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WWYD? Elective repeat caesarean or vaginal? - Page 2

post #21 of 49
Quote:
Originally Posted by velcromom
here is some info about the risks of repeat c/s from ICAN:


"Recently, a few physicians have claimed that elective primary cesareans and elective repeat cesareans are safer for babies, and even for mothers, than vaginal birth.1,2 While selective use of the medical literature might seem to back up this claim, a review of the studies which consider short- and long-term risks of cesareans does not.

Elective cesareans put babies and mothers at risk, use valuable and limited healthcare resources, have negative psychological and financial consequences for families, and substantially increase serious risks in subsequent pregnancies. The high rate of cesarean in the United States has not resulted in improved outcomes for babies or mothers. Additionally, vaginal birth after cesarean (VBAC) is still less risky for mothers and babies than cesarean section, despite recent claims to the contrary. ICAN is opposed to cesarean sections performed without true medical indication."


Risks to the baby from elective cesarean section

• Babies delivered by elective cesarean have an increased risk of neonatal respiratory distress syndrome (RDS), a life-threatening condition,3-7 and other respiratory problems that may require NICU care.

• Babies delivered by elective cesarean have a five-fold increase in persistent pulmonary hypertension (PPH) over those born vaginally.6

• Babies delivered by elective cesarean are at increased risk of iatrogenic (physician-caused) prematurity, usually related to failure to conform to protocols for determining gestational age prior to delivery, or errors in estimating weeks of gestation even with the use of clinical data.7,8 Prematurity can have life-long effects on health and well-being, and even mild to moderate preterm births have serious health consequences.9

• Babies delivered by elective cesarean are cut by the surgeon’s scalpel from two to six percent of the time.10 Researchers believe these risks to be underreported.


Risks to the mother from elective cesarean section


• Up to 30% of women who have a cesarean acquire a postpartum infection. Infections are the most common maternal complication after cesarean section and account for substantial postnatal morbidity and prolonged hospital stay.

• Other serious complications for women undergoing cesarean include massive hemorrhage,12 transfusions,13 ureter injury,14 injury to bowels,15 and incisional endometriosis.16,17

• Women who undergo cesarean report much lower levels of health and well-being at seven weeks postpartum than women who have vaginal births.18

• Women who undergo cesarean section have twice the risk of rehospitalization for reasons such as infection, gallbladder disease, surgical wound complications, cardiopulmonary conditions, thromboembolic conditions, and appendicitis. Rehospitalization has a negative social and financial effect on the family.19

• Women who undergo cesarean section report less satisfaction than women having vaginal births.20,21

• Women undergoing cesarean are at increased risk of hysterectomy in both the current and future pregnancies.22,23

• The maternal death rate is twice as high for elective cesarean as for vaginal birth.24

• In subsequent pregnancies, women with a prior cesarean have higher rates of serious placental abnomalities which endanger the life and health of the baby and the mother.25-27 Women are rarely told that a cesarean places future babies at higher risk.

• After cesarean section, women face higher rates of secondary infertility as well as higher rates of miscarriage and ectopic pregnancy.28,29


References are included if you view the paper at the ICAN site.
charles baudelaire,

Another , to what velcromom said to you.
post #22 of 49
Quote:
Originally Posted by dlm194
They ARE underreported. In fact, in my case, the hospital lied about them. My dd came out screaming and screamed for HOURS after she was delivered by c-section. I'd cry too if my first introduction to this world was having a knife cut my head.

The hospital told me that it must have happened in utero when "her head was banging against my pelvis." I was a mess of hormones and drugs making me loopy so it didn't occur to me to question them at the time. Wouldn't she have had bruising if it happened in utero? Funny how cuts in utero can be so straight and even. :
Dana,

, to what happen to you with your c-section and the hospital you had at.
post #23 of 49
As a VBAC mom, I can't say that I'd recommend anything else. I still can't fathom that physicians who take the hippocratic oath seriously wouldn't push for the same, if they actually looked at the evidence. (faulty studies not included!)
post #24 of 49
My opinion is to leave it up to the birth mother. The risks either method are not enough to try to tell her which to choose. She has done such a generous thing to carry the baby, since they are both within the realm of standard practice I would leave the choice up to her. If it were me I would probably, of course, want the VBAC, but I couldn't butt in and tell someone else what to do especially in this case. If she asked my opinion I would tell her but I wouldn't try to pressure her to chose an option she was uncomfortable with.

Good point about the surgery and avoiding some of the oxytocin effects. Especially if I didn't want any more kids in the future, maybe that would be something I would consider.
post #25 of 49
The risks are basically irrelevant to me since they are both pretty low - the real issue to me is that it's her birth, her choice. If she wanted a C-section and the parents wanted VBAC, I'd say the same thing.
post #26 of 49
VBAC. My body, my choice. I'd go with the odds that VBAC is safer and healthier for mum and baby. If the intended parents didn't agree I wouldn't carry a baby for them.
post #27 of 49
Thread Starter 
Quote:
Originally Posted by mara
My opinion is to leave it up to the birth mother. The risks either method are not enough to try to tell her which to choose. She has done such a generous thing to carry the baby, since they are both within the realm of standard practice I would leave the choice up to her. If it were me I would probably, of course, want the VBAC, but I couldn't butt in and tell someone else what to do especially in this case. If she asked my opinion I would tell her but I wouldn't try to pressure her to chose an option she was uncomfortable with.

Good point about the surgery and avoiding some of the oxytocin effects. Especially if I didn't want any more kids in the future, maybe that would be something I would consider.
It is up to Jane, and other than Janet and Jim feeling that a c-section is safest for the baby and not a substantial risk for Jane, they're not "insisting" or forcing her to choose one way or another: it really is her decision. They're just afraid that their one-and-only baby will die. However, what's at stake for Jane is that she wants the birth choice to be the one that's safest for the baby, but not at the expense of her life (reasonably speaking -- NO form of birth is without risk, and Jane is well aware of this).

Do me a favor, you study-knowledgeable mamas:

In terms of a percentage, what is the percentage of births that go wrong in a VBAC (unmedicated) and result in serious, permanent fetal injury?

In terms of a percentage, what is the percentage of births that go wrong in a VBAC (unmedicated) and result in death for the baby?

In terms of a percentage, what is the percentage of mothers who experience serious, permanent injury from a C-section or its complications?

In terms of a percentage, what is the percentage of mothers who die from a C-section or its complications?

Thanks again.
post #28 of 49
Perinatal mortality rate - babies that die:
3 per 1000 for planned vbac
4 per 1000 for elective cesarean


Maternal mortality rate - moms that die:
2.8 per 10,000 with a trial of labor
2.4 per 10,000 with an elective cesarean


The risk of a mother dying from a cesarean is small but is still considerably higher than with a vaginal birth:
Maternal death with cesarean: 4 in 10,000
Maternal death with all vaginal births 1 in 10,000
Maternal death with elective cesareans 2 in 10,000
Maternal death with all normal vaginal births 0.5 in 10,000

Countries with some of the lowest perinatal mortality rates in the world have cesarean rates under 10%. The World Health Organization says, "Clearly there is no justification in any specific region to have more than 10-15% cesarean section births."

The infant mortality rate in the US is currently 6.9/1,000. This report states "The United States continues to rank poorly in international comparisons of infant mortality."

The maternal mortality rate in 1996 (the last year statistics were available) was 12 per 100,000 births. There has been no decrease in maternal mortality in the US for 20 years according to a Mortality and Morbidity Weekly Report.*



Sources:
Trends in Cesarean Birth and Vaginal Birth After Previous Cesarean, 1991-1999
National Vital Statistics Reports, Volume 49, Number 13, December 27, 2001
A Guide to Effective Care in Pregnancy and Childbirth, Chapter 38, Labor and birth after previous cesarean, M. Enkin, M.J.N.C. Keirse, J. Nielson, C. Crowther, L. Duley, E. Hodnett, and J. Hofmeyr. Oxford University Press, 2000
Annual Summary of Vital Statistics: 2000, Hoyert DL, Freedman MA, Strobino DM, Guyer B. Division of Vital Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland 20782, USA
post #29 of 49
Thread Starter 
Thank you so much!

Quote:
Originally Posted by velcromom
Perinatal mortality rate - babies that die:
3 per 1000 for planned vbac
4 per 1000 for elective cesarean


Maternal mortality rate - moms that die:
2.8 per 10,000 with a trial of labor
2.4 per 10,000 with an elective cesarean


The risk of a mother dying from a cesarean is small but is still considerably higher than with a vaginal birth:
Maternal death with cesarean: 4 in 10,000
Maternal death with all vaginal births 1 in 10,000
Maternal death with elective cesareans 2 in 10,000
Maternal death with all normal vaginal births 0.5 in 10,000

Countries with some of the lowest perinatal mortality rates in the world have cesarean rates under 10%. The World Health Organization says, "Clearly there is no justification in any specific region to have more than 10-15% cesarean section births."

The infant mortality rate in the US is currently 6.9/1,000. This report states "The United States continues to rank poorly in international comparisons of infant mortality."

The maternal mortality rate in 1996 (the last year statistics were available) was 12 per 100,000 births. There has been no decrease in maternal mortality in the US for 20 years according to a Mortality and Morbidity Weekly Report.*



Sources:
Trends in Cesarean Birth and Vaginal Birth After Previous Cesarean, 1991-1999
National Vital Statistics Reports, Volume 49, Number 13, December 27, 2001
A Guide to Effective Care in Pregnancy and Childbirth, Chapter 38, Labor and birth after previous cesarean, M. Enkin, M.J.N.C. Keirse, J. Nielson, C. Crowther, L. Duley, E. Hodnett, and J. Hofmeyr. Oxford University Press, 2000
Annual Summary of Vital Statistics: 2000, Hoyert DL, Freedman MA, Strobino DM, Guyer B. Division of Vital Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland 20782, USA
post #30 of 49
Quote:
Originally Posted by Charles Baudelaire
It is up to Jane, and other than Janet and Jim feeling that a c-section is safest for the baby and not a substantial risk for Jane, they're not "insisting" or forcing her to choose one way or another: it really is her decision. They're just afraid that their one-and-only baby will die. However, what's at stake for Jane is that she wants the birth choice to be the one that's safest for the baby, but not at the expense of her life (reasonably speaking -- NO form of birth is without risk, and Jane is well aware of this).

Do me a favor, you study-knowledgeable mamas:

In terms of a percentage, what is the percentage of births that go wrong in a VBAC (unmedicated) and result in serious, permanent fetal injury?

In terms of a percentage, what is the percentage of births that go wrong in a VBAC (unmedicated) and result in death for the baby?

In terms of a percentage, what is the percentage of mothers who experience serious, permanent injury from a C-section or its complications?

In terms of a percentage, what is the percentage of mothers who die from a C-section or its complications?

Thanks again.

charles baudelaire,

:
post #31 of 49
The most recent comprehensive study is from the December 2004 New England Journal of Medicine "Maternal and Perinatal Outcomes Following Associated with a Trial of Labor Following a Prior Cesarean Delivery". This study was a bit unique in that it actually broke out the difference in rupture rates for deliveries that were spontaneous, non-induced AND those induced in various ways. This study also looked at many, many morbidities associated with both VBAC and ERCS. There are other morbidities than maternal death and neonatal death at delivery to consider.

I would encourage anyone who is planning a VBAC or ERCS to read this article for themselves. It is FULL of charts and is relatively easy for the lay person to understand I think.

The full text of the article can be found here:
http://content.nejm.org/content/vol3...25/index.shtml

But in teasing out some of the answers to your questions:

Quote:
In terms of a percentage, what is the percentage of mothers who experience serious, permanent injury from a C-section or its complications?
Quote:
In terms of a percentage, what is the percentage of mothers who die from a C-section or its complications?
The study didn't look at things in quite this way. It compared maternal death rates for ERCS and trial of labor (TOL, the study's terminology, not mine).
The risk of maternal death for all women undergoing TOL was .02%. For all women undergoing ERCS, it was .04%. The rate for all morbidities (and they looked at many) was 5.5% for the TOL group and 3.6% for the ERCS group.

They also broke out women who had successful VBACs vs not successful VBACs. By FAR women who experienced an unsuccessful VBAC had the most complications. The maternal death rate was .04% for failed VBAC and .01% for successful VBAC. The maternal morbidity rate was 14.1% for the failed VBAC and 2.4% for the successful VBAC group. (The overall VBAC success rate in the study was 73%.)

Quote:
In terms of a percentage, what is the percentage of births that go wrong in a VBAC (unmedicated) and result in serious, permanent fetal injury?
Quote:
In terms of a percentage, what is the percentage of births that go wrong in a VBAC (unmedicated) and result in death for the baby?
The overall neonatal morbidity rate (including death) was .38% in the TOL group and .13% in the ERCS group.

The study goes on to tease out many more details and nuances. The study is NOT without its flaws, but I think it is very comprehensive and deserves to be read for the information it provides.
post #32 of 49
Thread Starter 
Quote:
Originally Posted by egoldber
The most recent comprehensive study is from the December 2004 New England Journal of Medicine "Maternal and Perinatal Outcomes Following Associated with a Trial of Labor Following a Prior Cesarean Delivery". This study was a bit unique in that it actually broke out the difference in rupture rates for deliveries that were spontaneous, non-induced AND those induced in various ways. This study also looked at many, many morbidities associated with both VBAC and ERCS. There are other morbidities than maternal death and neonatal death at delivery to consider.

I would encourage anyone who is planning a VBAC or ERCS to read this article for themselves. It is FULL of charts and is relatively easy for the lay person to understand I think.

The full text of the article can be found here:
http://content.nejm.org/content/vol3...25/index.shtml

But in teasing out some of the answers to your questions:





The study didn't look at things in quite this way. It compared maternal death rates for ERCS and trial of labor (TOL, the study's terminology, not mine).
The risk of maternal death for all women undergoing TOL was .02%. For all women undergoing ERCS, it was .04%. The rate for all morbidities (and they looked at many) was 5.5% for the TOL group and 3.6% for the ERCS group.

They also broke out women who had successful VBACs vs not successful VBACs. By FAR women who experienced an unsuccessful VBAC had the most complications. The maternal death rate was .04% for failed VBAC and .01% for successful VBAC. The maternal morbidity rate was 14.1% for the failed VBAC and 2.4% for the successful VBAC group. (The overall VBAC success rate in the study was 73%.)





The overall neonatal morbidity rate (including death) was .38% in the TOL group and .13% in the ERCS group.

The study goes on to tease out many more details and nuances. The study is NOT without its flaws, but I think it is very comprehensive and deserves to be read for the information it provides.
Thank you so much, esp. for providing the link for my reference. Okay, I am *lousy* at reading studies, but from the data you quoted, it would appear that the following are true...correct me if I am wrong.

Jane's chance of death with a VBAC =.02%
Jane's chance of death with a C-section=.04%

So it's double the risk, mas o menos, but it's still pretty low. Sorry to be VERY stupid, but I'm number-impaired -- does .02% translate to 2 out of 1000? 2 out of 10,000?

Baby's chance of death with a VBAC = .38%
Baby's chance of death with a C-section = .13%

Clearly, at least to judge from this data, it would appear safer for the baby to go with the section. Given the small discrepancy of .02% between maternal mortality rates (.02 to .04%) for VBAC to c-section versus the much larger difference to the baby of .25% (from a .38% chance of death to the .13% chance) for the c-section, it would appear the more ethical choice to choose the section if the preservation of the baby's life and the mother's life are the two highest priorities. Is this a correct interpretation of the data?? Or am I missing something?:
post #33 of 49
To me, it really seems unethical to reduce the whole situation to a numbers and statistics game. These can be manipulated in many different ways to indicate and support different assumptions. I have not read the study in detail, but I'm sure when I have the time there will be items contained within it that draw concern for me.

For me, the truly ethical choice would be for the couple and the surrogate to honestly and openly discuss the options and for each to respect and listen to the other's wishes. Although the baby is not biologically the surrogate's child, it is "renting space" in her body until it is a viable human capable of sustaining life on its own and her body deserves the respect of selecting the method of birth that the surrogate prefers regardless of it has the lowest mortality and morbidity for the baby, especially since the numbers presented are very, very small.

And fyi, .02% is equivalent to 2 in 10,000.

~claudia
post #34 of 49
Thread Starter 
Quote:
Originally Posted by TurboClaudia
To me, it really seems unethical to reduce the whole situation to a numbers and statistics game. These can be manipulated in many different ways to indicate and support different assumptions.
Agreed, but they're about all one has if one wants to get a look at the total picture or the general odds of a particular decision, especially one that has many variables. Without that kind of raw data, it's hard to come to any kind of valid conclusion of any kind, either way.

Quote:

I have not read the study in detail, but I'm sure when I have the time there will be items contained within it that draw concern for me.

For me, the truly ethical choice would be for the couple and the surrogate to honestly and openly discuss the options and for each to respect and listen to the other's wishes. Although the baby is not biologically the surrogate's child, it is "renting space" in her body until it is a viable human capable of sustaining life on its own and her body deserves the respect of selecting the method of birth that the surrogate prefers regardless of it has the lowest mortality and morbidity for the baby, especially since the numbers presented are very, very small.

And fyi, .02% is equivalent to 2 in 10,000.

~claudia
But the surrogate in this case also has a desire to give birth to a healthy baby. Not as great a desire as Jim and Janet, which is to be expected, but a great desire nevertheless. It's a cost-benefit situation: no form of delivery is without its cost to baby and mother; no form of delivery is without its benefit to both. Balancing one against the other can be tricky at best, and at the very least, I think whatever decision anyone makes has to start with as reliable a set of data as is possible to get, and to question the assumptions of that data, read opposing viewpoints, and then decide.

Hey, thanks for letting me know about 2 out of 10,000. I wish my brain worked better with numbers.
post #35 of 49
I attended a lecture by Ina May Gaskin a few years ago about maternal death and birth safety in the USA. It was very interesting and sad. Many of the deaths were complications of C-sections which were never recorded as birth related events as they happened beyond the general reporting time to be considered birth related.

Here is a link to the project: http://www.rememberthemothers.net/home.html

This is a topic I really know little about but I thought maybe this link could serve as a launch point for some more research.
post #36 of 49
Another thought. With the maternal death rate of c-sections I am a little upset that they would ask this of a woman who is already doing something so unselfish for them. It seems extremly ungrateful

So, just had to say that.
post #37 of 49
Thread Starter 
Quote:
Originally Posted by huggerwocky
Another thought. With the maternal death rate of c-sections I am a little upset that they would ask this of a woman who is already doing something so unselfish for them. It seems extremly ungrateful

So, just had to say that.
Look at it this way, Huggerwocky. Jim and Janet strongly believe that although c-sections carry a risk, that so do VBACs, and that the danger to their baby from a VBAC is greater than the danger to Jane for a c-section. Ultimately, they know it's Jane's decision and they can't do much about it other than state their wishes. Imagine feeling powerless over how your baby was born. Imagine, for example, being strongly in favor of homebirth while your surrogate wanted to have a scheduled c-section or an induction. It's not as simple as Mean Jim and Janet imposing their wishes on Poor Helpless Jane.
post #38 of 49
Quote:
Originally Posted by huggerwocky
Another thought. With the maternal death rate of c-sections I am a little upset that they would ask this of a woman who is already doing something so unselfish for them. It seems extremly ungrateful

So, just had to say that.
From the study quoted above:

Jane's chance of death with a VBAC =.02%
Jane's chance of death with a C-section=.04%

That's 2 per 10,000 with VBAC and 4 per 10,000 with c-section.

We're not talking big numbers either way. Yes, that's double for c-section moms, but come on....4 in 10,000? I hardly consider that 'extremely ungrateful'. If her risk was more like 1 in 100 or something...sure, I could see it, but 1 in 2500 just isn't going to have me all up in arms when the alternative (VBAC) is 1 in 5000.

Especially when you consider the additional risks to the baby in question. If 1 in 2500 (the c-section risk) gets you all up in arms, what about the risk of death for the baby from VBAC? It's listed as 38 per 10,000 vs. 13 per 10,000 for c-section. That's 25 babies out of every 10,000 that would still be alive if they'd sectioned mom in the first place.

Hmmm....25 babies alive that would have been dead vs. the 2 additional moms that will die as a result of being sectioned.

Going off of YOUR line of thinking, how could this surrogate be so selfish as to put this baby at such an increased risk knowing an additional TWENTY FIVE babies per 10,000 will DIE as a result of a VBAC attempt? If THAT number is small enough that VBAC is still ok, I fail to see how an additional TWO mothers dying in the section group is something to get all upset over.
post #39 of 49
Quote:
Originally Posted by velcromom


Maternal mortality rate - moms that die:
2.8 per 10,000 with a trial of labor
2.4 per 10,000 with an elective cesarean




From these numbers, it appears that c-sections are safer for mom when compared to TOL moms attempting VBAC.
post #40 of 49
VBAC

I think its important to think about other side effects to Jane besides just death. Will there be epidural after effects? Numbness that never goes away around the scar? Its more than just death, its about the effects on her body all together.
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