Time Magazine Examines Risks Associated With Repeat Caesareans

Main Category: Pregnancy / Obstetrics
Article Date: 26 Feb 2009 - 2:00 PDT

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Although there is increasing scrutiny of the rising rate of elective caesarean sections, "little attention has been paid to the vast number of moms who are forced to have" c-sections, Time Magazine reports in an article that will appear in its March 2 issue. According to Time, more than nine in 10 births to women who have had a previous c-section are surgical deliveries, "proving that 'once a caesarean, always a caesarean' -- an axiom thought to be outmoded in the 1990s -- is alive and kicking." Although vaginal births after caesarean carry the risk of uterine rapture -- which can be fatal to the woman and infant -- the problem occurs in only 0.7% of cases. In addition, "the number of catastrophic cases is low; only one in 2,000 babies die or suffer brain damage as a result of oxygen deprivation," Time reports. Further, the risks associated with repeat c-sections -- including heavy bleeding, infertility and infection -- increase with each repeat procedure. Repeat c-sections also increase a woman's chance of developing potentially fatal placental abnormalities that can cause hemorrhaging during childbirth.

In previous decades, physicians encouraged women to have VBACs because of the lower cost and the faster healing recovery period, Time reports. By 1996, VBACs accounted for 28% of births among women who had previously had a c-section, and the government in 2000 set a target VBAC rate of 37% in its Healthy People 2010 report. However, by 2006, only 8% of births were VBACs, and the "numbers continue to fall -- even though 73% of women who go this route successfully deliver without needing an emergency caesarean," Time reports. Recent research by the International Cesarean Awareness Network found that 28% of 2,850 hospitals with labor and delivery wards do not allow VBACs, an increase from 10% in 2004. ICAN also found that an additional 21% of hospitals have no official policies against VBACs but also have no obstetricians willing to perform them.

According to Time, the decrease in VBACs began around 1999, after several high-profile cases in which women undergoing VBACs experienced uterine ruptures. This prompted the American College of Obstetricians and Gynecologists to change its guidelines from recommending that surgeons and anesthesiologists be "readily available" during a VBAC to "immediately available." Time reports that "many interpreted the revision to mean that surgical staff must be present the entire time a VBAC patient is in labor," an unrealistic requirement for smaller hospitals that typically rely on on-call anesthesiologists. In addition, many obstetricians are unable or unwilling "to stay for what could end up being a 24-hour delivery," when a c-section can be performed in about one hour.

Malpractice insurance is another factor in the decrease in VBACs, as a few major lawsuits over the procedure have prompted many insurers to increase the price of malpractice insurance for physicians who perform them, according to Time. Shelley Binkley, an ob-gyn in private practice in Colorado Springs who stopped offering VBACs in 2003, said it is a "numbers thing. You don't get sued for doing a c-section. You get sued for not doing a c-section." A 2006 ACOG survey of 10,659 ob-gyns in the U.S. found that 26% said they no longer performed VBACs because of high insurance costs or unavailability of insurance. Additionally, 33% said that they stopped performing the procedure out of fear of litigation.

Some physicians say that fewer patients are requesting the procedure. Hyagriv Simhan, medical director of the maternal-fetal medicine department of the University of Pittsburgh Medical Center Magee-Women's Hospital, said the decrease in VBACs is "driven both by patient preference and by provider preference." Other physicians argue that the medical profession has been too discouraging of VBACs. A survey by Childbirth Connection found that 57% of women who had previous c-sections in the U.S. in 2005 were interested in VBACs but were denied the option of having one. Stuart Fishbein, a Carmarillo, Calif., ob-gyn whose hospital does not allow VBACs, said he is concerned women are getting "skewed" information about the risks associated with a VBAC "that leads them down the path that the doctor or hospital wants them to follow, as opposed to medical information that helps them make the best decision." Time reports that to "reverse the trend" physicians and patients "need to be as aware of the risks of multiple caesareans as they are of those of VBACs." The topic is likely to be on the agenda when the National Institutes of Health holds its first conference on VBACs next year (Paul, Time Magazine, 3/2).

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