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#31 of 49 Old 06-09-2006, 10:33 PM
 
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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%.)

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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?
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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.

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#32 of 49 Old 06-09-2006, 11:24 PM - Thread Starter
 
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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?:
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#33 of 49 Old 06-10-2006, 01:23 AM
 
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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.

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#34 of 49 Old 06-10-2006, 01:48 AM - Thread Starter
 
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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.
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#35 of 49 Old 06-10-2006, 09:21 PM
 
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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.

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#36 of 49 Old 06-11-2006, 02:40 AM
 
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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.
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#37 of 49 Old 06-11-2006, 03:50 AM - Thread Starter
 
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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.
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#38 of 49 Old 06-11-2006, 04:14 AM
 
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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.
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#39 of 49 Old 06-11-2006, 04:16 AM
 
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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.
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#40 of 49 Old 06-11-2006, 04:31 AM
 
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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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#41 of 49 Old 06-11-2006, 04:32 AM
 
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Originally Posted by Charles Baudelaire
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
That's not quite the way percentages work. Although you can add and subtract them in certain situations, when you want to compare them to each other you have to multiply and divide, because it is about proportion...like percentages of percentages. What I think you really want to say is:

The discrepancy between maternal morality rates for VBAC vs. ERCS is (out of 10,000) 2 vs. 4. 4 is 2 times 2; that is, 200%, or twice the risk.

The discrepancy between child's mortality rates for ERCS vs. VBAC is (out of 10,000) 38 vs. 13. 38 is 2.92 times 13; that is, 292%, or almost three times the risk.

The difference between 2.92 and 2 is a lot less than the difference between 25 and 2. The figure of 25 that you arrived at has some limited validity inasmuch as that many more children die per 10,000, but it's not that much more of a percentage of 13 than 4 is of 2. The relative proportions are not that different.

(I hope I am explaining this OK. This is all just arithmetic I remember from high school; I don't know anything about the actual science of statistics. I hope someone who does know will come along. I find the apparent absence of such a person from these 'cesarean risk' threads very frustrating. 'Cause the one thing I do know about statistics is it's more complicated than it looks, and I suspect these back of the envelope type calculations aren't really getting us too far.)

But anyway, as far as I can tell, it comes down to whether you prefer to tolerate (almost) three times the risk to the child, or two times the risk to the mother.

Assuming this is hypothetical, I am curious why you are mixing up the separate ethical problem of surrogacy/autonomy/"who decides" with the question of maternal vs. fetal risks. Are you just trying to highlight the conflict of interest between child and maternal outcomes, or....? ISTM like we need to figure out what's really going on with the stats before it would be useful to get into any specific ethical scenarios.
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#42 of 49 Old 06-11-2006, 04:42 AM
 
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Originally Posted by wifeandmom
From these numbers, it appears that c-sections are safer for mom when compared to TOL moms attempting VBAC.
Oh. Hmm. When I saw that, I assumed "trial of labor" meant they attempted VBAC and had an emergency cesarean, because it uses different language - TOL vs. elective c/s - from the language for baby's statistics, which compares -"VBAC" to elective c/s. Confusing. And now I'm starting to wonder where the attempted VBACs that end in emergency c/s are showing up in the statistics.
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#43 of 49 Old 06-11-2006, 10:33 AM
 
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I hope someone who does know will come along. I find the apparent absence of such a person from these 'cesarean risk' threads very frustrating.
LOL! I actually am a statistican, but I have to admit that the way people are adding and trying to compare things is confusing to me. I'm not sure I understand what people are trying to get at. I think some people are confusing mortality (death) rates with morbidity (adverse outcomes, including death) rates.

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When I saw that, I assumed "trial of labor" meant they attempted VBAC and had an emergency cesarean, because it uses different language
In the NEJM study, any VBAC attempt is called a TOL. They broke out the maternal and neonatal death and morbidity rates for ERCS, successful TOL (VBAC), and unsuccessful TOL (VBAC).

If you look at the study in a gross way, the best outcomes for mom are in successful VBACs. The next best outcomes are from ERCS. The worst outcomes for mom are in unsuccessful VBACs.

The best outcomes for baby are in ERCS. The next best outcomes are in successful VBAC. The worst outcomes are in unsuccessful VBACs.

If you compare successful VBAC to ERCS, the rates are very, very similar (in a gross way) for mom and babies. The biggest risk with VBAC is if it fails, especially if it fails for a catastrophic reason. Thats when risks for mom and baby go way up.

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#44 of 49 Old 06-11-2006, 12:33 PM - Thread Starter
 
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Thank you so much for clarifying this stuff, Galatea -- I'm normally a reasonably intelligent person, I swear, but when it comes to dealing with numbers, honestly, it's like I lose I.Q. points -- they float out of my ears or something.

Quote:

. I hope someone who does know will come along. I find the apparent absence of such a person from these 'cesarean risk' threads very frustrating. 'Cause the one thing I do know about statistics is it's more complicated than it looks, and I suspect these back of the envelope type calculations aren't really getting us too far.)
Far enough, anyway, to be able to tell that for the baby, C-section is safer. For the mother, VBAC is safer, but C-section doesn't represent, in terms of a percentage, a huge increase in danger. At least, not if I understood the calculations and your analysis.

Quote:

But anyway, as far as I can tell, it comes down to whether you prefer to tolerate (almost) three times the risk to the child, or two times the risk to the mother.

Assuming this is hypothetical, I am curious why you are mixing up the separate ethical problem of surrogacy/autonomy/"who decides" with the question of maternal vs. fetal risks. Are you just trying to highlight the conflict of interest between child and maternal outcomes, or....? ISTM like we need to figure out what's really going on with the stats before it would be useful to get into any specific ethical scenarios.
I'm trying to understand the conflict between maternal and fetal risks in order to come to a more clear understanding of what the most ethical choice would be.

If it were her own baby, Jane would do a VBAC -- but Jane has a child already and could have more if she chose. Jim and Janet have this one child. That's it. Forever. They care very much for Jane's welfare, so they don't want to make a choice that puts her health at risk (well, more than it's at risk already in general for birth, but they all know birth has risks). They are also understandably scared that their one-and-only child will die -- something I know every mother on here can sympathize with from the bottom of her heart...we've all been there. That's why they lean more toward c-section. Jane would prefer a VBAC, but she will do a c-section if that, overall, is the safest choice for both Jane and the baby. Determining what is "safest" though -- that is the question.

Thank you so much for taking the time to explain more about percentages...I really thank you.
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#45 of 49 Old 06-11-2006, 07:25 PM
 
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Originally Posted by GalateaDunkel
That's not quite the way percentages work. Although you can add and subtract them in certain situations, when you want to compare them to each other you have to multiply and divide, because it is about proportion...like percentages of percentages. What I think you really want to say is:

The discrepancy between maternal morality rates for VBAC vs. ERCS is (out of 10,000) 2 vs. 4. 4 is 2 times 2; that is, 200%, or twice the risk.

The discrepancy between child's mortality rates for ERCS vs. VBAC is (out of 10,000) 38 vs. 13. 38 is 2.92 times 13; that is, 292%, or almost three times the risk.

The difference between 2.92 and 2 is a lot less than the difference between 25 and 2. The figure of 25 that you arrived at has some limited validity inasmuch as that many more children die per 10,000, but it's not that much more of a percentage of 13 than 4 is of 2. The relative proportions are not that different.

(I hope I am explaining this OK. This is all just arithmetic I remember from high school; I don't know anything about the actual science of statistics. I hope someone who does know will come along. I find the apparent absence of such a person from these 'cesarean risk' threads very frustrating. 'Cause the one thing I do know about statistics is it's more complicated than it looks, and I suspect these back of the envelope type calculations aren't really getting us too far.)

But anyway, as far as I can tell, it comes down to whether you prefer to tolerate (almost) three times the risk to the child, or two times the risk to the mother.
In another lifetime, I taught high school math, so I understand how percentages work.

What you are saying is true, the risk to mom is 2x greater for c-section vs. VBAC and the risk to baby is ~3x greater for VBAC vs. c-section.

However, it's perfectly valid to look at the raw data as well, which is what most people have been doing. The reason you 'see' more of a difference in the raw data in this case is because for the c-section risk, you start out with 2 moms dead from VBAC and 4 from c-section. With c-section risk to baby, you have 13 dead babies vs. 38 dead babies from VBAC.

So, while you are absolutely correct that the numbers are 2x the risk for section (to mom) and ~3x the risk for VBAC (for baby), you are starting with a much larger number of dead babies (13 dead with c-section), so roughly 3x that risk is what gives you 38 dead babies with VBAC.

Indeed you WILL have 25 ADDITIONAL dead babies in VBAC attempts vs. ERCS. We ARE talking about 25 out of 10,000, still a very small number, but valid nonetheless.

I think the problem comes in when people use varying ways to look at percentages to 'prove' their point. Obviously in this case, it looks 'worse' for VBACs to use raw numbers (the fact that 25 additional babies will die instead of just giving the .13 and .38 which most people don't really understand in the first place, they just both look really, really small).

How many times have I seen something like 'Elective section moms are TWICE as likely to die as vaginal delivery moms' or some such statement. Yet you rarely see those same people point out that we're talking 1 in 5000 vs. 1 in 10,000. Or even better are those who don't acknowledge the difference in stats between unplanned c-sections (1 in 2500 deaths for mom) vs. elective c-sections ( 1 in 5000 deaths for mom).

Another example that comes to mind is something I read recently that said very boldly 'C-section babies are FIVE TIMES more likely to have PPH.' There was ZERO mention of how likely PPH is in a newborn to begin with, and for me, that's a critical piece of information if the whole FIVE TIMES AS LIKELY business is going to be a major concern or something still so very rare that it's worth noting but not stressing over. (Off to look up actual stats after I post this as I am curious....)
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Ok, here's the first easy to read explanation I found:

Quote:
Who is affected by persistent pulmonary hypertension?
About one in every 500 to 700 babies develops PPHN. It occurs most often in full-term or post-term babies after a difficult birth, or birth asphyxia (a condition that results from too little oxygen).

From this, it sounds more like an issue of difficult birth, which obviously ends up in c-section much more often if baby isn't getting enough oxygen. So while it may very well be true that 5x more c-section babies have PPH in comparison to vaginal birth babies, it sounds to me like the CAUSE has zilch to do with the c-section and more to do with the fact that the baby was in trouble to begin with.

I wonder what the stats are for ERCS babies under NO distress in comparison to vaginally birthed babies. If THOSE babies also see a five fold increased risk in PPH, then there might be something noteworthy to consider, as I don't consider 1 in 500 to 700 (thus increasing the risk to close to 1 in 100 for c-section babies) a tiny number. It's not HUGE, mind you, but it is concerning IF the ERCS babies are seeing the same risk increase.
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Originally Posted by wifeandmom
How many times have I seen something like 'Elective section moms are TWICE as likely to die as vaginal delivery moms' or some such statement. Yet you rarely see those same people point out that we're talking 1 in 5000 vs. 1 in 10,000. Or even better are those who don't acknowledge the difference in stats between unplanned c-sections (1 in 2500 deaths for mom) vs. elective c-sections ( 1 in 5000 deaths for mom).

Another example that comes to mind is something I read recently that said very boldly 'C-section babies are FIVE TIMES more likely to have PPH.' There was ZERO mention of how likely PPH is in a newborn to begin with, and for me, that's a critical piece of information if the whole FIVE TIMES AS LIKELY business is going to be a major concern or something still so very rare that it's worth noting but not stressing over. (Off to look up actual stats after I post this as I am curious....)
That's precisely the kind of thing I'm talking about. Jane's concern with a C-section is that she'd die -- not a surprise, given that ERCS stats vs. VBAC stats are usually put in terms of "X times more/less likely than Y," and it's why I wanted BOTH figures in terms of a percentage..sort of to level the playing field.
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#48 of 49 Old 06-11-2006, 07:48 PM - Thread Starter
 
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Originally Posted by wifeandmom
Ok, here's the first easy to read explanation I found:




From this, it sounds more like an issue of difficult birth, which obviously ends up in c-section much more often if baby isn't getting enough oxygen. So while it may very well be true that 5x more c-section babies have PPH in comparison to vaginal birth babies, it sounds to me like the CAUSE has zilch to do with the c-section and more to do with the fact that the baby was in trouble to begin with.

I wonder what the stats are for ERCS babies under NO distress in comparison to vaginally birthed babies. If THOSE babies also see a five fold increased risk in PPH, then there might be something noteworthy to consider, as I don't consider 1 in 500 to 700 (thus increasing the risk to close to 1 in 100 for c-section babies) a tiny number. It's not HUGE, mind you, but it is concerning IF the ERCS babies are seeing the same risk increase.
From what I can see, to say that c-section babies have PPH five times more often than vag birth babies is genuinely putting the cart before the horse: it sounds like the CS may have been a response to fetal hypoxia, not the cause of it.
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#49 of 49 Old 06-11-2006, 07:59 PM
 
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Originally Posted by Charles Baudelaire
From what I can see, to say that c-section babies have PPH five times more often than vag birth babies is genuinely putting the cart before the horse: it sounds like the CS may have been a response to fetal hypoxia, not the cause of it.
That's what I'm thinking, but have been unable to find a whole bunch of actual statistical evidence on elective c-section with NO fetal distress present at delivery and subsequent PPH risks.

Stats are played both ways, and it's very frustrating, esp considering the average American hasn't a clue how to interpret stats. My high schoolers in the classroom literally shut down when they saw a fraction or decimal. Word problems? Ha! It makes it hard for anyone to actually read and UNDERSTAND the risks they are taking when you have to consider the source of information so carefully.

Obviously a site supporting VBAC is going to word risks of ERCS in the worst sounding way possible, which is really a shame cause it seems to work on the assumption that a woman can't possibly make an informed choice if given the WHOLE picture.
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