why are repeat c-sections so dangerous?

[spu]

I'm pg with #4, and the first 2 attempts ended in c-sections for different reasons... during my last c, the ob said my uterus was 'very' thin... and if I got pg again, I might want to consider another c (and I got pg 6mos after DS was born, so not sure how well my uterus has healed). But I'm hearing that multiple c's are actually more dangerous than vbacs... why? Any info you can give me to help make the right decision would be great. I thought I read on everything from ICAN's website for my first vbac attempt, but now that I'm here again, I definitely need refresher information.

thanks!!
susan

[geckoed]

http://www.lamaze.org/institute/adva...nsequences.pdf
and the link is defunct, but another article:
Infant Deaths After C-Sections Rise Even in Low-Risk Pregnancies

Thu Aug 31, 11:48 PM ET

THURSDAY, Aug. 31 (HealthDay News) -- Among U.S. women with low-risk
pregnancies, those who opt for Caesarean section have higher infant and
neonatal death rates than women who deliver vaginally, a new study finds.
ADVERTISEMENT

Researchers at the U.S. Centers for Disease Control and Prevention analyzed
data from more than 5.7 million live births and nearly 12,000 infant deaths
over a four-year period.

Overall, neonatal (younger than 28 days) deaths were rare for infants of
low-risk women. The rate was about one death per 1,000 live births.

However, the study found that the death rate among neonatal infants
delivered by Caesarean section was more than twice that of infants delivered
vaginally. This held true even after the researchers adjusted for
socio-demographic and medical risk factors.

The researchers noted that there was a 41 percent increase from 1996 to 2004
in the number of U.S. babies delivered by Caesarean section. According to
the National Center for Health Statistics, nearly 1.2 million C-sections --
29.1 percent of all births -- were performed in the United States in 2004.

"These findings should be of concern for clinicians and policy makers who
are observing the rapid growth in the number of primary Caesareans to
mothers without a medical indication," lead researcher Marian MacDorman, a
CDC statistician and senior social scientist, said in a prepared statement.

She's also co-chair of the SIDS and Infant Mortality Committee for the
American Public Health Association.

"While timely Caesareans in response to medical conditions have proven to be
life-saving interventions for countless mothers and babies, we are currently
witnessing a different phenomenon -- a growing number of primary Caesareans
without a reported medical condition," MacDorman said. "Although the
neonatal mortality rate for this group of low-risk women remains low
regardless of the method of delivery, the resulting increase in the
Caesarean rate may inadvertently be putting a larger population of babies at
increased risk for neonatal mortality."

The study was published in the latest issue of the journal Birth: Issues in
Perinatal Care.

More information

The American College of Obstetricians and Gynecologists has more about
patient-requested Caesarean delivery.


and another

Caesarean birth triples maternal death risk

Thu Aug 31, 3:45 PM ET

LOS ANGELES (Reuters) - A Caesarean delivery more than triples a woman's
risk of dying in childbirth compared to a vaginal birth, according to a new
study from France.
ADVERTISEMENT

The risk is still quite small, but many developed countries have seen a
dramatic rise in the number of Caesareans performed each year as more women
elect to avoid a vaginal delivery.

Researchers, led by Catherine Deneux-Tharaux of the Maternite Hopital Tenon
in Paris, looked at 65 maternal deaths recorded in the French National
Perinatal Survey from 1996 to 2000.

All of the deaths followed births of a single child and were not due to
conditions existing prior to delivery. The women had also not been
hospitalized during pregnancy.

The researchers found that the risk of death -- from blood clots, infection
or complications from anesthesia -- was 3.6 times higher for women who had
Caesareans.

The risk of death after childbirth was increased whether or not the
Caesarean was performed before the onset of labor or during labor.

The study was published in the September issue of Obstetrics & Gynecology.

Although rates of maternal death in most developed countries are relatively
low -- U.S. women have a 1 in 3,500 chance of pregnancy-related death -- the
incidence of maternal mortality has not significantly decreased in the last
two decades, according to American College of Obstetricians and
Gynecologists.


you can google "risks of repeat cesarean" as well

[sarah0404]

Hi, a really quick reply here! I just came across these facts:

The risk of a mother who has one past caesarean ending up with a hysterectomy after a subsequent caesarean was 1 in 90, according to a recent study from the UK. However, for women having a vaginal birth who did not have a past caesarean, the rate was only 1 in 5,189.

A study of mothers in the Netherlands between 1983 and 1992 found that the death rate from caesareans was seven times that from vaginal birth.

I also remember reading recently, that for your 1st c/section it takes approx 5 minutes to get the baby out from the time they make the first cut. For each subsequent (sp?) c/s the time increases. With c/s number 4 it takes approx. 18 minutes to get the baby out from the time they make the 1st cut. It's a much more difficult operation, as there can be a lot of adhesions and scar tissue from the previous surgeries.

I'm hoping for a VBA3C this time. I feel that with 3 children already to care for I really don't want to do anything that seriously risks my health or my life. I believe for a VBA3C the chances uterine rupture are 0.7% (or was it 0.9%?) Anyway - it's a tiny percentage. I have a 99% chance of not having a ruptured uterus! Also, who knows what they are recording as a rupture. One of my scars seperated slightly last time. It did not cause any harm to me or my baby. It might have been recorded as a rupture though.

Good luck with your decision. It's so hard to know what to do for the best sometimes. I hope you can find a solution you are happy with.

[wifeandmom]

Originally Posted by sarah0404

I also remember reading recently, that for your 1st c/section it takes approx 5 minutes to get the baby out from the time they make the first cut. For each subsequent (sp?) c/s the time increases. With c/s number 4 it takes approx. 18 minutes to get the baby out from the time they make the 1st cut. It's a much more difficult operation, as there can be a lot of adhesions and scar tissue from the previous surgeries.

Interesting. I do believe it takes longer on average to perform subsequent c-sections when dealing with scar tissue and/or adhesions. However, FWIW, my third section was by far the fastest of the three. From first incision to completely closed was 20 minutes on the dot, so it obviously didn't take even close to 18 minutes to get baby out.

The flip side of this argument (that women shouldn't have ERCS cause it's a more difficult operation) should be considered, because many OB's will mention it to patients as a reason TO have an ERCS. What happens if baby goes into distress for whatever reason necessitating an emergency c-section? It's still going to take longer to get to baby, but now baby is in trouble vs. during an ERCS where taking 18 minutes isn't a big deal because baby is fine. I had that argument presented to me and had honestly never thought of it that way, but it does make sense to at least consider it, if for no other reason than to not be taken by surprise if it does come up.

As for the OP, many of the risk factors for multiple c-sections are present during subsequent pg *regardless* of whether or not you choose ERCS or VBAC. Of course there is the risk of UR. However, there are risks that increase fairly significantly with each subsequent c-section that apply to the pregnancy in general. Placental abruption, placenta previa, and placenta accreta come to mind right away. The obvious theme there is a problem with the placenta, and it should be fairly obvious to most people that the uterus simply isn't designed to be cut into over and over and over again.

There are very real risks associated with future pregnancies after c-sections, risks that increase with each additional c-section. It would be wise IMO to consider the overall family size planned by each individual woman when making the ultimate decision of whether or not VBAC or ERCS is the right choice.

[sarah0404]

Originally Posted by wifeandmom

The flip side of this argument (that women shouldn't have ERCS cause it's a more difficult operation) should be considered, because many OB's will mention it to patients as a reason TO have an ERCS. What happens if baby goes into distress for whatever reason necessitating an emergency c-section? It's still going to take longer to get to baby, but now baby is in trouble vs. during an ERCS where taking 18 minutes isn't a big deal because baby is fine. I had that argument presented to me and had honestly never thought of it that way, but it does make sense to at least consider it, if for no other reason than to not be taken by surprise if it does come up.

I thought about this too. If I had a real emergency would 18 minutes be too long? But I wonder how many emergency c/s are actually REAL emergencies? Things like cord prolapse yes but often where the baby isn't tolerating labour well and getting distressed it isn't quite a life or death situation. I was thinking, in a life or death emergency maybe they could do the classical style incision, so they wouldn't have to mess around with old scar tissue. I'm not sure how fast that kind of op is though.

On a different note: I couldn't sleep last night, and for some reason ended up thinking about Michael Jacksons nose! That seems like the perfect advert not to have surgery done in the same place multiple times!

[wombatclay]

seems like the perfect advert not to have surgery done in the same place multiple times!

Oh dear!

My OB told me when I asked about an emergency repeat that they would put me under general and have the babe out "pretty damn fast"...the "cost" for that though is a larger incision, usually a classic incision, and a harder recovery for mama since getting to the babe is the priority (instead of going slow and "gentle" for mama). She also said it wasn't something to worry about, that vbacs are perfectly normal births and the chance of something really bad happening are low.

So be prepared but don't let the thought of a mid-birth repeat take over!

OP- A c/s is a serious surgical procedure. With each c/s your risk for complications go up...an increased chance of secondary infertility, an increased chance of ectopic pregnancy, pregnancy complications like the placental attachment disorders mentioned above, stillbirth, higher risk for UR during pregnancy as well as during the birth, even a harder time finding supportive birth attendants!

Obviously there are mamas who can and do birth past these "risks" but it's better not to have these worries/risks in the first place...

Also, there are the basic risks of major surgery. You may heal well the first time, but there is no promise that a second surgery will go as well. So if you don't NEED the surgery it's better for you too to avoid it!

congrats on the new babe!

[mamalove07]

I haven't read all the replies so I apologize if I am repeating here. I think ERC are "more" dangerous than a primary c-section that is done for good cause because the benefits no longer outweigh the risks at that point. For example, if you have a primary c-section for a genuinely emergency situation (which is rare but that's another story!) the risks of the surgery are far outweighed by the benefits of getting that babe out. But in a RC where the mother is low-risk and there is no emergency situation then there is no risk-to-benefit ratio like there was in the genuine emergency situation. Am I making sense?

[spu]

wow - this is amazing information - thank you so much for the discussions! I have lots to think about... here are a few more questions:

Regarding these issues:
placental abruption, placenta previa, and placenta accreta
-- Can you refresh me on what each of these means?
-- are they a problem during the pregnancy for a woman who has already had a c-section? or can they be a problem during the vbac attempt? or more a problem when ttc?

My last dr. tried to scare me into an elective c by saying cerebal palsy is a huge risk for vbacs... how is that so? I never heard that before... hence, I switched to the mw practice... what causes cerebal palsy?

We're hoping this is our last babe (#4 is more than enough! ) so ttc in the future isn't really too big of an issue, but I want to make sure this current pregnancy is safe and healthy, as well as the delivery method.

tia again!!!
susan

[mighty-mama]

:

[wombatclay]

Spu-

Placenta previa- placenta is low and covers all or part of the cervix
Placenta accreta- placenta grows through the uterine wall (often through the prior scar) and attaches to other organs
Placental abruption- placenta pulls away from the uterine wall before baby is born

All of these are serious and are more common in women with scars on their uterus (but can affect all women). Placenta previa and accreta are mostly a problem at birth since the placenta isn't where it "should" be. Both require c/s for the safety of mama and babe. Accreta often leads to hysterectomy or additional surgery as well.

Abruption can cause a problem at any time during pregnancy and birth.

Cerebral Palsy is a specific set of conditions linked to non-progressive brain damage. Doctors don't actually know what causes CP though there are lots of possible options...low oxygen/lack of oxygen during birth or other birth trauma to the head is a possible cause. Preemie babes are at higher risk, babes with infections are at higher risk, and babes who experience low oxygen situations after birth are also at higher risk.

As far as I can tell, VBACs are at no greater risk for CP than any other vaginal birth. And a c/s wouldn't prevent all the possible causes of CP either so... I have no idea where your doc is getting that info or why they would bring it up!

[kltroy]

Originally Posted by wombatclay

Oh dear!

My OB told me when I asked about an emergency repeat that they would put me under general and have the babe out "pretty damn fast"...

According to a good friend of mine who is a 4th year OB resident, she can get a kid out in about 2 minutes if necessary.

[pampered_mom]

Don't forget the non-pregnancy related long term consequences of c/s (and only compouned by multiple c/s) - bowel obstruction (the same is true of all abdominal surgeries from what I understand). IMO it's a very under-mentioned complication, but one that needs to be considered as well.

[erica990]

Originally Posted by wombatclay

Spu-
Placenta accreta- placenta grows through the uterine wall (often through the prior scar) and attaches to other organs

Actually, in placenta accreta the placenta does not normally grow completely through the uterine wall but attaches to the myometrium, the middle layer of the uterine wall. It's only in one of it's rare forms (placenta percreta) where it goes through the entire wall and can attach to other organs.

A woman's chances of having placenta accreta are next to nothing if she's had no c-sections but are 0.3% if she has had one c-section, 2% if she's had 3 c-sections, and it goes up from there.

[majormajor]

hm, interesting question. i've only had 1 section, so i haven't paid too much attention to the data on multiple sections.

here's what i'm finding, generally: both VBAC and ERCS are riskier for the mother after multiple sections. ERCS tends to be riskier for the mother in terms of serious complications, less risky as far as minor complications go (seems counterintuituve).
VBAC seems to be riskier for the baby compared to ERCS. this is not what i want to keep seeing, but i keeps seeing it, and i'm resigning myself to it. the risks for the baby in your current pregnancy are greater if you VBAC. the risks for a next baby (just in case there is one) get higher if you section.

talk about a crappy spot to be in, huh? it's really been weighting on my mind lately.

[holly6737]

Originally Posted by majormajor

VBAC seems to be riskier for the baby compared to ERCS. this is not what i want to keep seeing, but i keeps seeing it, and i'm resigning myself to it. the risks for the baby in your current pregnancy are greater if you VBAC. the risks for a next baby (just in case there is one) get higher if you section.

I"m sorry but I don't really understand this logic. Elective rcs is riskier than VBAC which is riskier than emergency rcs? But the chance that an emergency rcs would be necessary is less than 1% (in terms of uterine rupture, which really is the only difference between vbac and another low-risk pregnancy in terms of emergency rcs for the baby). How does that equate to "the risks for the baby in your current pregnancy are greater if you VBAC"? Don't mean to be combative, just don't follow you.

[wombatclay]

holly6737- There are some studies that suggest that an scheduled section carries fewer risks for the baby than a repeat c/s done after labor is underway (not necessarily an "emergency", just an unplanned c/s). This is why some care providers argue against VBAC... although a successful VBAC is better for mama and babe than a c/s, a planned c/s is better than an unplanned one (I hate the term "failed vbac" but that's what you see in the literature).

But other studies show little difference between babes born via planned or unplanned c/s. The surgery carries risks for the babe too, and although planning can mitigate some of those risks, the babe is still exposed to some level of risk through the surgery itself (not just the events leading to the c/s).

A search of PubMed for terms like VBAC, Trial of Labor, Cesarean, Failed VBAC or Risk will pull up a variety of sudies on both sides of the fence.

And for the other bit majormahor brought up...risks increase with each surgery, so the more c/s you have had the higher your risk for various complications becomes. VBAC after multiple c/s is certainy possible (just ask the mamas here who have done it!) but it takes a bit more research and confidence and searching. So while a planned c/s might (depending on the study) carry fewer risks for the babe you are carrying now, it raises your risk of complications for a future pregnancy.

[majormajor]

Originally Posted by holly6737

I"m sorry but I don't really understand this logic. Elective rcs is riskier than VBAC which is riskier than emergency rcs? But the chance that an emergency rcs would be necessary is less than 1% (in terms of uterine rupture, which really is the only difference between vbac and another low-risk pregnancy in terms of emergency rcs for the baby). How does that equate to "the risks for the baby in your current pregnancy are greater if you VBAC"? Don't mean to be combative, just don't follow you.

in general, i'm seeing for baby, from safest to riskiest: elective CS, successful VBAC, emergency CS.
for mom, from safest to riskiest: successful VBAC, elective CS, emergency CS.

if you fold emergency CS into VBAC, it's still elective CS then VBAC for baby, VBAC then elective CS for mom.

part of the risk from VBAC comes from the fact that a first time vaginal delivery (if your VBAC is a first time. mine will be, i should have specified that! that affects all of the statistics) is more dangerous than a second one.

i'm sorry if this post is all over the place. DD is all over the place this morning.

as for the increased risk of VBAC, i'm pretty sure that VBACing increases your risk of placental problems too, which increases the baby's chance of death during labor. but i haven't looked for rates of placental problems (abruption, previa and accretia specifically) and compared them to non VBAC or CS, so i don't really know how that plays out yet.

ok have to go!

[wombatclay]

as for the increased risk of VBAC, i'm pretty sure that VBACing increases your risk of placental problems too,

Birth method does not increase or decrease risks of placental problems. The initial surgery increases these risks so unfortunately if you have a c/s or other uterine suregry in your past then the increased risk is already there by the time your next delivery comes around.

Placental problems can complicate both a vaginal delivery (in some cases a successful vaginal delivery would not be possible) and can also complicate a repeat c/s (due to the location of the placenta). But it's not the birth method that is causing the problem, it's the placenta's location/attachment.

Good luck with your VBAC!

[holly6737]

Ok, right, but I guess I'm talking about overall risk?? I have read those articles about emergency rc/s being riskier than elective rc/s when planning my HBAC, but since the chance of me having to have an emergency c/s was somewhere around 3% (and that's being generous) I didn't pay too much attention to them.

As in, what percentage of the time in planned vbacs do emergency c/s really become necessary where it would have been safer to have planned an elective c/s from the beginning, see what I'm saying? The previous poster made the comment that for the baby being carried now, elective c/s would be the safest choice, to which I'm saying, yes, if it was 100% that she would end up with an emergency c/s, but the chances of that are very small, so the risks involved with vbac are still smaller than the risks involved with elective c/s.

Or is that what the literature was saying?

[wombatclay]

Some studies say that c/s is safer than vbac for the babe. Others don't. If dd falls asleep I'll see what I can find...

But like they say, it's lies, damn lies, and statistics. I think a determined mother with a strong support team trumps the numbers more often than not!