Friday, February 8, 2008

Speaking of Cesarean Section Rates...

As the US cesarean section rate in 2006 climbed to a dreadful 31.1%, more media attention is being drawn to this ever-increasing epidemic.

One cause for this number is the ban that many hospitals have on VBAC, touting it as an unsafe practice. In most cases, the "once a c-section, always a c-section" mantra becomes the only option a mother has.

However, a new research study again shows the safety of VBAC vs. repeat elective cesarean section. In fact, it shows that multiple VBACs carry less risk of complication than multiple cesarean sections.

Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Brian M. Mercer, Sharon Gilbert, Mark B. Landon, Catherine Y. Spong, Kenneth J. Leveno, Dwight J. Rouse, Michael W. Varner, Atef H. Moawad, Hyagriv N. Simhan, Margaret Harper, Ronald J. Wapner, Yoram Sorokin, Menachem Miodovnik, Marshall Carpenter, Alan Peaceman, Mary J. O'Sullivan, Baha M. Sibai, Oded Langer, John M. Thorp, Susan M. Ramin, for the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network
Obstet Gynecol 2008 111: 285-291.

OBJECTIVE: To estimate the success rates and risks of an attempted 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)0.52%(P=.03). The risk of uterine dehiscence and 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.

In contrast, this study demonstrates the increased risks that accompany repeat cesarean sections:

Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries. Robert M. Silver, Mark B. Landon, Dwight J. Rouse, Kenneth J. Leveno, Catherine Y. Spong, Elizabeth A. Thom, Atef H. Moawad, Steve N. Caritis, Margaret Harper, Ronald J. Wapner, Yoram Sorokin, Menachem Miodovnik, Marshall Carpenter, Alan M. Peaceman, Mary J. O’Sullivan, Baha Sibai, Oded Langer, John M. Thorp, Susan M. Ramin, Brian M. Mercer, for the National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network. Obstet Gynecol 2006 107: 1226-1232.

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.

One of the most telling statements is in the conclusion of the second study: repeat cesarean section affects your future reproduction. This means that if you are planning a large family, cesarean sections may make this impossible and limit the number of children you can carry.

I wonder what would happen to the primary c-section rate if true informed consent became the standard of care. I'm afraid we'll never know...


brooke said...

A friend forwarded me to your blog with this post. I ended up having to have a c-section after 18 hours of dilating and then 4 hours of pushing naturally with my second child in May. I was extremely sad about how it all ended and vowed to never do another c-section. I most definitely opt for a VBAC and am very glad to meet others who are for the same thing. Thank you for the friendly info!

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