Judgment in the birth community: Fitting in after a cesarean

Judgment in the birth community: Fitting in after a cesarean

A woman who had four cesareans, after planning VBACs and home births, recently contacted me. She didn’t know where she fit into the birth community.

My heart went out to her because there have been periods in my life when I have felt isolated and alone. And it’s a crappy feeling.

I replied to her:

A vaginal delivery is not required to participate in the birth community. There are many cesarean moms just like you who are seeking compassion, connection, and understanding. You could be a soft place for other women to land as they mourn (or celebrate!) their cesarean deliveries.

The mission of VBAC Facts goes above and beyond our personal birth preferences. Really, the goal is education and access to VBAC.

The goal *is not* for everyone to have a VBAC because, as you know, there are many reasons why someone would have a cesarean birth, including scheduling an elective cesarean. And that is that parent’s choice! And those mothers are no less of a parent, advocate, or sister to those within the birth community.

I know one woman who had four cesareans and runs an ICAN chapter. Again, it’s not about how her births played out, but rather education and, ultimately, respecting the choices other parents make while holding space for them when birth doesn’t go as planned.

If you are feeling rejected, perhaps you need to find a new group of people to hang with! 🙂

We all don’t have to birth the same to support each other

The judgment that this mom is experiencing is why I spend so much time in my workshop, “The Truth About VBAC” talking about individualized risk assessment. This is a fancy way of saying, “There are a lot of different reasons that go into why someone plans a specific type of birth.”

I discuss this subject at great length, including all the factors that one might consider and the fact that both VBAC and repeat cesarean are valid options.

I really want to assure students that there is no Right Way to Birth. Only what is Right for Them.

Releasing the judgment about how other people birth

I also want to explore the subject so that people who staunchly believe that there is a Right Way to Birth can see how there are so many reasons why someone might choose to birth differently than them… and possibly release that judgment.

(That’s also why I recently revamped the VBAC Facts homepage to feature two cesarean births.)

The whole point is: How you birth, is up to you. It’s frankly no one else’s business. Not mine. Not your girlfriend’s. Not the PTA president’s. It’s Your Birth.

And no matter what birth you choose, if you believe that parents should have access to VBAC, VBAC Facts is your birth community.

I have said this so many times in so many venues and yet I still receive comments like this from email subscribers:

I’m leaning toward repeat c-section. I already feel you scrunching up your face. I feel shamed for going with repeat c-section. People assume I am ignorant to the facts. They assume a lot of things. I feel like I have to justify this decision to everyone.

Ouch. Dear reader, I don’t feel that way at all. It hurts my heart that what should be a joyous time in your life is filled with deflecting the unsupportive opinions of others. Regardless of how you birth, your choices should be respected because it’s Your Birth.

Supporting access and respect, not dictating outcomes

It’s tough because there is so much judgment and so much defensiveness when it comes to birth and even what advocacy really means.

For me, VBAC advocacy is about access to VBAC, which is very different than saying, “I think everyone should have a VBAC.” And because my focus is access and not a specific mode of delivery, I don’t judge women who plan to have a repeat cesarean section. Full stop.

One of the reasons why I started VBAC Facts is that I saw people cherry picking information, misinterpreting the conclusions of medical studies, and basically manipulating the facts in order to convince other people to make the same birthing decisions they did.

Because they judged those that birthed differently than them.

How what other people think can impact your options

I created VBAC Facts, and I ultimately developed educational programs, so parents, birth professionals, and even medical providers could get the actual facts. The actual statistics. The actual recommendations. Rather than basing their opinion on someone else’s personal risk assessment of what was “safe” or “risky.”

And sometimes what other people think – like the Head of Obstetrics at your hospital or your hospital administrator – can set the tone of your facility and even if they “allow” you to attend VBAC.

And for pregnant people, it can be the well-intended, but misinformed opinion of their friends and family. And that judgment and disapproval is enough to persuade some mothers to schedule a repeat cesarean just to keep the family peace.

It’s all about learning the facts so you can make your own decisions… and giving others the space to make theirs. And once people realize that there is no Right Way to Birth and that everyone knows the Right Way for Them, we can truly celebrate how we each start and grow our families without judging each other for how we do it. That’s what I call #factsoveragenda.

How do you describe your birth community? As a cesarean parent, how were you received and did you feel supported? If not, where did you go to find support?

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.

A woman who had four cesareans, after planning VBACs and home births, recently contacted me. She didn’t know where she fit into the birth community.

My heart went out to her because there have been periods in my life when I have felt isolated and alone. And it’s a crappy feeling.

I replied to her:

A vaginal delivery is not required to participate in the birth community. There are many cesarean moms just like you who are seeking compassion, connection, and understanding. You could be a soft place for other women to land as they mourn (or celebrate!) their cesarean deliveries.

The mission of VBAC Facts goes above and beyond our personal birth preferences. Really, the goal is education and access to VBAC.

The goal *is not* for everyone to have a VBAC because, as you know, there are many reasons why someone would have a cesarean birth, including scheduling an elective cesarean. And that is that parent’s choice! And those mothers are no less of a parent, advocate, or sister to those within the birth community.

I know one woman who had four cesareans and runs an ICAN chapter. Again, it’s not about how her births played out, but rather education and, ultimately, respecting the choices other parents make while holding space for them when birth doesn’t go as planned.

If you are feeling rejected, perhaps you need to find a new group of people to hang with! 🙂

We all don’t have to birth the same to support each other

The judgment that this mom is experiencing is why I spend so much time in my workshop, “The Truth About VBAC” talking about individualized risk assessment. This is a fancy way of saying, “There are a lot of different reasons that go into why someone plans a specific type of birth.”

I discuss this subject at great length, including all the factors that one might consider and the fact that both VBAC and repeat cesarean are valid options.

I really want to assure students that there is no Right Way to Birth. Only what is Right for Them.

Releasing the judgment about how other people birth

I also want to explore the subject so that people who staunchly believe that there is a Right Way to Birth can see how there are so many reasons why someone might choose to birth differently than them… and possibly release that judgment.

(That’s also why I recently revamped the VBAC Facts homepage to feature two cesarean births.)

The whole point is: How you birth, is up to you. It’s frankly no one else’s business. Not mine. Not your girlfriend’s. Not the PTA president’s. It’s Your Birth.

And no matter what birth you choose, if you believe that parents should have access to VBAC, VBAC Facts is your birth community.

I have said this so many times in so many venues and yet I still receive comments like this from email subscribers:

I’m leaning toward repeat c-section. I already feel you scrunching up your face. I feel shamed for going with repeat c-section. People assume I am ignorant to the facts. They assume a lot of things. I feel like I have to justify this decision to everyone.

Ouch. Dear reader, I don’t feel that way at all. It hurts my heart that what should be a joyous time in your life is filled with deflecting the unsupportive opinions of others. Regardless of how you birth, your choices should be respected because it’s Your Birth.

Supporting access and respect, not dictating outcomes

It’s tough because there is so much judgment and so much defensiveness when it comes to birth and even what advocacy really means.

For me, VBAC advocacy is about access to VBAC, which is very different than saying, “I think everyone should have a VBAC.” And because my focus is access and not a specific mode of delivery, I don’t judge women who plan to have a repeat cesarean section. Full stop.

One of the reasons why I started VBAC Facts is that I saw people cherry picking information, misinterpreting the conclusions of medical studies, and basically manipulating the facts in order to convince other people to make the same birthing decisions they did.

Because they judged those that birthed differently than them.

How what other people think can impact your options

I created VBAC Facts, and I ultimately developed educational programs, so parents, birth professionals, and even medical providers could get the actual facts. The actual statistics. The actual recommendations. Rather than basing their opinion on someone else’s personal risk assessment of what was “safe” or “risky.”

And sometimes what other people think – like the Head of Obstetrics at your hospital or your hospital administrator – can set of the tone of your facility and even if they “allow” you to attend VBAC.

And for pregnant people, it can be the well-intended, but misinformed opinion of their friends and family. And that judgment and disapproval is enough to persuade some mothers to schedule a repeat cesarean just to keep the family peace.

It’s all about learning the facts so you can make your own decisions… and giving others the space to make theirs. And once people realize that there is no Right Way to Birth and that everyone knows the Right Way for Them, we can truly celebrate how we each start and grow our families without judging each other for how we do it. That’s what I call #factsoveragenda.

How do you describe your birth community? As a cesarean parent, how were you received and did you feel supported? If not, where did you go to find support?

What do you think? Leave a comment.

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction. DOWNLOAD NOW

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.

Woman has 4th cesarean and requires 33 gallons of blood

Woman has 4th cesarean and requires 33 gallons of blood

Update: This powerhouse of a woman has since started the non-profit organization “Hope for Accreta Foundation.”


What a miracle this woman survived!  This was her fifth baby and fourth cesarean.

She had a complication known as placenta percreta which is when “the placenta attaches itself and grows through the uterus, sometimes extending to nearby organs, such as the bladder” (March of Dimes 2012).  The risk of having placenta accreta, increta, or percreta during a fourth cesarean or a VBA3C (vaginal birth after three cesareans) is 2.13% (1 in 47) (Silver 2006).

Image credit: Wikipedia

Image credit: Wikipedia

Most women planning a VBA1C (vaginal birth after one cesarean) are aware of the risks of uterine rupture.  However, women planning their first vaginal birth or VBA1C need the WHOLE picture so they can really work to prevent an unnecessary cesarean.  They need to understand the risks and benefits of VBAC versus repeat cesarean for mom and baby now as well as how current choices impact mom’s future health, fertility, delivery options, and complications that present in subsequent births.

A huge part of this – I believe – is hiring a vaginal birth/VBAC supportive care provider because once a woman has that first cesarean, her options narrow, and they do so even more drastically after that second cesarean.  As her options narrow, her risks increase and unlike uterine rupture which you can circumvent through a repeat cesarean, the risk of accreta, percreta, and increta are not as easily mitigated.

By avoiding one complication, we are increasing our risk for another serious complication in future pregnancies.  For women who plan for large families, this should be on your radar and every practitioner should be discussing intended family size with their patients so that it can be taken into consideration.

Read more about placenta abnormalities, the risks of multiple cesarean sections, the marketing of risk, and how reversing VBAC bans would make birth safer for everyone.

And please donate blood. These women need it.

Woman survives crisis delivery with 33 gallons of donated blood

Posted on April 11, 2012 at 9:46 PM

SAN ANTONIO — University Hospital is sharing an incredible story of survival. A San Antonio woman was saved during a crisis baby delivery. But it took more than 33 gallons of blood.

Two-month-old Addison Walker came into the world in an unusual way. Her mother, Gina, had a rare pregnancy condition called placenta percreta. The placenta invaded through the uterine wall into the bladder, causing massive bleeding during a delivery operation.

Doctors at University Hospital recalled the February eight-hour operation.

“Unfortunately, Ms. Walker had blood loss that superseded anything that we could have prepared for,” said Dr. Jason Parker, U.T. Health Science Center OB/GYN.

Walker lost more than ten times the amount of blood surgeons anticipated. She needed more than 33 gallons. That’s 540 units to keep her alive.

“After I watched cooler after cooler after cooler with my wife’s name on it full of blood going up and down the hallways, yeah, I did get worried,” recalled Gina’s husband Dustin. Read more.

A couple comments left on Facebook:

University is a Level 1 trauma center.  It is the trauma center in San Antonio.  Only other hospital that takes the worst of the worst is SAMMC [San Antonio Military Medical Center] which is the military hospital.  University takes all the gunshots, stabbings, multiple injury accidents, etc…. And these come in multiple times a day.  If any hospital has 100+ units on hand it would be that hospital.  Even if it didn’t, it is literally a couple hundred yards from a half dozen other hospitals that could dip into their supply.

It’s approx $1060 per unit of blood from the blood bank, not including the one time cost of all the testing, which is about $400-500. (These costs depend on the facility, but are a ball park.) Think about what the cost of the blood alone was…

I laboured just fine with my attempted VBA3C but the labour pains at the end were intense and I needed some meds of sorts so I went off to the hospital only to be bullied into the surgery room. All stats were excellent with me and my baby (and noted by the doctors in surgery that my little girl was down the birth canal and had I only been given something to help with pain, I would have pushed her out just fine). Because of that unnecessarian I had to endure a 6 hour reconstructive surgery to fix the mistakes of all the other batched c-sections and to repair the fistula left by the 4th C. But in the meantime I got the pleasure of toting around a catheter for the 5 months in between surgeries. That’s on top of the other procedures, tests and pain I had to go through. All of this could have been avoided had the doctors not allowed me that very first c-section and all the others that were not required. I kick myself in the butt for not educating myself right from the beginning, but how was I to know the doctors wouldn’t be educated either!

I desire to go on to have more children, but am terrified for things like this article speaks of.

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.

Chipping away at the “too posh to push” myth

Chipping away at the “too posh to push” myth

Some new research questions the idea that women who are “too posh to push” are responsible for America’s rising cesarean rate. The work of University of Arizona sociologist Louise Roth has been featured in an University of Arizona UA News article dated April 13, 2012.

Watch for Roth’s research which will be “published in the May issue of the sociology journal Social Problems, published by the Society for the Study of Social Problems.”

I’ve highlighted a few passages for those who like to skim.

By Jeff Harrison, University Communications, April 13, 2012

UA sociologist Louise Roth says the increasing number of cesarean deliveries negatively impacts the health of women and their children and health-care costs.

University of Arizona sociologist Louise Roth wonders why women, at least according to news reports, are increasingly opting to give birth by cesarean section, rather than via natural delivery. Stories have focused on better-educated and more well-to-do women having the surgical procedure, a phenomenon dubbed “too posh to push.”

Roth, an associate professor of sociology who is interested in the effects of malpractice and, more generally, on the impact of the organizational environment on maternity care, looked at the data surrounding the issue and found herself totally stumped.

“I’d been reading a lot in the news about how women were choosing to have cesareans, and what I discovered was that women you would expect would have more cesareans – if that story were true – were not the women who were more likely to have them,” Roth said.

“In fact, the women who were most likely to have cesareans were low-education, Black and Hispanic women, which was not what I expected based on the ‘too-posh-to-push’ story. That was the impetus of this paper. I started playing with the data and found this finding that seemed counter-intuitive to me, and so I decided to investigate further.”

The results of her study will be published in the May issue of the sociology journal Social Problems, published by the Society for the Study of Social Problems.

Roth said the disparities in the rates of cesareans are an important issue because the procedure is tied to maternal deaths and the cost of health care. One key issue is understanding the “pervasive racial-ethnic and socioeconomic disparities in maternity care (and) health care more generally, yet there has been little scrutiny of how overuse of cesarean deliveries might be linked to these disparities.

Roth poured through a year’s worth of data, approximately 4 million recorded births in 2006, the most recent year available. Black, Native American, Hispanic and women from lower socio-economic backgrounds were less likely to have needed cesareans or more likely to have medically unnecessary cesareans.

Either scenario has potentially negative outcomes for both the mother and child. While maternal deaths are statistically low, they still are a concern to public health officials – and deaths from c-sections are four times higher than from vaginal births. Likewise, infants born earlier than 36 weeks, whether naturally or via c-section, are at higher risk for respiratory ailments.

What then is driving the increase in surgeries? Roth asked several researchers, including one who studies cesareans, if this trend was because women want them.

“I think the answer is ‘no.’ Women can have different preferences, but those who have the most ability to exercise those preferences seem to exercise them in the direction of avoiding cesareans rather than choosing them,” she said.

What’s more, lack of prenatal care does not seem to be a factor, and Roth noted that women who get more prenatal care are more likely to have cesareans.

There are other confounding issues. Some studies suggest women in a higher socio-economic status are more likely to get cesareans because they are getting more care than would otherwise be warranted. Other literature report that minority women are more likely to get cesareans.

“I have a statistical model where I account for all of those clinical indications. And when we look at the cases where the clinical indications don’t appear to be there, who is more likely to end up with a cesarean delivery?”

“One thing I find is that if you just look at education alone, with rising education, there are more cesareans, which would suggest that it is the more affluent women who are being overtreated,” Roth said.

“But that is because they are older and maternal age is correlated with cesarean delivery. Once you take that into account, you see that education is actually associated with a much lower probability of having a cesarean.”

A woman who is the same age but has less education is actually more likely to have a cesarean delivery, she said.

“There is that confounding effect that if you look at education alone, without accounting for all those other factors, you might think the ‘too-posh-to-push’ story might be correct. But once you look at everything together, you see that it is not. In fact, it’s the opposite. The ‘posh’ women are more likely to avoid the cesarean.

From a public policy standpoint, Roth said the rising number of cesarean deliveries significantly contributes to the high cost of health care, as well as increasing the risks for women in subsequent pregnancies. Insurance companies and Medicade plans pay more for cesarean deliveries. Hospitals are able to charge more for them.

One goal of her research is dispelling the myth that cesarean deliveries have increased are because women are choosing to have them.

“The most recent data, the last two years suggest that the increase is close to a third, so it is very high, and higher than would be clinically recommended. There also are things that suggest that practice patterns are the cause of this, not the choices that women make,” Roth said.

“In a larger way, there hasn’t been that much attention paid on the beginning of life and the unnecessary costs that are incurred at the beginning of life through these practice patterns.

“There is some discussion of end-of-life care, but not that much on maternity care and how the maternity care system could be made more cost-effective and lead to public health improvements. These things have implications, especially in subsequent pregnancies.”

Contact Info
Louise Roth
UA Department of Sociology
520-621-3531
lroth@email.arizona.edu

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.

Placenta problems in VBAMC/ after multiple repeat cesareans

Placenta problems in VBAMC/ after multiple repeat cesareans

I thought that I would take the data from the Silver (2006) that I’ve previously discussed and share it in a different way that would be helpful to women with multiple prior cesareans.  (You might find it worthwhile to read this article specifically, where you can view the data below in graphs, as well as other articles on placental abnormalities first.)  Remember that accreta is when the placenta abnormality deeply attaches into the uterus requiring surgical removal.  There is a 7% maternal mortality rate with accreta as well as a high rate of hemorrhage and hysterectomy.   One of the factors that determines your risk of accreta or previa is your number of prior cesareans.

Whether a mom has a repeat cesarean or a VBA1C, her risk of accreta (including increta and percreta) and previa in that pregnancy are:

risk of accreta: 0.31% (1 in 323)
risk of previa: 1.3% (1 in 77)
risk of accreta if previa is present: 11% (1 in 9)

Whether a mom plans a third cesarean or a VBA2C, her risk of accreta and previa in that pregnancy are:<

risk of accreta: 0.57% (1 in 175)
risk of previa: 1.14% (1 in 88)
risk of accreta if previa is present: 40% (1 in 2.5)

If a mom plans a fourth cesarean or a VBA3C, the risk during that pregnancy increases to:

risk of accreta: 2.13% (1 in 47)
risk of previa: 2.27% (1 in 44)
risk of accreta if previa is present: 61% (1 in 1.6)

The jump in risk from two prior cesareans to three prior cesareans is pretty huge…

If mom plans a fifth cesarean or a VBA4C, the risk during that pregnancy increases to:

risk of accreta: 2.33% (1 in 43)
risk of previa: 2.3% (1 in 43)
risk of accreta if previa is present: 67% (1 in 1.5)

If mom plans a sixth cesarean or a VBA5c, the risk during that pregnancy increases to:

risk of accreta: 6.74% (1 in 15)
risk of previa: 3.4% (1 in 29)
risk of accreta if previa is present: 67% (1 in 1.5)

Here are some stats to consider:

Silver (2006) found the following rates of accreta (including increta and percreta), during the first, second, third, fourth, fifth, and sixth cesareans: 0.24%, 0.31%, 0.57%, 2.13%, 2.33%, 6.74%.  (View a graph of this data.)

In other words, your risk of placenta accreta increases from first to sixth cesarean delivery:
1 in 417,
1 in 323,
1 in 175,
1 in 47,
1 in 43,
1 in 15.

Read more about accreta.

The studies that have been conducted (that I’m aware of) on uterine rupture in VBAMC are kind of small (including hundreds, not thousands of women).  So I don’t think we have an accurate idea of VBA3C rupture risk.  This site is a great resource.

Update:  When I posted a link to this article on Facebook, a mom left this comment:

Thank you for posting. My friend had 2 previous c-sections, and with her 3rd pregnancy had the bad luck of having both placenta accreta and placenta previa (both risks of repeat c-section). Her pregnancy was awful..lots of bleeding, hospitalizations, steriods and other drugs to help hold onto the pregnancy and bedrest at 20 weeks. They couldn’t do cerclage because of the placenta previa). In the end she had a healthy baby, but a 5 hour c-section surgery where she lost a lot of blood and needed a blood transfusion of 6 units of blood. She had to have a hysterectomy and also they removed part of her bladder because her placenta had embedded so far it was attached to her bladder! She was pissed that her doctor never warned her of the risks of repeat c-sections. She is 39 years old.

[and]

yes, you can share my comment. again, my friend ultimately is ok bec she was planning on having her tubes tied after this 3rd unplanned pregnancy — but she was upset initially bec her OB never shared with her any of these risks of repeat c-section…and she said “had I known, I would have really pushed for a vbac with #2”

These are the complication rates that Silver 2006 found in 30,000
women during multiple cesareans.The rates quoted were what he found during the third CS but, I think
the accreta and previa rates illustrate the risks that are present
during a third pregnancy after two prior CS.In other words, whether a mom has a third CS or a VBA2C, her risk of
accreta and previa in that third pregnancy are:

risk of accreta: 0.57% (1 in 175)
risk of previa: 1.14% (1 in 88)
risk of accreta *if* previa is present: 40% (1 in 2.5)

If she has a third CS and becomes pregnant again, the risk during that
fourth pregnancy increases to:

risk of accreta: 2.13% (1 in 47)
risk of previa: 2.27% (1 in 44)
risk of accreta *if* previa is present: 61% (1 in 1.6)

Compare that to the risks in a first pregnancy:

risk of accreta: 0.24% (1 in 417)
risk of previa: 6.4% (1 in 16) [yes, that figure is correct, previa was the reason for many of these women’s primary CS] risk of accreta *if* previa is present: 3% (1 in 33)

That means the risk of accreta increases 887% from the first pregnancy – a huge jump.

So, if it was me, getting that ultrasound and knowing I didn’t have these complications would give me huge peace of mind.

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.

Just kicking the can of risk down the road

Just kicking the can of risk down the road

This is why cesareans should not be casual or performed for the convenience of anyone.  They should be reserved for real medical reasons so that the benefits of having the cesarean outweigh the risks.  And there are real risks to cesareans, but since the ones list below are future risks, they may seem less real.  Per a November 2011 study published in the Journal of Maternal-Fetal and Neonatal Medicine:

If primary and secondary cesarean rates continue to rise as they have in recent years, by 2020 the cesarean delivery rate will be 56.2%, and there will be an additional 6236 placenta previas, 4504 placenta accretas, and 130 maternal deaths annually. The rise in these complications will lag behind the rise in cesareans by approximately 6 years.

Placenta previa and accreta are nothing to mess around with.  Accreta in particular has a very high maternal mortality rate and many mothers end up having cesarean hysterectomies.   I write more about accreta here.

Many women do not think these complications are applicable to them as they don’t plan on more children after their two cesareans.  But I know many women, and I’m sure you do too, who were not planning on more children, but got pregnant nonetheless.  Unless you or your partner get sterilized or practice abstinence (what fun!), the chance of you getting pregnant is there.

By performing routine scheduled repeat cesareans, we do reduce the risk of uterine rupture in the current pregnancy, but we are also increasing the risks of accreta, previa, maternal death as well as uterine rupture in future pregnancies.  In addition, another large study found

[t]he risks of placenta accreta, cystotomy [surgical incision of the urinary bladder], bowel injury, ureteral [ureters are muscular ducts that propel urine from the kidneys to the urinary bladder] injury, and ileus [disruption of the normal propulsive gastrointestinal motor activity], 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.

And this is especially relevant in rural hospitals which institute VBAC bans because they don’t offer 24/7 anesthesia.  Even though the “immediately available” clause was removed in the latest (2010) ACOG VBAC Practice Bulletin, many of these bans still stand.

However, in order to rapidly respond to the potentially sudden diagnosis of accreta, previa, or abruption, the hospital will have to enact many of the same ideas provided at the 2010 NIH VBAC Conference on how a hospital without 24/7 anesthesia can safely offer VBAC and respond to uterine rupture.  So why not just institute those ideas from the get-go and offer VBAC to those who want it?  (I know, I know: medico-legal reasons, which the NIH also addressed, but that is another post.)  From VBAC Ban Rationale is Irrational:

 As David J. Birnbach, M.D., M.P.H (2010), who presented on the impact of anesthesiologists on the incidence of VBAC [at the 2010 NIH VBAC Conference] asserted:

Lack of immediate available of anesthesia may not always be a key factor in outcome [during a uterine rupture], especially in cases where the obstetrician is not present. Many cases of uterine rupture can be stabilized while the anesthesiologists becomes available, and examples have been suggested of ways to reduce the risk associated with such a crisis. These include antepartum [prenatal] consultation of VBAC patients with the anesthesia departments, development of cesarean delivery under local anesthesia protocols, finding methods of improving communication on labor and delivery suites, practice “fire-drills,” and development of protocols matching resources to risk.

I urge you to watch Dr. Birnbach’s presentation along with all the presentations from the 2010 NIH VBAC conference.

Read more about the how the risk of serious complications increase with each cesarean surgery.

Below is Silver’s (2006) study abstract:

J Matern Fetal Neonatal Med. 2011 Nov;24(11):1341-6. Epub 2011 Mar 7.

The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality.

Solheim KN, Esakoff TF, Little SE, Cheng YW, Sparks TN, Caughey AB. Source Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA. Abstract

OBJECTIVE: The overall annual incidence rate of caesarean delivery in the United States has been steadily rising since 1996, reaching 32.9% in 2009. Primary cesareans often lead to repeat cesareans, which may lead to placenta previa and placenta accreta. This study’s goal was to forecast the effect of rising primary and secondary cesarean rates on annual incidence of placenta previa, placenta accreta, and maternal mortality.

METHODS: A decision-analytic model was built using TreeAge Pro software to estimate the future annual incidence of placenta previa, placenta accreta, and maternal mortality using data on national birthing order trends and cesarean and vaginal birth after cesarean rates. Baseline assumptions were derived from the literature, including the likelihood of previa and accreta among women with multiple previous cesarean deliveries.

RESULTS: If primary and secondary cesarean rates continue to rise as they have in recent years, by 2020 the cesarean delivery rate will be 56.2%, and there will be an additional 6236 placenta previas, 4504 placenta accretas, and 130 maternal deaths annually. The rise in these complications will lag behind the rise in cesareans by approximately 6 years.

CONCLUSIONS: If cesarean rates continue to increase, the annual incidence of placenta previa, placenta accreta, and maternal death will also rise substantially.

Resources Cited

http://www.ncbi.nlm.nih.gov/pubmed/21381881

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.

Two-Thirds of OB-GYN Guidelines Have No Basis in Science

Two-Thirds of OB-GYN Guidelines Have No Basis in Science

PushNews from The Big Push for Midwives Campaign
CONTACT: Katherine Prown, (414) 550-8025, katie@pushformidwives.org
FOR IMMEDIATE RELEASE: August 15, 2011
Study: Two-Thirds of OB-GYN Clinical Guidelines Have No Basis in Science
Majority of ACOG Recommendations for Patient Care Found to Be Based on Opinion and Inconsistent Evidence
WASHINGTON, D.C. (August 15, 2011)—A study published this month in Obstetrics & Gynecology, the journal of the American College of Obstetricians and Gynecologists, found that barely one-third of the organization’s clinical guidelines for OB/GYN practice meet the Level A standard of “good and consistent scientific evidence.” The authors of the study found instead that the majority of ACOG recommendations for patient care rank at Levels B and C, based on research that relies on “limited or inconsistent evidence” and on “expert opinion,” both of which are known to be inadequate predictors of safety or efficacy.

“The fact that so few of the guidelines that govern routine OB/GYN care in this country are supported by solid scientific evidence—and worse, are far more likely to be based on anecdote and opinion—is a sobering reminder that our maternity care system is in urgent need of reform,” said Katherine Prown, PhD, Campaign Manager of The Big Push for Midwives. “As the authors of the study remind us, guidelines are only as good as the evidence that supports them.”

ACOG Practice Bulletin No. 22 on the management of fetal macrosomia—infants weighing roughly 8 ½ lbs or more at birth—illustrates the possible risks to mothers and babies of relying on unscientific clinical guidelines. The only Level A evidence-based recommendation on the delivery of large-sized babies the Bulletin makes is to caution providers that the methods for detection are imprecise and unreliable. Yet at the same time, the Bulletin makes a Level C opinion-based recommendation that, despite the lack of a reliable diagnosis, women with “suspected” large babies should be offered potentially unnecessary cesarean sections as a precaution, putting mothers at risk of surgical complications and babies at risk of being born too early.

“It’s no wonder that the cesarean rate is going through the roof and women are seeking alternatives to hospital-based OB/GYN care in unprecedented numbers,” said Susan M. Jenkins, Legal Counsel of The Big Push for Midwives. “ACOG’s very own recommendations give its members permission to follow opinion-based practice guidelines that have far more to do with avoiding litigation than with adhering to scientific, evidence-based principles about what’s best for mothers and babies.”

The Big Push for Midwives Campaign represents tens of thousands of grassroots advocates in the United States who support expanding access to Certified Professional Midwives and out-of-hospital maternity care. The mission of The Big Push for Midwives is to educate state and national policymakers and the general public about the reduced costs and improved outcomes associated with out-of-hospital maternity care and to advocate for expanding access to the services of Certified Professional Midwives, who are specially trained to provide it.

Media inquiries: Katherine Prown (414) 550-8025, katie@pushformidwives.org

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.