The Trouble With Repeat Cesareans (Time Magazine)

Time Magazine is starting to get it... the mainstream media is publishing articles that are telling the truth about what has gone wrong in our modern maternity care system.


"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..."

Read the full article here at Time.

Are We Causing Our Incredibly High Preterm Rate?

The San Francisco Chronicle on the national trend towards C-section:

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.

Read the rest of the article here.

Study: Vaginal Delivery May Increase Maternal Responsiveness to Newborns

Yet another study telling us another good reason why cesarean birth should be avoided when possible.

"We found a significant difference in activity in certain cortical and subcortical areas of the brain in this group of mothers who delivered vaginally compared with those who delivered by cesarean section. Broadly speaking, the cortical brain regions are believed to be important for regulating emotions and empathy," principal investigator James Swain, MD, PhD, FRCPS, told Medscape Psychiatry.

....While the mechanism is not entirely clear, researchers believe vaginal stimulation caused by vaginal delivery results in the release of oxytocin, a neuropeptide that is a key mediator of maternal behavior in animals.

Cesarean section, said Dr. Swain, may alter the neurohormonal experience of childbirth and therefore may decrease the responsiveness of the human maternal brain in the early postpartum.

The investigators are currently looking at 3- to 4-month postpartum data to determine whether these effects of vaginal delivery on the maternal brain endure. Although the final analyses are not complete, Dr. Swain said preliminary analysis in this healthy group indicates the contrast between the 2 groups may not persist, suggesting that mothers who deliver via cesarean section may eventually "catch up" to those who deliver vaginally.

-- Medscape Medical News

Some time I'm gonna compile a list of all the reasons why one should try to avoid a c-section.

As one of my doctor friends says, "We talk about the 'hard' outcomes - the deaths, the morbidity... When do we factor in the 'soft' outcomes - like breastfeeding and bonding and emotional health and on and on?" And then as she often states so simply and yet so meaningfully, "Birth matters. It really does. We better get it right."

Is It Safer to Have Another Cesarean or Attempt a Vaginal Birth (VBAC)?

And the evidence in favor of vaginal birth over repeated cesareans just keeps piling up!
Check out this most recent study, just published in the journal of
Obstetrics & Gynecology
(2008;111:285- 291).

The study's OBJECTIVE:
To estimate the success rates and risks of anattempted 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. Contrast that study with another from Obstetrics & Gynecology (2006;107:1226- 1232) which found that there is maternal morbidity associated with multiple repeat cesareans.

OBJECTIVE:

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.