Tuesday, June 1, 2010

The dangers of repeat Cesarean deliveries

One of my biggest passions/obsessions is to advocate for natural birth, and the avoidance of unnecessary C-sections. Sadly, the rates of successfully achieving a natural delivery after a Cesarean (VBAC) have dropped into the single digits in recent years, while rates of surgical deliveries have now reached an all-time high of 1 in 3 births nationwide (with some cities/states/hospitals having rates as high as 70%).

These two factors combined mean that there are many ladies who will end up with a repeat Cesarean for no other reason than that she had one before. What many women may not realize fully is how the risks and dangers associated with that rise dramatically with each additional C-section.

For anyone interested in having a large family, or allowing God to determine the size of their family, this can be a serious health threat. So much so, that many OBs will strongly urge/pressure a lady having her third (or more) C-section to consent to having tubal ligation during the delivery, and medically speaking, I can certainly see their point. The mistake was to perform what was most likely an unnecessary surgery to begin with. I can right now think of probably a dozen or more ladies who all have three children after three C-sections, and who no longer can have kids although they would have loved to have more. It is such a sad state to be in.

I found the following article very shocking, but also informative.


Dangerous delivery shows peril of multiple C-sections

The worst surgical case of my residency came when we delivered my patient's baby by cesarean - her ninth cesarean birth.

The baby came out fine, but for the mother we suspected one of most feared complications in obstetrics - that her placenta had burrowed deep into the muscle of the uterus.

To get oxygen and nutrients to the fetus, the placenta needs to attach just a few millimeters deep into the uterus. We worried that hers had gone much farther and might eat through the entire thickness of the uterus, keeping it from shrinking back to its normal size after delivery and causing a massive hemorrhage.

We gave a gentle tug on the umbilical cord. Usually the placenta peels off with such gentle pulling, but hers remained stuck - an ominous sign.

The case points out a fundamental truth about surgical delivery: a first cesarean for most women leads to a cesarean with every pregnancy. And while a first section is quick, easy to perform, and rarely complicated, each repeat surgery carries greater risk.

More and more women are finding themselves on the C-section path. Almost one in three babies was delivered by cesarean in 2007, the most recent year for which data are available, an increase of more than 50 percent from a decade earlier.

At the same time, it's becoming harder for mothers to avoid repeat surgery. The number of vaginal births after a C-section fell by two-thirds, to fewer than 10 percent, over the same time period. This year, the National Institutes of Health estimated that since 1996, one-third of hospitals and one-half of doctors who offered vaginal births after a C-section no longer do so.

"There can be tremendous morbidity after three or four or five prior cesarean deliveries," said Gary Cunningham, an OB-GYN professor and former department chair at Southwestern Medical School in Dallas, who chaired the NIH panel.

"Women need to be counseled appropriately and accurately so that they can make an informed decision," Cunningham said. "But this doesn't do much good if she cannot find an obstetrician or hospital that will allow a trial of labor."

Repeat C-sections pose more risk than a first section for many reasons. One factor concerns anatomy. When a doctor performs a first cesarean, the layers of tissue look and feel very different from each other. These visual cues and textures guide the surgeon, indicating exactly where to cut.

The surgery is simple: the surgeon cuts, spreads, and pokes, layer by layer, until reaching the baby. The surgeon first opens the skin a few centimeters above the pubic bone. The fat underneath easily gives way until the connecting fascia is reached. The tough, fibrous fascia, which holds the intestines in the abdomen, is cut at the midline and opened in either direction. The beefy abdominal muscles beneath are spread.

Finally, the glossy peritoneum, the last layer of the abdomen, is entered, and only the uterus lies between the doctor and the baby. In a term patient, the maroon, swollen uterus, flanked by finger-size veins, fills almost the whole abdomen, pushing the intestines up. The surgeon moves the bladder out of the way, cuts the lower uterus open, and is met by a baby's foot, face, elbow, or behind, depending on how the baby is positioned.

The surgeon loses the advantage of good anatomy after the first section. The tissue undergoes scarring, toughens, and blends together as it heals. The variations in color and texture disappear. The intestines and bowel sometimes stick to the healing wound, putting them in harm's way the next time surgery is performed.

These changes increase the chances of an unexpected injury. "Her belly was cement," we'd say to one another during residency after a tough section.

A study from 2006 published in the journal Obstetrics and Gynecology compared C-section complications in more than 30,000 patients. Risks of requiring a large blood transfusion, incurring a bladder injury, needing to be on a ventilator, and ending up in intensive care all increased significantly with the number of sections after the first.

The study also showed greater risk for my patient's complication. Scarring on the inside of the uterus after a cesarean causes the placenta to attach abnormally in future pregnancies. During a first section, the risk of this complication was less than 1 in 400. After a sixth section, the risk ballooned to more than 1 in 15.

So we knew the risks my patient faced from her ninth cesarean and prepared the best we could. We matched extra blood, placed additional IV lines, and arranged for expert surgeons to back us up.

But with my patient's placenta stuck and bleeding, only one option remained: removing the entire uterus with the placenta still attached. Because the pregnant uterus is large, swollen, and filled with blood, a hysterectomy after a delivery is very dangerous and performed only as a last resort.

By the time we finished the surgery, blood covered the floor. Blood filled suction buckets, and saturated our sterile gowns and drapes. Blood-soaked sponges piled up in the corner.

My patient lost three times the entire blood volume of a normal person, sixteen liters in all. Only a massive transfusion kept her alive. Anesthesiologists pumped in 51 units of red blood cells and seven six-packs of platelets.

Vessels deep in her pelvis refused to stop bleeding, and instead of closing her, we packed her abdomen with surgical towels, hoping the pressure would stanch the slow, steady flow. She left the operating room and headed to the intensive-care unit with her abdomen still open.

After a reoperation the following morning and days in the ICU, she stabilized and slowly recovered.

With a first cesarean, the up-front costs - a few more days in the hospital, a longer recovery - may seem reasonable. Only in retrospect can the true costs become apparent.


19 comments:

  1. This does not surprise me at all and I am very glad that I armed myself with knowledge *before* I got to the delivery room. Luckily for me my husband was on board with my decision to go to c-section only if I (or the baby) was going to die. Also, I was very lucky to find out about hypnobirthing and prepared myself mentally for labour.
    You might also find the following link very interesting
    http://www.essentialbaby.com.au/parenting/pregnancy/natural-births-better-for-babies-20100530-wnl5.html
    hope things are looking up for you and that the morning sickness is abating

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  2. Thanks for posting this. I've had one C-section and am praying SO HARD that the Lord allows me to VBAC here in 1.5 months with my midwife. I want to have as many children as the Lord wants us to have and just hope that my mis-education during the first pregnancy doesn't mess that up. I'd appreciate your prayers--thanks again for the encouraging post!

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  3. I am also a huge advocate of natural birth and avoidance of unnecesareans, so I suppose it is ironic that I ended up with what was a very necessary C-section. My son is only 3 months old, but I am already doing everything I can (losing weight, etc.) to get a natural VBAC next time. I am only hoping that my experiences give me some credibility when advocating for natural childbirth with other women in the same boat. I'm devastated that I didn't get the natural birth I wanted, but I did stay in control of the situation the whole time, so that's encouraging. I can't help but feel like my body failed me and that I failed as a woman by not being able to deliver naturally, but I know that God is sovereign, and I WILL have a VBAC this next time! (will be a while due to LAM, but we'll see)

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  4. It is vitally important for women to be informed and proactive in their birth choices but sometimes things are taken out of our hands and a choice is needed to be made out of necessity. Unfortunately for me, I cannot give birth vaginally. True cephlo-pelvic disproportion is the case and after getting to full dilation with my first, the baby was moving UP during the contractions - the baby never even made it out of my uterus due to a large head and my fused pelvis. I was afraid but knew that God is in control of my fertility and He made me this way so He would bless us with a healthy child. I went on to have 5 more pregnancies, 3 more births and was given the doctor's blessing to "keep on going". Each of my other deliveries were c-sections as well and I healed very well with each one of them. Women need to educate themselves as to the truths of birth but they do not need to fear a c-section should it be necessary. I know numerous women who almost lost children because they refused a c-section and it wasn't until their husband stepped in after mom could no longer make a choice that the birth was able to happen. C-sections should never be done out of "convenience", "fear of birth pain" (it's SO much better to have your entire middle section cut open *rolling eyes*) or whatever and we need to be sure we have a doctor who is skilled in complications and able to handle difficult births if necessary. But I also thank God for the skills of my doctor and the way He made my body to heal well so that I could also experience the joys of motherhood and raising 4 gorgeous children for the Lord.

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  5. Wow. That is scary. I have really been trying to educate myself for this upcoming birth of our second baby as our first was a cesarean and I want to avoid a second at all costs.

    Part of the reason I had the first one is because during an oxytocin test (which is when oxytocin is given to the mother which stimulates mild contractions to see how baby will respond to true labor contractions) my daughter's heart rate would drop very low during a mild contraction and then come back up afterwards. (I wasn't told that I was being given an oxytocin test either...which I believe I should have.) They told me that the baby wouldn't handle hard contractions well at all and that I would have to have a c-section.

    I also felt like the cesarean was orchestrated in some ways. The reason is because the day before I was scheduled to be induced, I received a call from the doctor who would be on call during that time. She "wanted me to know" that I was high risk for a cesarean because #1: my baby was big
    #2: The baby hadn't dropped (which I was told that she had at a prior visit.)When I told her that I wanted to go into labor and try to deliver vaginally, she said "We can torture you if you want to do that". WOW!!!!!!!!!!! How unprofessional is that????

    I was also shocked because I hadn't heard the word cesarean throughout my whole pregnancy and had gone through 7 sonograms (due to my Lupus). I was also told by one of the doctors that I had a big pelvis and a perfect body to deliver the baby. So, as you can imagine all of this was very disheartening to hear.

    Well, the doctor got her way and I ended up with a cesarean (6 hours after being admitted to be induced and no labor experienced.) My daughter weighed in at 8 pounds and was 21 inches long. I believe the Lord had His hand in everything and trusted Him for leadership. I have now switched doctors to one who does VBACs on a regular basis and am hoping for a birth that I so desperately wanted for my first. Thanks for the post (and for putting up with my lengthy comment!) :)

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  6. A majority of my friends have been talked into c-sections. I myself was also. I naturally delivered a set of twins, then 7 years later was coaxed into a c-section with my second set of twins. They were both in breech presentation. I should have fought them, I should have gone ahead with a natural birth. They scared me into thinking my babies could die.

    I have a friend having a c-section in two weeks, just because she's had one already, and they did ask if they could tie her tubes since they'd be in there anyway.

    I know a woman who just naturally delivered breech twins, her 11th and 12th children and they are wonderfully perfect and healthy.

    If I'm ever blessed with more children, I'm having them at home away from the c-section knives.

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  7. Thank you for posting this. I am pregnant w/ my 2nd child. I had to have a c-section with my daughter. I had low amniotic fluid, but they were patient and allowed me to be induced, however my body and baby were not ready, so after 72hrs with still no progress, it was time to get her out. I'm praying that God will allow me to have a VBAC this time.

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  8. After having 3 natural deliveries I had a c-section last yr. because my son was "sunny side up" and after 3.5 hrs. of pushing we were making no progress and I was in extreme pain. They had tried a vacuum and that did nothing. So we agreed to the surgery. It was something I never thought I'd have to have and after the research I've done I think it could have been avoided. When a baby is sunny side up the position the mom is in is very important. I obviously was in the wrong position and was in so much pain I was afraid to move. If I have another baby I will use a different doctor (why didn't she know this?)and try a VBAC.
    Thanks for educating others in so many different ways.

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  9. My birth may not have gone as well as I planned it would(induction) but I am SO happy I refused the c-section they wanted to give me! I can honestly say I have you to thank Zsuzsa. Everyone else thought I was nuts for refusing, I was scared and didn't know what I was doing and I'm sure I would have caved into getting one had I not known better.

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  10. Katie, best of luck on your VBAC, I will be praying for you.

    Rachel, your best chance of achieving a VBAC is to have a home birth with a skilled midwife. Your next best choice (but not nearly as good) would be to find an OB who not only says that they "allow" VBACs, but who is actually a VBAC advocate, and has patients that successfully have them. Plus, you definitely want to have a doula at your birth in addition. Going to the hospital to give birth without a doula is like going to court without an attorney.

    Mamame, no doubt, some C-sections are necessary to save the life of mother and/or child. However, I believe that rate should be somewhere around 2% or less. Most conditions that today are given as a reason for C-section could have been prevented in the first place. True cephalo-pelvic disproportion is extremely rare, and usually only seen in women who either have injured/broken their pelvis in the past (i.e. in an accident) and it did not heal properly, or women who had poor nutrition during their growing years to the extent that their bones (including the pelvis) did not develop right. Many cases of CPD can be solved by proper chiropractic care, although I certainly am not disputing that there are true cases of this condition. I would advise anyone who has been given this diagnosis to get a second and third opinion, especially if it is not diagnosed until labor, and particularly if the labor is medically induced (those drugs can make the baby act in all sorts of disadvantageous ways).

    Sally, your story is unbelievable, and you should consider filing a complaint against your OB. For one, being artificially induced is nothing like experiencing true labor, and most women/babies do not respond well to it (hence the astronomically high c-sec rates after induction). It's like saying that honey and aspartame are the same because they both taste sweet - one is natural, the other artificial. Secondly, your OB clearly wanted to pressure and scare you into a cesarean all along for whatever reasons.

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  11. Kimmie, among skilled midwives, delivering breeches and twins naturally is a common occurrence. They actually know how to do it, while OBs usually never learn about these cases during their training because it spells automatic cesarean anyway. The midwife I see now has had only one hospital transfer (it resulted in a c-section) in the last 5 years, which is a rate of less than 1%. Even in that case, she said they had not exhausted all their options, but the mom finally just wanted to go to the hospital and get it over with. No doctor can even hold a candle to that. And no, most midwives don't pick and choose healthy clients. They usually never turn anyone down. Instead, they educate women how to have a healthy and safe pregnancy.

    ssbean, the medical profession always has a favorite card they like to play of why women need c-sections. A few decades ago, it was cephalo-pelvic disproportion (babies head too big to fit through the mother's pelvis). The current favorite by far is "low amniotic fluid". For starters, they have no way of measuring that within a reasonable margin of error. Secondly, if your fluid was in fact low, you should have been told to rest and drink lots of fluids. Thirdly, the fluid will be low at the end of your pregnancy because there simply is only a limited amount of space left in your abdomen to accommodate baby, uterus, placenta, and fluid. The vast majority of women who are induced with their first end up with a c-section. The mistake was for them to induce you in the first place. Good luck for a VBAC, please read my tips above on how to increase your chances of having one.



    Kerri, our first was born sunny side up, and it definitely hurt much worse, especially because I was also being induced with pitocin. Thankfully, by God's grace, I was still able to have him "naturally" (what they consider natural, anyway). I have never heard of this leading to a c-section, but then again, nothing surprises me any more. My nurse at the hospital coached me into various positions that helped bring the baby down, but that was back when the c-section rate was about 10% lower, in the low 20s (only 8 years ago). If you have this problem in the future, chiropractic adjustment (particularly by someone skilled in the Webster technique) is very helpful, as are various exercises you can do at the end of your pregnancy. A skilled midwife can determine the babies position simply by palpating your abdomen long before you go into labor.

    Karen, thank you. Your birth story was pretty rough, but I am glad you hung in and made it through.

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  12. This is great information! There is so much confusion out there. I had a successful VBAC at home!

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  13. Zsusa,

    I have a question about your advice to Rachel about having a VBAC at home with a midwife.

    I recently heard that it is against the law in AZ for a midwife (or doctor, for that matter)to attend a VBAC home birth. Have you ever heard that? I don't even know where to look for that info.

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  14. I've seen this article, too. It makes me angry, how the medical world is today, especially concerning women and birthing.
    I had to have a c-sec. with my very first baby, which could've been avoided if I hadn't been put through "the system," and then I went on to have 3 HOMEBIRTHS after that, totally unmedicated and completely natural in every way. So amazing, I can't even begin to tell you! Anyway, if there are to be more, I am hopeful this uterus of mine will hold up where the scarring is, I had each baby about 18 months apart so not a lot of time to heal but I am confident in my body's abilities and in faithful to God's plans. My sister is a doula and a HUGE advocate for women in these types of situations; it's often very hard for her to witness the system at work. You guys would have much to talk about!! ;-)
    Love your blog!

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  15. Heather, midwives in AZ are not allowed to attend HBACs (home birth after cesarean). There are only a handful of doctors who will do VBACs at the hospital, and only a few hospitals in the whole state that allow them. I know one lady who lives in Prescott (or was it Payson) was threatened with a court-ordered Cesarean because she was refusing to go back for an automatic repeat cesarean. In the end, she moved down to the valley to be close to one of the hospitals/doctors that allow them.

    You can read more about that subject here:

    http://stevenandersonfamily.blogspot.com/2009/08/court-ordered-cesareans.html

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  16. Thanks! Caroline was a VBAC (my 2nd twin Caleb was c-sec.), and I'm so thankful that my doctor never pressured me with another cesarean. I've thought about home births for the future, but that may not be an option for me I guess. Unless, of course, my hubby wants to do it! :)

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  17. Heather, if you want to have a home birth, you would have no difficulty finding a midwife that would take you on. Just because they're not allowed to doesn't mean that they don't do it. Especially in your case, since you have already had a successful VBAC, I am certain they would not turn you down.

    Home birth really is a great option. Our first was born "naturally" at the hospital, and as far as hospital births go, it really was not a bad birth at all. Still, the difference at home was like night and day. I would never ever go back to the hospital again unless the baby's or my life depended on it.

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  18. Great article, except for those of us that had no choice but to medically have a c-section. I have had three and I just found out I am expecting a 4th! And I am scared to death because all the articles like this on the web. I always wanted 4 kids, so I hope it goes well. Just keep in mind that a c-section 1st or 4th is not always a decision that can be "made" sometimes it's made for you.

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  19. I've had five kids four natural and one via c-section, because she was transverse breach and too big to turn as she was over 9lbs at 37 weeks. My doctor made an attempt at turning her which on put her into distress so really a c-section was my only option at that point. If you can manage to give birth naturally go for it, but should things go a bit pear-shaped and you end up with a real medical emergency there's no shame in doing what's best for you and baby. Granted I'd much rather recover from a vaginal delivery than a c-section. Sadly my fifth was my last age, a serious medical condition, and nearly miscarrying with her convinced me having my tubes tied during the c-section was for the best. Maybe when my youngest is older if I have any baby urges I can foster some that need a loving home.

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