/200 risk of uterine rupture (with an even less risk of death or severe morbidity), while setting up a future baby to be in the position of the first baby mentioned in the article — being born much too early, and possibly dying or having severe long-term difficulties. Plus the mother may hemorrhage and necessitate a blood transfusion (perhaps even massive), and/or lose her uterus.

Read the entire article, because it is very informative. I wonder how many women are truly given informed consent before their first C-section, or any subsequent ones. Time for a VBAC-lash!

One Little Word

Well-Rounded Mama has an excellent and thoughtful post on the importance of one little word — that word being the change in ACOG’s guidelines in 1999 concerning VBACs, which changed from suggesting that doctors be “readily available” to being “immediately available.” Go read the article, pass it along to your friends, blog about it, etc. Even if you have not had a C-section yet (hey, neither have I!), read this article, because you never know when you will be faced with the knife, and then be forced into subsequent C-sections from then on, for no evidence-based reason! Besides, even if it doesn’t affect you personally, it probably affects several of your friends; and the climate that allows a VBAC ban is not a beneficial attitude for any birth-related practices.

ICAN VBAC ban/allow list!!

Earlier I blogged about the VBAC article in Time magazine, and now the awesome, wonderful, and amazing volunteers of ICAN have put together a comprehensive list of all the hospitals in America, and whether they allow VBACs or not. The number of hours that it took for all the volunteers to call the hospitals and enter the information was incredible — somebody estimated that it would have taken $100,000, had they been paid, so this truly was a tremendous effort.

Unfortunately almost half of the hospitals have either a formal VBAC ban or a de facto VBAC ban — that is, there is no official policy against allowing VBACs at that hospital, but no doctor will actually attend one.

But just because a hospital is listed as “allowing” VBACs doesn’t mean you’ll actually get one, or that it will be easy. Many of the volunteers who called hospitals noted that many hospitals or doctors had such strict guidelines for the VBACs they allowed that it would be difficult for anyone to actually have a successful VBAC. Some restrictions include that the woman has to have had a successful VBAC already in order to attempt another one, or at least that she has to have a “proven pelvis” — a vaginal birth. That means that if her first baby was breech and she’s currently pregnant with her second, then she will not be allowed even a chance at a vaginal birth. Other hospitals won’t allow women who have had more than one C-section to attempt a VBAC. Some hospitals or doctors require that women attempting a VBAC to give birth by 5:00 p.m., or be wheeled back for an automatic C-section — regardless of any other factor!

The Trouble With Repeat Cesareans

Woo-hoo!!! Finally! An article — in Time magazine, no less — that highlights the burgeoning number of women who are being forced to undergo “elective” repeat C-sections, since they are not allowed to attempt a vaginal birth.

While I had some quibbles with the wording of the article (doctors don’t perform VBACs — the mothers do!! Doctors perform C-sections! They attend vaginal births), it was an excellent and timely article.

Elective C-sections and the Risk to the Baby

Many women have a C-section for no medical reason, which is considered an “elective” C-section. Some of these include the “too posh to push” women; those who are afraid of labor and birth; those who want to schedule a “no-muss, no-fuss” C-section rather than go through the unpredictable and sometimes messy labor (which, by the way, I gotta question why these women even get pregnant in the first place — are not babies by their very natures unpredictable and sometimes messy? Perhaps the unpredictability and mess associated with labor somehow helps these women come to grips with the reality of life with a new baby, but I digress…); women who are not allowed to have a VBAC, women whose first birth was a C-section so go with what they know rather than attempt a vaginal birth, etc.

My husband’s cousin was sort of in this last group — her first baby was born preterm by C-section due to some health issue (I think pre-eclampsia, but can’t remember for sure right now), and her doctor told her she could have a VBAC IF she got all her work done and IF she could find something suitable to wear. No, wait a second, that was Cinderella’s wicked stepmother. No, her OB required that she go into labor naturally after she reached term but before the date of her already-scheduled C-section, which was at 38 weeks. Oh, yeah, just conjure up labor sometime in that week, and you’re good to go; if not, we’ll slice you open! Is it any wonder so many Cinderellas out there end up in rags instead of going to the ball?

But, a recent study (hopefully I’ll be able to find the article somewhere, but until then, I’ll make do with this) has looked at elective C-sections — that is, surgery for no medical reason — and found that babies who are born by C-section prior to 39 weeks have a much higher risk of complications, including respiratory distress, low blood sugar, infection or need for a respirator or intensive care. It also found that a full 36% of these elective C-sections were performed prior to 39 full weeks of gestation, which is the minimum age or cut-off point recommended by ACOG.

While “term” is considered to begin at 37 weeks, ostensibly, babies who are born after that time by C-section should not have any more problems than those born vaginally. However, in speaking of the difference between babies born at 37 weeks after the spontaneous onset of labor and those born at the same time with no labor but by elective C-section, one of the authors of this study says,

“We would not worry about a 37 1/2-week baby born vaginally with the onset of labor,” Thorp says. In that case, “there is some signal from a baby to his mother that says, ‘I’m ready …’ “

Hmm, maybe a baby should still be considered “premature” until the onset of labor. After all, while the exact mechanism may be unknown, it is accepted that, normally, the baby sends a “readiness” signal to his mother signifying to her body that he is ready to be born — he is mature enough to leave the womb and survive on the outside without the need of respirators and all the other gadgets I’m so glad exist to save the lives of premies.

Those born at 37 weeks were twice as likely

and those born at 38 weeks 50% more likely

to have a problem than those at 39 [weeks].

Wow, so nature knows best, huh? Who’d’a thunk it?

h/t to Dr. Jen for bringing the article to my attention

Early preterm birth by C-section

Here was an interesting article about the rise in late preterm births (34-36 weeks) in the United States. Here is an excerpt:

The Centers for Disease Control and Prevention have tracked an increase in preterm births for decades, with the percentage of births delivered before 37 weeks of gestation rising 21 percent between 1990 and 2006. That increase is the main reason the nation’s infant mortality rate has stubbornly refused to decline, remaining higher than most other developed nations.

Some preterm births were linked to mothers’ smoking, and others to the mothers’ lacking insurance. But more than 90 percent of the increase in preterm, nonmultiple births is attributable to an increase in babies being delivered by C-section at 34 to 36 weeks gestation, according to the March of Dimes.

“It comes from a general change in obstetric practice in our society,” said Dr. Alan Fleischman, medical director of the March of Dimes Foundation. “The doctors and the women are intervening in a much more aggressive style toward the end of pregnancy.”

Fleischman and other medical experts say there are a number of reasons doctors and mothers are choosing C-section delivery – and not all of them stem from medical necessity, the health of the mother or infant.